Proposed Update to Physician Fee Schedule is First Since Repeal of SGR
Today, CMS released the first proposed update to the physician payment schedule since the repeal of the Sustainable Growth Rate through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The proposal includes a number ofprovisions focused on person-centered care, and continues the Administration’s commitment to transform the Medicare program to a system based on quality and healthy outcomes.
“CMS is building on the important work of Congress to shift the Medicare program toward a system that rewards physicians for providing high quality care,” said Andy Slavitt, Administrator of CMS. “Thanks to the recent landmark Medicare and children’s health insurance program legislation, CMS and Congress are working together to achieve a better Medicare payment system for physicians and the American people.”
In the proposed CY 2016 Physician Fee Schedule rule, CMS is also seeking comment from the public on implementation of certain provisions of the MACRA, including the new Merit-based Incentive payment system (MIPS). This is part of a broader effort at the Department to move the Medicare program to a health care system focused on the delivery of quality care and value.
The proposed rule includes updates to payment policies, proposals to implement statutory adjustments to physician payments based on misvalued codes, updates to the Physician Quality Reporting System, which measures the quality performance of physicians participating in Medicare, and updates to the Physician Value-Based Payment Modifier, which ties a portion of physician payments to performance on measures of quality and cost. CMS is also seeking comment on the potential expansion of the Comprehensive Primary Care Initiative, a CMS Innovation Center initiative designed to improve the coordination of care for Medicare beneficiaries.
The proposed rule also seeks comment on a proposal that supports patient- and family-centered care for seniors and other Medicare beneficiaries by enabling them to discuss advance care planning with their providers. The proposal follows the American Medical Association’s recommendation to make advance care planning services a separately payable service under Medicare.
The release of the rule triggers a 60-day comment period, during which time CMS welcomes the input of stakeholders and the public. A final rule will be published this fall. For a fact sheet on the proposed rule, please see here. For further information, please see the rule on display here.
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Jun 11, 2015
A key provision of the Affordable Care Act (ACA) is the requirement that private insurance plans cover recommended preventive services without any patient cost-sharing.1 Research has shown that evidence-based preventive services can save lives and improve health by identifying illnesses earlier, managing them more effectively, and treating them before they develop into more complicated, debilitating conditions, and that some services are also cost-effective.2 However, costs do prevent some individuals from obtaining preventive services (Figure 1). The coverage requirement aims to remove cost barriers.
ACA Requirements for Coverage of Preventive Services
Under Section 2713 of the ACA, private health plans must provide coverage for a range of preventive services and may not impose cost-sharing (such as copayments, deductibles, or co-insurance) on patients receiving these services.3 These requirements apply to all private plans – including individual, small group, large group, and self-insured plans in which employers contract administrative services to a third party payer – with the exception of those plans that maintain “grandfathered” status. In order to have been classified as “grandfathered,” plans must have been in existence prior to March 23, 2010, and cannot make significant changes to their coverage (for example, increasing patient cost-sharing, cutting benefits, or reducing employer contributions). In 2014, 26% of workers covered in employer sponsored plans were still in grandfathered plans,4 and it is expected that over time almost all plans will lose their grandfathered status.
The required preventive services come from recommendations made by four expert medical and scientific bodies – the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices (ACIP), the Health Resources and Services Administration’s (HRSA’s) Bright Futures Project, and HRSA and the Institute of Medicine (IOM) committee on women’s clinical preventive services. The requirement that insurers cover preventive services recommended by the USPSTF, ACIP, and Bright Futures program went into effect for non-grandfathered plans with plan-years beginning on or after September 23, 2010. The coverage requirements for women’s clinical preventive services became effective for plans starting on or after August 1, 2012. New or updated recommendations issued by these expert panels are required to be covered without cost-sharing in the plan year that begins on or after exactly one year from the new recommendation’s issue date.5 Individual and small group plans in the new health insurance marketplaces are also required to cover an essential health benefit (EHB) package – in addition to the full range of preventive requirements described in this fact sheet. There is some crossover as several of the specific preventive services fall into the EHB categories. However, only preventive services recommended by one of the four groups discussed in this factsheet are covered without cost-sharing.
