CMS has put on display a proposed rule that would update Medicare Advantage (MA) and Medicare Part D prescription drug benefit policies for contract year 2021 and 2022.  CMS projects that its proposed policies would decrease federal spending by $4.4 billion over 10 years, primarily as a result of a proposal to remove outliers prior

The Centers for Medicare & Medicaid Services (CMS) has issued a final rule updating Medicare end-stage renal disease (ESRD) prospective payment system (PPS) rates for 2020 – which CMS expects to increase total payments to ESRD facilities by 1.6% compared with 2019.  The final 2020 ESRD PPS base rate is $239.33, compared with the 2019

The Centers for Medicare & Medicaid Services (CMS) has proposed updating Medicare end-stage renal disease (ESRD) prospective payment system (PPS) rates by 1.7% for calendar year 2020.  This update reflects a proposed 2.1% market basket increase, partially offset by a -0.4% productivity adjustment.  After application of a wage index budget-neutrality adjustment, the proposed CY 2020

The Trump Administration has announced a number of policy goals and innovation models that seek to “improve the lives of Americans suffering from kidney disease, expand options for American patients, and reduce healthcare costs,” according to the Department of Health and Human Services (HHS).  The broad policy framework was outlined in an executive order on

The Centers for Medicare & Medicaid Services (CMS) has issued its final Medicare end-stage renal disease (ESRD) prospective payment system (PPS) rates and policies for calendar year 2018. CMS projects that the final rule will increase total Medicare payments to all ESRD facilities by 0.5% in 2018 (lower than the 0.8% increase forecast in the

The White House Office of Management and Budget (OMB) is reviewing several CMS rules that would finalize CY 2018 Medicare payment policies for various types of providers and suppliers. Specifically, OMB is reviewing final rules to update the hospital outpatient and ambulatory surgical center PPS; the Medicare physician fee schedule and physician Quality Payment Program;

While the Capitol Hill spotlight is focused on the Senate debate on legislation to repeal or revise the Affordable Care Act, the House of Representatives quietly approved by voice vote HR 3178, the Medicare Part B Improvement Act of 2017. The bipartisan bill would impact a number of Medicare policies, including the Stark physician self-referral law, home infusion therapy and dialysis service policies, and documentation requirements for orthotics and prosthetics. In particular, the bill would:
Continue Reading With All Eyes on Senate ACA-Repeal Debate, House Passes Bill to Tweak Stark Law and Other Medicare Part B Policies

The Centers for Medicare & Medicaid Services (CMS) has published a proposed rule to update the Medicare end-stage renal disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2018. CMS anticipates that the proposed rule would increase total Medicare payments to ESRD facilities by 0.8% in 2018, with hospital-based ESRD facilities having an

Citing “differences between providers’ and suppliers’ financial interests and patients’ interests” that “may result in providers and suppliers taking actions that put patients’ lives and wellbeing at risk,” CMS is imposing stringent new requirements on Medicare-certified dialysis facilities that seek to make payments of premiums for individual market health plans.

By way of background, earlier this year CMS received anecdotal reports that some dialysis providers were paying Medicare- or Medicaid-eligible patients’ private insurance premiums to take advantage of higher private payer reimbursement rates. According to a CMS fact sheet, individual market reimbursement for dialysis treatment can be four times higher than Medicare and Medicaid rates – a difference of $100,000 to $200,000 or more per patient per year, which “easily dwarfs the several thousand dollar cost of providing premium assistance.” CMS published a request for information on August 23, 2016 to receive more information on the prevalence of such arrangements, which CMS believed could increase health system costs and be financially disadvantageous for beneficiaries.

In an interim final rule with comment period published December 14, 2016, CMS states that commenters indicated widespread facility involvement in end-stage renal disease (ESRD) patients’ coverage decisions. While the agency acknowledged receiving letters from patients satisfied with such premium arrangements, CMS cited other commenters who documented that providers and suppliers were “influencing enrollment decisions in ways that put the financial interest of the supplier above the needs of patients.” Commenters argued that such arrangements can harm patients by negatively impacting their determination of readiness for a kidney transplant; potentially exposing patients to additional costs for health care services; and putting them at significant risk of a mid-year disruption in health care coverage.Continue Reading Conflict of Interest Concerns Prompt New CMS Restrictions on Dialysis Facility Payment of Beneficiary Health Plan Premiums; Allows Plans to Reject Third-Party Payments

Included in the 21st Century Cures Act are numerous changes to Medicare and Medicaid policies, including provisions with significant reimbursement impacts for certain types of Medicare providers and suppliers, along with changes intended to reduce the regulatory and administrative burdens associated with the use of electronic health records.  Furthermore, the law once again expands the

