CMS begins probe of providers who misdirect patients to individual market plans

On August 11, the Centers for Medicare and Medicaid Services (CMS) published a proposed rule that would update portions of its Programs of All-inclusive Care for the Elderly (PACE) in order to attract more state participation. The update plans to strengthen protections and improve care for aging and frail Medicare and Medicaid patients receiving medical care and social services at home, with the latest advances in care and technology. CMS also intends the update to come with greater administrative flexibility and regulatory relief for PACE organizations. It would also require PACE organizations to comply with Medicare Part D’s prescription drug program requirement.

On August 12, CMS published a proposed rule regarding disproportionate share hospital Medicaid payments. CMS is seeking to clarify that Medicaid disproportionate share hospital payments are to be based only on uncompensated care costs for Medicaid eligible patients who are not covered by another source. The proposed rule seeks to eliminate inflation in uncompensated care by hospitals who had calculated their disproportionate share payments, while excluding costs and payments from Medicaid eligible patients with third party coverage.

On August 18, CMS released its Prescription Drug Data for prescription drugs paid under Medicare Part D in 2014. The release, which included data from over one million healthcare providers, chronicles the approximate $121 billion in prescription drug costs for Medicare Part D enrollees who constitute 70 percent of all Medicare beneficiaries. The data shows a 17 percent increase in prescription drug cost in comparison to 2013’s data set and contains new aggregate information on opioids, antibiotics, antipsychotics, and high risk medication among senior citizens.

On August 18, CMS announced it is seeking information regarding reports of some healthcare providers directing Medicaid and Medicare eligible, or current, patients to ACA-compliant individual market plans. According to CMS this practice results in higher reimbursement rates for providers, while raising overall costs in the healthcare system. CMS is additionally encouraging authorities to impose civil monetary penalties for providers who delayed Medicare eligible patients from enrolling in Medicare by directing them to individual market plans first.

A new report from the Government Accountability Office calls for greater focus in verifying underlying sales price data for Medicare Part B prescription drug reimbursement determination. The report examines Part B spending for 2014, and the 551 Part B drugs that were paid based on average sales price of that year. The report cites six drugs as responsible for 37 percent of the $21 billion Part B prescription drug spending, despite not being among the most frequently prescribed drugs.  

CMS’s Nursing Home Five-Star Quality Ratings on its Nursing Home Compare web tool have been updated to include new metrics. Visitors to the website can now view new information on successful discharges, re-hospitalizations and quality of care at the listed Medicaid and Medicare certified facilities. CMS expects the new metrics to change existing nursing home ratings on the Nursing Home Compare tool.

The Department of Health and Human Services released data showing medical costs for Obamacare exchange customers dropped by 0.1 percent from 2014 to 2015. This is contrary to the 3 percent increase found in the broad health insurance market. Within states with substantial growth in exchanges, medical costs were found to have an average decrease of 5 percent. The decrease suggests risk pools within exchanges improved during the second year of enrollment, counter to claims by some insurers of rising costs.

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