Health Care Reform Update (8/11)
CATEGORY / PPACA / STAFF TEAM (Lead underlined) / EFFECTIVEDATE[S] / ITEMS POSTED ON THE AHCA/NCAL WEB:
(final rules highlighted yellow) / UPDATE:
Coverage and Health Insurance Reforms
Coverage and Health Insurance Reforms / §§ 1001, 1101-1304, 1321-1334, 1501-1502, 1511-1515
Individual mandate: all individuals must have health insurance or pay a fine;
Employer mandates: Most employers (50+ FTEs) must offer coverage that meets specified eligibility, affordability and value requirements or potentially pay a fine; and
Insurance market changes/coverage subsidies/Medicaid expansion. / Karl Polzer; Dianne DLM / 2010-2019
2014=Critical date for LTC providers: Employers with 50+ FTEs will face penalties if one or more of their full time employees obtains a premium credit through an insurance exchange. / Policy paper at: http://www.ahcancal.org/advocacy/Pages/HealthCoverageExpansionEmployerMandateProvisions.aspx.
Follow-up CC articles:
1. Waivers for mini-med plans (available until 2014) at http://newsmanager.commpartners.com/ahcamemo/issues/2010-10-22/2.html;
2. Employers given 1-year reprieve (until 2012) to report health plan costs at http://newsmanager.commpartners.com/ahcamemo/issues/2010-10-26/2.html;
3. States receive monies (awarded 10/11) for exchanges at http://newsmanager.commpartners.com/ahcamemo/issues/2010-10-08/4.html;
4. Approved funding for early retiree health subsidies (until 2014) at http://newsmanager.commpartners.com/ahcamemo/issues/2010-10-08/5.html;
5. New “insurance finder” web tool at http://newsmanager.commpartners.com/ahcamemo/issues/2010-09-07/4.html;
6. Established Pre-Existing Condition Insurance Plan (until 2014) at http://newsmanager.commpartners.com/ahcamemo/issues/2010-07-09/3.html;
7. HHS/DOL/IRS interim final rule re: reform and consumer protection (effective 9/23/10) at http://newsmanager.commpartners.com/ahcamemo/issues/2010-07-02/7.html;
8. HHS/DOL/IRS interim final rule re: “grandfathering” or exempting plans already in place (as of 3/23/10) at http://newsmanager.commpartners.com/ahcamemo/issues/2010-06-18/1.html;
9. HHS interim final rule re: establishment of Internet Website (by 7/1/10) at http://newsmanager.commpartners.com/ahcamemo/issues/2010-05-18/3.html;
10. HHS final rule re: early retiree reinsurance program (effective 6/1/10) at http://newsmanager.commpartners.com/ahcamemo/issues/2010-05-07/6.html;
11. IRS guidance re: health coverage provided to an employee’s children under 27 tax-free at http://newsmanager.commpartners.com/ahcamemo/issues/2010-04-29/2.html. / On-going regulatory discussions with DOL, IRS and Treasury regarding employer mandate hardships.
Submitted informal comments to IRS’ request on upcoming proposed rule re: shared responsibility for employers regarding health coverage (due 6/17/11).
TAX CHANGES
Premium Tax Credits and Cost-Sharing Reductions / §§ 1401-15, 1001
Allows individuals to receive premium tax credits and cost-sharing reductions to assist in the purchase of health insurance. / Bill Hartung / 2014=Critical date for LTC providers: Employees that qualify for the premium tax credit or cost-sharing reductions either due to lack of minimum essential coverage or unaffordable coverage could force the employer to pay a penalty. / Policy paper at http://www.ahcancal.org/advocacy/Pages/PremiumTaxCreditsCostSharingReductions.aspx.
Small Business Tax Credit / §§ 1421
Provides a tax credit for qualified small businesses to help them afford insurance coverage of their workers. / Bill Hartung / 2010 / Policy paper at http://www.ahcancal.org/advocacy/Pages/SmallBusinessHealthInsuranceTaxCredit.aspx.
