Demonstration Projects

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The Centers for Medicare & Medicaid Services (CMS) has announced a controversial plan to allow states to apply to participate in a new Medicaid “Healthy Adult Opportunity” (HAO) Demonstration.  In short, the HAO Demonstration will give participating states greater flexibility in the scope and administration of Medicaid benefits for certain beneficiary populations (i.e., the Affordable…

CMS has announced that it is “pausing” its Pre-Claim Review demonstration in Illinois for at least 30 days, effective April 1, 2017, and it is not expanding the demonstration to Florida in April as previously planned. During this pause period, Medicare contractors will not accept additional pre-claim review requests; instead, home health claims will be…

President Obama has signed into law S. 2873, the Expanding Capacity for Health Outcomes Act (ECHO Act), which is intended to use “distance health education” to improve health care, particularly in medically-underserved areas.  Specifically, this program will test “technology-enabled collaborative learning and capacity building models” – or the use of simultaneous interactive videoconferencing to connect …

CMS has announced a new three-year Medicare “pre-claim review” demonstration for home health services in five states — Illinois, Florida, Texas, Michigan, and Massachusetts  — with “high incidences of fraud and improper payments for these services.”  The pre-claim review demonstration requires currently-mandated documentation to be furnished to the Medicare Administrative Contractor (MAC) earlier in the claims payment process.  The initiative does not require the home health agencies (HHAs) to wait for a determination prior to furnishing services, however, nor does it modify the scope of the Medicare home health services benefit.  CMS expects this initiative to “bolster the efforts that CMS and its partners have taken in implementing a series of anti-fraud initiatives in these states,” such as the use of temporary moratoria on the enrollment of new home health providers in selected geographic areas.
Continue Reading CMS Announces Pre-Claim Review Demonstration for Medicare Home Health Services

CMS has announced that it is extending its Medicare Prior Authorization for Power Mobility Devices (PMDs) demonstration for three years, through August 31, 2018. This demonstration was launched on September 1, 2012 in seven states that CMS describes as having “high levels of improper payments and incidents of fraud related to PMDs” – California, Illinois,…

A House Ways and Means Subcommittee on Oversight hearing recently reviewed the effects of the Affordable Care Act (ACA) on health insurance premiums.  In addition, a House Energy and Commerce Health Subcommittee hearing examined the Obama Administration’s approval of Medicaid demonstration projects.   The Energy and Commerce Health Subcommittee also reviewed three bipartisan bills that aim…

The CMS Independence at Home Demonstration saved more than $25 million during its first performance year while delivering high-quality patient care, according to a June 18, 2015 CMS announcement. The Independence at Home Demonstration is an ACA innovation model testing the effectiveness of delivering comprehensive primary care services at home to Medicare beneficiaries with multiple…

On June 24, 2015, the House Energy and Commerce Health Subcommittee is holding a hearing to examine the Obama Administration’s approval of Medicaid demonstration projects. According to a background memo, the panel will focus on the following questions:
Continue Reading Energy & Commerce Committee Hearing on Administration’s Approval of Medicaid Demonstrations

A recent GAO report examined expenditure authorities in “section 1115” demonstrations approved by HHS between June 2012 and October 2013. Section 1115 of the Social Security Act gives HHS broad authority to approve “expenditure authorities” that allow states to receive federal funds for costs that would not otherwise be matchable under Medicaid if the Secretary…

CMS has scheduled a series of provider calls in February and March on the following topics:

  • February 3: Special Open Door Forum on the upcoming Prior Authorization of Non-Emergent Hyperbaric Oxygen Therapy model to be implemented in March in Illinois, Michigan, and New Jersey.
  • February 4: Special Door Forum on the introduction of star ratings

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In light of government reports finding high utilization and potential improper Medicare payments associated with repetitive scheduled nonemergent ambulance transports, CMS will test a prior authorization model program for these services in New Jersey, Pennsylvania, and South Carolina. CMS defines repetitive ambulance service as medically necessary ambulance transportation that is furnished in 3 round trips…

CMS is seeking input on potential initiatives to test innovative models that increase the engagement of Medicare, Medicaid, and/or Children’s Health Insurance Program (CHIP) beneficiaries in their health and health care. CMS is especially interested in models that use evidence-based social and behavioral insights to improve beneficiary involvement in behaviors and activities meant to improve…

CMS has announced a new “Medicare Intravenous Immune Globulin (IVIG) Demonstration” that will evaluate the potential benefits of providing payment for items and services needed for in-home administration of IVIG for the treatment of primary immune deficiency disease (PIDD). Under this demonstration, which will last three years, Medicare will provide a bundled Part B payment…

CMS is hosting a conference call on Tuesday, August 12, 2014 to discuss its planned expansion of its current demonstration project testing a prior authorization (PA) process for Medicare power mobility device claims.  This demonstration was launched on September 1, 2012 in seven states with what CMS describes as “high populations of fraud- and…

On July 14, 2014, HHS announced a $100 million Medicaid Innovation Accelerator Program to assist state health system reform efforts designed to improve health care while reducing costs. The initiative, which is intended to complement other federal-state delivery system reform efforts, will “help jumpstart innovation” by providing data analytics, quality measurement, and other technical supports…

CMS is hosting a Special Open Door Forum on June 17, 2014 to provide an overview regarding new Medicare prior authorization initiatives impacting durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) suppliers and ambulance suppliers. Specifically, the call will cover the Medicare Expanded Prior Authorization Demonstration for Power Mobility Devices (PMDs) Demonstration, the Hyperbaric Oxygen…

CMS has announced what it is describing as a “limited demonstration” of an internet-based notice and comment mechanism on requests to discontinue Level II HCPCS codes. The internet-based process would apply to HCPCS discontinuation requests that are generated by CMS based on national program operating needs, and that are not the subject of other…