CMS to create new settlement options for providers

At the agencies

The Centers for Medicare and Medicaid Services (CMS) announced that it will create a new settlement option for providers with fewer than 500 Part A or B appeals pending in the Departmental Appeals Board’s Medicare Appeals Council and the Office of Medicare Hearing and Appeals (OMHA). To qualify, the total billed amount must be $9,000 or less per appeal. CMS will settle appeals at 62 percent of the net allowed amount, compared to 68 percent and 66 percent under two previous hospital appeals settlement regarding patient status reviews. OMHA also announced it will expand its Settlement Conference Facilitation Program, an alternate dispute-resolution process for Part A and B appeals. The new settlement option comes amidst the Department of Health and Human Services’ (HHS) difficulties reducing the Medicare appeals backlog, which it says exceeds OMHA’s capacity despite efforts to reduce incoming appeals.

CMS recently confirmed in its 2019 draft letter to insurers participating in the federal exchanges that issuers would continue cost-sharing reduction (CSR) payments to consumers. Reimbursements to issuers, however, will still depend on congressional appropriations. Other policies in the letter resemble past years, including the application window for issuers to submit Qualified Health Plan (QHP) applications, which will go from May 9 to June 20. CMS also plans to give states more control over designing QHPs and will defer to states to review federally-facilitated exchanges (FFEs) when determining a plan’s minimum geographic area. Furthermore, CMS is considering expanding states’ role in QHP certification reviews for quality improvement strategy (QIS). Prior to implementing rate increases, QHPs will have to submit a rate filing justification, and rate increases will have to be taken into consideration by exchanges when certifying plans as QHPs. 

On the Hill

The House and Senate each passed tax reform legislation and conferees have been announced for the conference committee responsible for reconciling the differences in the House and Senate bills. One difference is the repeal of the Affordable Care Act’s individual mandate, a provision that was included in the Senate bill but not the House bill. There are ongoing negotiations about how to stabilize the insurance market, including funds for reinsurance programs and cost-sharing reductions, but it remains unclear what the final compromise will be. It is highly likely that the individual mandate will be repealed as a part of tax reform, and the conference committee is expected to resolve the differences by the end of the year.

The House and Senate passed a two-week spending bill, which includes authorization for states to use existing Children’s Health Insurance Program (CHIP) funding, but it did not authorize new federal funding. Due to the limited authorization, many states will begin to run out of funding in early 2018. Congress is aware of the need to authorize additional spending and is planning to pass a more robust CHIP extension with the larger spending bill. There is little information about the status or content of that spending bill.


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