Revenue Provisions / §§ 9001-9017
Provides revenue offset provisions. / Bill Hartung,
Teresa Cagnolatti / 2018-2020
1/1/2012=Critical date for LTC providers: Must file 1099 information return with IRS if the total amount of payments made in exchange for goods or
services are $600 or more in one year. / Policy paper at http://www.ahcancal.org/advocacy/Pages/RevenueOffsetProvisions.aspx
Follow-up CC articles:
1. Baucus introduces bill to repeal 1099 at http://newsmanager.commpartners.com/ahcamemo/issues/2010-11-16/3.html;
2. House passes bill to repeal 1099 at http://newsmanager.commpartners.com/ahcamemo/issues/2011-03-04/12.html;
3. Senate introduces bill to repeal 1099 at http://newsmanager.commpartners.com/ahcamemo/issues/2011-01-25/index.html. / AHCA was successful in getting 1099 repealed (4/11)
CLASS ACT / § 8002
Creates a new voluntary insurance program for purchasing community living assistance services and supports or “CLASS,” to provide assistance for individuals who have difficulty with activities of daily living and need LTC services. / Janice Zalen, Karl Polzer / 2011=Critical date for LTC providers: CLASS insurance program established.
10/12=Critical date for LTC providers:
CLASS benefit plan established.
1/12=Critical date for LTC providers: CLASS eligibility assessment system established. / Policy paper at http://www.ahcancal.org/advocacy/Pages/CommunityLivingAssistanceServicesandSupports(CLASS)Act.aspx.
Follow-up CC articles:
1. House holds hearing on CLASS at http://newsmanager.commpartners.com/ahcamemo/issues/2011-03-19/2.html.
CURRENT MEDICARE
Productivity Adjustment / § 3401
Describes how Medicare providers can expect a reduction in annual market basket updates. / Bill Hartung, Peter Gruhn, Elise Smith / 10/1/11=Critical date for LTC providers:
Revision of market basket updates; incorporating productivity adjustments. / Policy paper at
http://www.ahcancal.org/advocacy/Pages/RevisionofCertainMarket.aspx
RUG IV / § 10325
Forego any delay on the implementation of the changes to the concurrent therapy rules or the look-back period, or launch of the MDS 3.0. / Bill Hartung, Peter Gruhn, Elise Smith / 10/1/11=Critical date for LTC providers:
RUGs IV cannot be implemented prior to this date.
10/1/10=Critical date for LTC providers:
Implement concurrent therapy and lookback changes included in RUGs IV.
10/1/10=Critical date for LTC providers:
Implement MDS 3.0. / Policy paper at
http://www.ahcancal.org/advocacy/Pages/RevisiontoSkilledNursingFacilityProspectivePaymentSystem.aspx.
Therapy Caps / § 3103
Extends the outpatient therapy cap exception process through 2010. / Peter Gruhn, Bill Hartung / 12/31/10=Critical date for LTC providers:
Provides an extension of the exceptions process for Medicare therapy caps until this date. MMEA extends it further until 12/31/11. / Policy paper at
http://www.ahcancal.org/advocacy/Pages/ExtensionofTherapyCapsExceptionsProcess.aspx.
MEDICARE PAYMENT REFORMS
Value-based Purchasing (SNF P4P) / § 3006
Requires CMS to develop a plan to implement a "value based purchasing" program for SNFs. / Elise Smith, Sandra Fitzler, Bill Hartung / 10/1/11=Critical date for LTC providers:
P4P plan due to Congress. / Policy paper at
http://www.ahcancal.org/advocacy/Pages/PlanValueBasedPurchasingProgramforSkilledNursingFacilities.aspx. / Response to RTI International Interview February 27, 2011
Response to CMS Open Door Session - AHCA Technical Comments – CMS Value-Based Purchasing Implementation Plan, march 18, 2011
Shared Savings Program –Accountable Care Organizations (ACOs) / § 3022
Rewards ACOs that take responsibility for the costs and quality of care received by their patient panel over time. ACOs can include groups of health care providers (including physician groups, hospitals, nurse practitioners and physician assistants, and others). ACOs that meet quality-of-care targets and reduce the costs of their patients relative to a spending benchmark are rewarded with a share of the savings they achieve for the Medicare program. / Elise Smith / CMS must establish program by January 1, 2012 / March 31, 2001
CMS Issues Proposed ACO Proposed Rule
CMS/OIG issues Waiver Proposed Rule
IRS issues Tax-Exempt Proposed Rule
Joint FTC and DOJ Proposed Statement of Enforcement Policy -- Antitrust Policy Statement).