CMS has issued a proposed rule that would require certain dialysis facilities participating in Medicare or Medicaid to meet updated fire safety standards.  The proposed fire safety rule, published November 4, 2016, would apply only to dialysis facilities that do not provide one or more exits to the outside at grade level from the treatment

The Centers for Medicare & Medicaid Services (CMS) has released a long-awaited final rule establishing emergency preparedness requirements for Medicare- and Medicaid-participating providers and suppliers to ensure that they can meet the needs of patients and residents during emergency situations, both natural and man-made. According to CMS, the final requirements “establish a comprehensive, consistent, flexible, and dynamic regulatory approach to emergency preparedness and response that incorporates the lessons learned from the past, combined with the proven best practices of the present.”  CMS projects that compliance with the rule will cost $373 million in the first year, with subsequent annual costs of approximately $25 million.

The new requirements apply to 17 provider types (with certain variations): hospitals; critical access hospitals (CAHs); long-term care (LTC) facilities; psychiatric residential treatment facilities; intermediate care facilities for individuals with intellectual disabilities; religious nonmedical health care institutions; transplant centers; hospices; ambulatory surgical centers; Program for the All-inclusive Care for the Elderly (PACE) organizations; home health agencies; comprehensive outpatient rehabilitation facilities; community mental health centers; organ procurement organizations; clinics, rehabilitation, and therapy providers; rural health clinics/federally qualified health clinics; and end-stage renal disease providers.

The sweeping final rule (the advance version spans 651 pages) covers four aspects of emergency preparedness:
Continue Reading CMS Finalizes Emergency Preparedness Requirements for Medicare/Medicaid Providers

Congress has returned from recess, and health care policy continues to be on the agenda. The following health-related hearings and markups were held this week:

  • The House Ways and Means Committee approved H.R. 5942, a bill to establish a demonstration program to provide integrated care for Medicare beneficiaries with end-stage renal disease, and H.R. 954, the “CO-OP Consumer Protection Act of 2016,” which would provide an exemption from the requirement to maintain minimum essential coverage if an individual’s Consumer Operated and Oriented Plan (CO-OP) coverage is terminated.
  • The Ways and Means Health Subcommittee held a hearing on “the Evolution of Quality in Medicare Part A.”
  • The House Budget Committee examined the CMS Center for Medicare & Medicaid Innovation: Scoring Assumptions, and Real World Implications.
  • The House Energy and Commerce Health Subcommittee held a legislative hearing on bipartisan bills intended to improve public health, including: H.R. 1192, the National Diabetes Clinical Care Commission Act; H.R. 1807, the Sickle Cell Disease Research Surveillance, Prevention and Treatment Act; H.R. 3119, the Palliative Care and Hospice Education and Training Act; and H.R. 3952, the Congenital Heart Futures Reauthorization Act.

Continue Reading Congressional Health Policy Hearings, Markups Resume After Summer Break

CMS is putting health care providers on notice that it considers it “inappropriate” for providers to offer premium or cost-sharing assistance to Medicare or Medicaid beneficiaries in order to “steer” the patient to an individual market plan “for a provider’s financial gain.”  In a request for information to be published on August 23, 2016, CMS cites anecdotal reports that some health care providers have determined that private plan rates are sufficiently high compared to Medicare or Medicaid reimbursement to allow a provider to pay a Medicare- or Medicaid-eligible patient’s private insurance premiums and still benefit financially.
Continue Reading CMS Flags Potential Provider “Steering” of Medicare/Medicaid Beneficiaries to Favorable ACA Marketplace Plans to Obtain Higher Rates

On July 13, 2016, the Ways and Means Committee approved HR 5659, which would enable Medicare beneficiaries with end stage renal disease (ESRD) to enroll in Medicare Advantage plans. Earlier this month, the Committee approved HR 5613, to prevent CMS from enforcing a Medicare requirement for direct physician supervision of certain outpatient therapeutic services furnished

The Centers for Medicare & Medicaid Services (CMS) has published its proposed rule to update the Medicare end-stage renal disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2017. CMS anticipates that the proposed rule would increase overall Medicare payments to ESRD facilities by 0.5 percent in 2017 compared with CY 2016 levels (with a slightly higher increase – 0.7 percent — for hospital-based ESRD facilities). This update reflects a 0.35 percent market basket increase and the application of wage index and self-dialysis training budget-neutrality adjustment factors. The proposed CY 2017 ESRD PPS base rate is $231.04, compared to the CY 2016 base rate of $230.39.
Continue Reading CMS Issues Proposed CY 2017 Medicare ESRD PPS Update