At the agencies
The Centers for Medicaid and Medicare Services (CMS) has released an interim final rule requiring dialysis facilities to educate patients on coverage options and alert issuers before patients change their coverage partway through the plan year. The rule is a response to firms who had been reportedly steering patients into buying private insurance rather than enroll in Medicaid or Medicare. During the public comment period, CMS received several comments pointing to the financial incentives firms receive by steering patients, despite the complications a patient’s course of care and increased spending can incur in commercial coverage.
On Dec. 16, CMS released the final 2018 notice of benefit and payment parameters, which outlines changes to the Affordable Care Act risk adjustment models, standardized plan benefits and special enrollment periods. Of the changes, the most significant is the decision to reduce statewide average premiums by 14 percent in the risk transfer formula to account for administrative costs. The final rule also lowers the threshold back down to $1 million but retains the 60 percent co-insurance rate. For states, the fee for state-based exchanges seeking to use the Healthcare.gov platform fell from a proposed 3 percent to 2 percent for 2018.
CMS announced on Dec. 15 that it would terminate the Part B drug price demonstration, a demonstration that the Obama Administration strongly supported despite resistance from the drug industry, patient advocates, Republicans and some Democrats. It was widely considered unsalvageable after Republicans gained control of Congress.
The Department of Health and Human Services (HHS) has finalized new Medicare alternative payment models (APMs) for cardiac and orthopedic care. The new bundle payment model goes into effect in 98 metropolitan areas in July 2017. The payment model provides Medicare incentives to clinicians who coordinate care and rehabilitation for patients receiving treatment for hip surgery, heart attacks, coronary bypass surgery and cardiac treatment. CMS reports that 70,000 clinicians could qualify for the program in 2018, joining 70,000-125,000 expected in APMs next year.
HHS has announced its selection of eight states for participation in a two-year Certified Community Behavioral Health Clinic (CCBHC) demonstration. The demonstration is designed to improve behavioral health services in the selected states of Minnesota, Missouri, New York, New Jersey, Nevada, Oklahoma, Oregon and Pennsylvania. The demonstration is engineered to “improve access to behavioral services for Medicaid and CHIP beneficiaries and will help individuals with mental and substance use disorders obtain the healthcare they need.” The program would allow the selected states to be reimbursed through Medicaid for behavioral health treatment, services and support to Medicaid-eligible beneficiaries using a prospective payment system.
On the Hill
On Dec. 13 President Obama signed 21st Century Cures into law and restored federal oversight to prevent insurance companies from discriminating against mental health treatments. The new law calls for HHS to release guidance on how health insurance companies should comply with existing mental health parity laws and grants the agency the authority to audit plans to ensure companies are complying. The law additionally provides funding for addressing the opioid crisis. The funding is intended to “supplement opioid abuse prevention and treatment activities, such as improving prescription drug monitoring programs, implementing prevention activities, training for healthcare providers and expanding access to opioid treatment programs.”
In the courts
The Third Circuit Court of Appeals has sided with HHS in its efforts to reduce Medicaid payments to Pennsylvania nursing homes, upholding a 2008 amendment to its state plan. The court said CMS had the authority to reopen its review of a decision made by state regulators and rely on data collected from the year the new policy had been in effect. The case developed from the Pennsylvania Department of Public Welfare’s decision to decrease the per diem reimbursement rates it was paying to private providers of nursing homes from 2008 and 2009. The original case had 53 nursing homes, which fell to 21 after a 2013 Third Circuit decision that sided with CMS.