April, 2011 -- Added ACO responsibility to AHCA Bundling Work Group
May 31, and June 6, 2011 – AHCA submits comments on all proposed rules
March 17, 2011 IO Conference -- Session on ACOs
May 10,2011- State Executive Conference Call on ACOs, Mark Reagan, Nancy Rehkamp
May 18, 2011 – Webinar on ACOs,
Briefings to CPAC and the Board
Governor Mark Parkinson key address at Brookings ACO Summit -- Role of SNFs in the ACO
Medicare Bundling – National Pilot Program / § 3023
Establishes a Payment Bundling pilot to make all healthcare providers responsible during an episode of care by rewarding value over volume with incentives to coordinate patient care across the continuum of an entire episode of care. / Elise Smith, Bill Hartung,
Peter Gruhn,
Sandra Fitzler / 1/1/13=Critical date for LTC providers:
HHS must establish a national, voluntary pilot program on payment bundling. / Policy paper at
http://www.ahcancal.org/advocacy/Pages/NationalPilotProgramBundling.aspx. / On-going CMS discussions.
Bundling member/staff Work Group - bundling research and bundling policy development.
Independent Medicare Advisory Board / § 3403
Establishes a 15-member IPAB to extend Medicare solvency and reduce spending growth through the use of a spending target system and fast-track legislative approval process. / Bill Hartung, Elise Smith / 1/15/14=Critical date for LTC providers:
IPAB must develop and submit detailed proposals to Congress. / Policy paper at http://www.ahcancal.org/advocacy/Pages/IndependentPaymentAdvisory.aspx.
Medicare and Medicaid
CMS Medicare and Medicaid Innovation Center / §§ 3021
Expands HHS Secretary authority to resolve health care financing issues and to develop innovative methods for the administration of the Medicare and Medicaid programs. / Janice Zalen,
Steven Gregory / 1/1/11=Critical date for LTC providers:
CMS must establish CMI. / Policy paper at
http://www.ahcancal.org/advocacy/Pages/EstablishmentofCenterforMedicareandMedicaidInnovationWithinCMS.aspx. / AHCA web site on Innovation Center at http://www.ahcancal.org/facility_operations/medicaid/Pages/CenterforInnovation.aspx
Federal Coverage and Payment Coordination for Duals / § 2602
Establishes a coordinated health care office, called Medicare – Medicaid Coordination Office (MMCO) reporting to the CMS Administrator, with the purpose of ensuring that Medicare and Medicaid dual eligibles obtain full access to terms/services. / Steven Gregory, Janice Zalen / 3/1/10=Critical date for LTC providers:
New Federal Coordinated Health Care Office to provide coverage and payment coordination for dual eligibles. / Policy paper at
http://www.ahcancal.org/advocacy/Pages/NewFederalCoordinated.aspx.
Submitted response to MMCO’s Request for Information on aligning Medicare and Medicaid. / Contacted Melanie Bella and Jennifer Coleman re integrated care for duals. Met with Jennifer Coleman and Tim Englehardt and regular telephone and email communication continues. (July 18)
OTHER MEDICARE ISSUES
RACs – Extension to Medicaid and Medicare Parts C & D / § 6411
Expands the RAC program to Medicaid and Medicare Parts C and D. / Elise Smith / 4/1/11=Critical date for LTC providers:
CMS expects states to fully implement their RAC programs. / Medicaid Program; Recovery Audit Contactors, Proposed Rule, 75 Federal Register 69037 (November 10, 2010).
January 10, 2011, Comments on Medicaid Program; Recovery Audit Contactors, Proposed Rule,75 Federal Register 69037 (November 10, 2010)
Maximum Period of Submission for Medicare Claims / § 6404(a)
Reduces the maximum period for submission of Medicare claims to not more than 12 months from the date of service. / Elise Smith / 12/31/10=Critical date for LTC providers:
Reduced statutory timely filing deadline for Medicare fee-for-services claims under Medicare Parts A and B to one year. / Policy paper at
http://www.ahcancal.org/advocacy/pages/ReductionTimelyFilingMedicareClaims.aspx.
Follow-up CC articles:
1. CMS details new timely filing for Medicare claims at http://newsmanager.commpartners.com/ahcamemo/issues/2010-05-11/index.html. / On-going discussions with CMS.
Physician Assistants to Certify Need for Post Acute Care / § 3108
Allows a physician assistant who does not have a direct or indirect
employment relationship with a SNF, but who is working in collaboration with a physician, to
certify the need for post-hospital extended care services for Medicare payment purposes. / Elise Smith, Sandra Fitzler / 1/1/11=Critical date for LTC providers:
Physician assistants may order post-acute extended care services. / Policy paper at
http://www.ahcancal.org/advocacy/Pages/PhysicialAssistantCertifying.aspx. / 42CFR424.20(e)(2)
Issued in final rule November 29, 2010
Physician Fee Schedules and other revisions to Part B for CY 2011
Payment Adjustment for Conditions Acquired in Hospitals – Report on Extending to Other Providers (e.g., NFs) / § 3008
HHS Secretary must make recommendations
to expand Medicare’s health acquired condition payment policy to other
facilities, including IRFs, LTCHs, hospital outpatient departments, inpatient psychiatric facilities,
cancer hospitals, skilled nursing facilities, ambulatory surgery centers and health clinics. / Elise Smith,
Sandra Fitzler / 1/1/12=Critical date for LTC providers:
Report to Congress due.