Clinical Preventive Services for Adults and Children
The ACA requires private plans to cover the following four broad categories of services for adults and children (summarized in Tables 1 and 2):
I. Evidence-Based Screenings and Counseling
Insurers now must cover evidence-based services for adults that have a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF), an independent panel of clinicians and scientists commissioned by the Agency for Healthcare Research and Quality. An “A” or “B” letter grade indicates that the panel finds there is high certainty that the services have a substantial or moderate net benefit. The services required to be covered without cost-sharing include screening for depression, diabetes, cholesterol, obesity, various cancers, HIV and sexually transmitted infections (STIs), as well as counseling for drug and tobacco use, healthy eating, and other common health concerns.
II. Routine Immunizations
Health plans must also provide coverage without cost-sharing for immunizations that are recommended and determined to be for routine use by the Advisory Committee on Immunization Practices, a federal committee comprised of immunization experts that is convened by the Centers for Disease Control and Prevention. These guidelines require coverage for adults and children and include immunizations such as influenza, meningitis, tetanus, HPV, hepatitis A and B, measles, mumps, rubella, and varicella.
III. Preventive Services for Children and Youth
The ACA requires that private plans cover without cost-sharing the preventive services recommended by the Health Resources and Services Administration’s (HRSA’s) Bright Futures Project, which provides evidence-informed recommendations to improve the health and wellbeing of infants, children, and adolescents. The preventive services to be covered for children and adolescents include some of the immunization and screening services described in the previous two categories, behavioral and developmental assessments, iron and fluoride supplements, and screening for autism, vision impairment, lipid disorders, tuberculosis, and certain genetic diseases.
IV. Preventive Services for Women
The recommendations issued by USPSTF, ACIP, and Bright Futures predate the ACA. In addition to these services, the ACA authorized the federal Health Resources and Services Administration (HRSA) to make additional coverage requirements for women. Based on recommendations by a committee of the Institute of Medicine (IOM),6 federal regulations require new private plans to cover additional preventive services without cost-sharing for women, including well-woman visits, all FDA-approved contraceptives and related services, broader screening and counseling for STIs and HIV, breastfeeding support and supplies, and domestic violence screening.
Coverage Rules and Implementation Challenges
While the ACA aims to reduce the burden of cost and increase use of preventive services, there are certain rules that both plans and policy holders must follow. There are circumstances, however, under which insurers may charge copayments and use other forms of cost-sharing when paying for preventive services. These include:
* If the office visit and the preventive service are billed separately, the insurer may still impose cost-sharing for the office visit itself.
* If the primary reason for the visit is not the preventive service, patients may have to pay for the office visit.
* If the service is performed by an out-of-network provider when an in-network provider is available to perform the preventive service, insurers may charge patients for the office visit and the preventive service. However, if an out-of network provider is used because there is no in-network provider able to provide the service then cost-sharing cannot be charged.
* If a treatment is given as the result of a recommended preventive service, but is not the recommended preventive service itself, cost-sharing may be charged.7
The Public Health Service (PHS) Act and federal regulations also allow plans to use “reasonable medical management” techniques to determine the frequency, method, treatment, or setting for a preventive item or service to the extent it is not specified in a recommendation or guideline.8 While there is no formal regulatory definition or parameters for reasonable medical management, medical management techniques are typically used by plans to control cost and utilization of care or comparable drug use. For example, plans can impose limits on number of visits or tests if unspecified by a recommendation, cover only generics or selected brands of pharmaceuticals, or require prior authorization to acquire a preferred brand drug.
