Archives: Other CMS Developments

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CMS Considering New Medicare Advantage Payment Arrangement Incentive (MAQI) Demonstration

CMS is planning a new “Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration” that would allow clinicians who participate in certain Medicare Advantage (MA) plans that involve taking on risk to be treated as Advanced Alternative Payment Model (Advanced APM) participants under the Medicare physician fee schedule. By way of background, the Medicare Access and … Continue Reading

CMS Announces First Rural Health Strategy

 CMS has released an-agency-wide Rural Health Strategy that seeks to “better serve individuals in rural areas and avoid unintended consequences of policy and program implementation.” The Strategy has five objectives: Apply a rural lens to CMS programs and policies (e.g., apply a new checklist to relevant policies, procedures, and initiatives that impact rural communities) Improve … Continue Reading

CMS Floats Concept of Direct Provider Contracting Innovation Model, Posts Comments on “New Direction” RFI

Last fall, CMS requested public comments on the CMS Innovation Center’s “New Direction,” under which CMS will seek to “promote patient-centered care and test market-driven reforms.” In the interest of transparency and to facilitate discussion, CMS has posted a summary of the more than 1,000 comments it received from medical societies, providers, manufacturers, and other … Continue Reading

New CMS Guidance for ADLT Lab Tests and ADLT Application Released

CMS is still rolling out policies and procedures to fully implement the major clinical laboratory payment reforms mandated by the Protecting Access to Medicare Act of 2014 (PAMA). As previously reported, the June 23, 2016 final PAMA rule established the framework for basing Medicare clinical laboratory fee schedule (CLFS) payment on private insurance payment amounts, with … Continue Reading

CMS Gives Providers More Time to Consider Low Volume Appeals (LVA) Initiative Participation

CMS has extended until June 8, 2018 the deadline to submit an expression of interest (EOI) for the Low Volume Appeals Initiative. As previously reported, the LVA option is available for providers, physicians, and suppliers with fewer than 500 total Medicare Part A or Part B claim appeals pending at the Office of Medicare Hearings … Continue Reading

CMS Appoints Ombudsman to Handle Pharmaceutical/Technology Industry Concerns

James Bailey is the new CMS Medicare Pharmaceutical and Technology Ombudsman, a role Congress established in the 21st Century Cures Act to help expedite resolution of industry Medicare reimbursement concerns. The Ombudsman’s office is charged with fielding questions from pharmaceutical, biotechnology, medical device, diagnostic product manufacturers, and other stakeholders regarding Medicare coverage, coding, and payment … Continue Reading

CMS Releases Proposed 2019 Medicare Advantage/Part D Reimbursement Methodologies and Policies

CMS is seeking comments on its proposed updates to the methodologies used to pay Medicare Advantage (MA) and Part D plan sponsors for 2019.  This year CMS released its 2019 Advance Notice and Draft Call Letter in two parts.  In late 2017, CMS released proposed changes to the Part C risk adjustment model (Part I … Continue Reading

Trump Administration Proposes Rules to Expand Short-Term, Limited Duration Insurance Plans

The Trump Administration has issued a potentially highly-significant proposed rule intended to expand the availability of short-term, limited duration insurance policies that are exempt from Affordable Care Act (ACA) qualified health plan standards.  Under the proposed rule, issued by the Departments of Treasury, Labor, and Health and Human Services (the “Departments”), the maximum duration of … Continue Reading

CMS Cancels Another Pending CMS Innovation Project: the Direct Decision Support (DDS) Model

CMS will not proceed with its planned Direct Decision Support (DDS) innovation model “due to operational and technical issues with the proposed Model design.” When this model was announced in December 2016, it was expected to test a shared decision-making approach outside of the clinical delivery system. On February 2, 2018, CMS announced that it has … Continue Reading

VA and HHS Team Together to Combat Health Care Fraud, Waste, and Abuse

The Department of Veterans Affairs (VA) and the Centers for Medicare & Medicaid Services (CMS) have announced a partnership to leverage CMS’s program integrity tools to detect and prevent fraud within VA programs.  The collaboration will focus on applying state-of-the-art data analytics tools and best practices identified by CMS to VA claims payment processes.  In … Continue Reading

Trump Administration Unveils Its First Bundled Payment Initiative — BPCI Advanced

The Trump Administration has rolled out its first CMS Innovation Center Medicare bundled payment initiative, the Bundled Payments for Care Improvement Advanced (BPCI Advanced). Under the new voluntary model, CMS will test whether bundled payments for 29 inpatient and 3 outpatient clinical episodes will lead to reduced Medicare expenditures while improving quality of care for … Continue Reading

CMS Clears the Way for States to Add Medicaid Work/Community Engagement Requirements