2015=Critical date for LTC providers:
Implementation deadline. / Policy paper at
http://www.ahcancal.org/advocacy/Pages/PaymentAdjustmentsforHealthCareAcquiredConditions.aspx. / No report as yet.
Community-Based Care Transitions / § 3026
Establishes a five-year
Community Care Transitions Program under Medicare / Janice Zalen
Karl Polzer / 1/1/11=Critical date for LTC providers:
Implementation begins and lasts for a period of 5 years. / Policy paper at
http://www.ahcancal.org/advocacy/Pages/CommunityBasedCareTransitionsProgram.aspx.
Independence at Home Demo / § 3024
HHs Secretary must
conduct a Medicare demonstration program to test a
payment incentive and service delivery model that uses physician- and nurse practitioner-directed
home-based primary care teams designed to reduce expenditures and improve health outcomes in
the provision of items and services to certain chronically ill Medicare beneficiaries. / Janice Zalen, Karl Polzer / 1/1/12=Critical date for LTC providers:
Medicare demonstration program for chronically ill Medicare beneficiaries that test a payment incentive and service delivery model. / Policy paper at
http://www.ahcancal.org/advocacy/Pages/IndependentHomeMedicalPractice.aspx.
PHARMACY
Pharmacy Waste / § 3310
Requires Medicare Part D Plans to employ utilization management techniques to reduce the quantity dispensed per fill for beneficiaries who reside in LTC facilities. / Sandra Fitzler, / 1/1/12=Critical date for LTC providers:
Uniform dispensing techniques begin. / Policy paper at http://www.ahcancal.org/advocacy/Pages/ReducingWastefulDispensing.aspx.
Follow-up CC articles:
1.CMS short cycle dispensing proposed rule at http://newsmanager.commpartners.com/ahcamemo/issues/2010-12-03/7.html.
2. AHCA and Congress ask for delay in short cycle dispensing rule implementation at http://newsmanager.commpartners.com/ahcamemo/issues/2011-03-15/email.html
3. AHCA submits comments on Procedures for the Surrender of Unwanted Controlled Substances by Ultimate Users at http://newsmanager.commpartners.com/ahcamemo/issues/2011-01-14/5.html / CMS delays implementation short cycle dispensing for 1 year to Jan 1, 2013. Short cycle changes from 7 to 14 day, only branded oral solids. CMS states that it expects dispensing fees to double. No requirement to return unused meds to pharmacy but reporting requirement remains. CMS was persuaded by comments not to extend requirement to LTC and to work with industry stakeholders on more cost-effective approaches. Short cycle discussion is at pages 96-132,
http://www.ofr.gov/OFRUpload/OFRData/2011-08274_PI.pdf
Reduction in Coverage Gap – Part D / §§3301, 3315
§3301 provides $250 rebate check for part D enrollees who hit the gap in prescription drug coverage known as the “donut hole.” / Elise Smith / 1/1/10=Critical date for LTC providers:
Reduce amount Medicare Part D enrollees are required to pay for their prescriptions when they reach the coverage gap. / Policy paper at
http://www.ahcancal.org/advocacy/Pages/ChangestoMedicarePartDDrugBenefitCoverage.aspx. / Final Rule
76 Federal Register 21478, 21479, 42 CFR 423 104
Elimination of Exclusion of Coverage for Certain Drugs / § 2502
Medicaid programs can no longer exclude smoking cessation agents, barbiturates, and benzodiazepines from coverage under Medicaid. This provision results in a small expansion of Part D coverage of barbiturates. / Elise Smith, Sandra Fitzler / 1/1/14=Critical date for LTC providers:
Medicaid programs can no longer exclude certain drugs from coverage. / Policy paper at
http://www.ahcancal.org/advocacy/Pages/EliminationofMedicaidExclusionCoverageofCertainDrugs.aspx.
MEDICAID
MACPAC / § 2801
MACPAC reviews state and federal Medicaid access and payment policies and makes recommendations
to states, Congress and HHS secretary.
Section 2801 amends statutes related to
MACPAC, and requires a review of provider reimbursement