CMS has announced a new initiative allowing states to propose demonstrations to “improve Medicaid enrollee health and well-being through incentivizing work and community engagement.” Specifically, states may propose Section 1115 waivers to make participation in work or other community engagement a requirement for continued Medicaid eligibility or coverage for non-elderly, non-pregnant adult Medicaid beneficiaries who … Continue Reading

CMS Gives States Options for Complying with Cures Act Mandate to Cap Medicaid DME Rates

As previously reported, the 21st Century Cures Act prohibits federal financial participation (FFP) payments to the states for certain Medicaid durable medical equipment (DME) expenditures that exceed what Medicare would have paid for such items, either on a fee schedule basis or under competitive bidding.  The provision is effective January 1, 2018. CMS recently provided … Continue Reading

CMS Finalizes Medicare Clinical Lab Fee Schedule for 2018

CMS has issued final 2018 Medicare clinical laboratory fee schedule (CLFS) rates, which are based on private payer data as mandated by the Protecting Access to Medicare Act of 2014 (PAMA).  A companion document explains changes the agency made in response to public comments on the September 2017 preliminary rates and clarifying its methodology.  In addition, … Continue Reading

CMS Releases 2018 HCPCS Update

The 2018 update to the alphanumeric Healthcare Common Procedure Coding System (HCPCS) files is now available on the CMS website.  The files include the Level II alphanumeric HCPCS procedure and modifier codes, their long and short descriptions, and information on Medicare coverage and pricing.  CMS also has begun posting application summaries for HCPCS applications discussed … Continue Reading

CMS Releases 2018 Open Payments/Sunshine Act Reporting Thresholds

CMS has announced inflation-adjusted de minimis reporting thresholds for 2018 under the Open Payments/Physician Payments Sunshine Act program.  Specifically, payments or transfers of value of less than $10.49 do not need to be reported in 2018, except when the total annual value of payments or other transfers of value to a covered recipient exceeds $104.90.  … Continue Reading

Medicare Clinical Lab Fee Schedule Payments to Fall by $670 Million in 2018 Under Preliminary PAMA Rates

CMS has posted preliminary Medicare clinical laboratory fee schedule rates for 2018 – the first year rates will be based on private payer data under the Protecting Access to Medicare Act of 2014 (PAMA). CMS estimates that 2018 Medicare Part B payments will be reduced by about $670 million for calendar year 2018. In fact, … Continue Reading

CMS Calls for “New Direction” for Innovation Center, Invites Ideas for New Payment Models

The Centers for Medicare & Medicaid Services (CMS) has announced a “new direction” for the CMS Innovation Center that is intended to “promote patient-centered care and test market-driven reforms.” The goal of these reforms – which may be tested on a smaller scale than current innovation models – is to “empower beneficiaries as consumers, provide price … Continue Reading

CMS Unveils New Medicare Beneficiary Card, Encourages Providers to Prepare Systems for Transition to New Numbers

In order to protect Medicare beneficiaries from fraud and identity theft, CMS has unveiled a new Medicare card that removes the beneficiary’s Social Security number from the card. Specifically, the current Social Security-based number – the Health Insurance Claim Number or HICN – is being replaced with a randomly-assigned Medicare Beneficiary Identifier (MBI) beginning in … Continue Reading

No IPAB Medicare Cuts Triggered for 2019, CMS Actuary Rules

The CMS Chief Actuary has officially determined that the projected Medicare per capita growth rate will not exceed the target that would require the Independent Payment Advisory Board (IPAB) to submit plans to reduce 2019 Medicare per-capita spending. Under the Affordable Care Act, if the threshold is breached, IPAB must submit detailed Medicare spending cut … Continue Reading

CMS Finalizes Changes to Payment Error Rate Measurement (PERM) & Medicaid Eligibility Quality Control (MEQC) Programs

CMS has published a final rule that modifies PERM and MEQC regulations to align with changes to how states adjudicate Medicaid and CHIP eligibility under the Affordable Care Act (ACA). According to CMS, the policy revisions are intended to “reduce state burden, improve program integrity, and promote state accountability.” Among other things, the rule changes … Continue Reading

CMS Announces Summer Meetings on 2018 Clinical Lab Fee Schedule Update

CMS has scheduled two days of meeting this summer on updates to the Medicare clinical laboratory fee schedule (CLFS) for 2018. First, the public meeting on payment amounts for new or substantially revised HCPCS codes being considered for Medicare payment under the 2018 CLFS will be held on July 31, 2017. This meeting also will … Continue Reading

CMS Expects Almost All Eligible Clinicians in Advanced APMs to Meet Qualifying APM Participant Status for 2017

CMS expects nearly 100% of eligible clinicians in Advanced Alternative Payment Models (APMs) to meet the Medicare Qualifying APM Participant (QP) standard for performance year 2017 and be eligible to receive a 5% APM incentive payment in 2019 under Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) rules. This projection is based on an … Continue Reading
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