The combination of these caveats and limitations has resulted in many questions about how plans should implement the preventive services policy. In particular, questions have arisen about the frequency, range of methods that can be used for certain services, and the types of providers that are subject to the policy. The Departments of Health and Human Services, Labor, and Treasury jointly issue memos as “Frequently Asked Questions” specifically on implementation of the Affordable Care Act which provide additional clarification on different aspects of coverage of preventive services:
* Colon cancer screening – Screening for colorectal cancer using colonoscopies receives an “A” rating from the USPSTF, yet there have been some cases of insured asymptomatic patients being charged unexpected cost-sharing for anesthesia and polyp removal during screening colonoscopies.9 The federal government has clarified that insurers cannot impose cost sharing for medically necessary anesthesia services and polyp removal performed in connection with a preventive colonoscopy in asymptomatic individuals.10 11
* Aspirin for the prevention of cardiovascular disease – Over the counter medications are provided without cost-sharing only with a prescription.
* Breastfeeding – While the USPSTF recommends prenatal and postnatal breastfeeding interventions, HRSA guidelines specifically incorporate lactation support, counseling and equipment rental without cost-sharing. Federally- issued FAQs clarified that this coverage should last as long as the woman is breastfeeding.
* Well-woman visits – The HRSA clinical preventive services for women include coverage for at least one well-woman preventive care visit for adult women, including preconception and prenatal care, yet controversy exists with the number of well-woman visits that are permitted per year. The government has clarified that multiple well-woman visits may be required to fulfill all necessary preventive services and should be provided without cost-sharing as needed, determined by clinical expertise. Federally issued guidance notes that all dependents, including sons and daughters, must also receive all preventive services coverage as applicable, without cost-sharing. The FAQ’s specifically outline that dependent daughters also receive preconception and prenatal care as part of a well-woman visit without cost sharing.
* Testing and medications for the risk reduction of breast cancer – Federal guidance reinforces the USPSTF recommendation that women with family history of breast, ovarian, or peritoneal cancer should be screened for BRCA-related cancer, and those with positive results should receive genetic counseling and genetic BRCA testing when appropriate. As long as the woman has not specifically been diagnosed with BRCA-related cancer in the past, genetic screening, counseling and testing should be covered without cost sharing when the services are medically appreciate and recommended by her provider. USPSTF also recommends the provision of chemo-preventive medications for women deemed to be at high risk. As such, risk-reducing medications, such as tamoxifen or raloxifene, must be covered without cost sharing as prescribed to women who are at increased risk for breast cancer and at low risk for adverse medication effects.12
* Special populations – In the cases where recommendations for preventive services, counseling, and immunizations apply only to a certain population, such as “high risk” individuals, the government clarified that it is up to the health care provider to determine whether a patient belongs to the population in consideration.13 An individual’s sex assigned at birth or gender identity also cannot limit them from a recommended preventive service that is medically appropriate for that individual; for example, a transgender man who has breast tissue or an intact cervix and meets other requirements for mammography or cervical cancer screening must receive those services without cost sharing regardless of sex at birth.
* Contraceptive coverage – Federal clarification states that issuers and plans must cover the full range of prescribed contraceptive methods for women, currently at 18 distinct methods, as outlined in the FDA’s Birth Control Guide. Issuers may not limit coverage to any contraceptive method, such as oral contraceptives, but must provide at least one version of each FDA-approved contraceptive method without cost sharing. Insurers may use reasonable medical management within a method, however, to limit coverage to generic drugs and can impose cost-sharing for equivalent branded drugs. Plans are required to have an accessible and timely “waiver” process for patients who have a medical need for contraceptives otherwise subject to cost-sharing. In addition, federal rules regarding contraceptive coverage specifically exempt or accommodate certain employers who believe that the requirement violates their religious rights.14
Impact of the Preventive Services Rules
The federal HHS Assistant Secretary for Planning and Evaluation (ASPE) estimates that approximately 137 million people (55.6 million women, 53.5 million men, and 28.5 million children) have received no-cost coverage for preventive services since the policy went into effect.15 While the number of individuals who have gained coverage for no-cost preventive services is large, public awareness of the preventive services requirement is relatively low. In March 2014, three and half years after the rule took effect, less than half the population (43%) reported they were aware that the ACA eliminated out-of-pocket expenses for preventive services.16 As awareness of the benefit grows and the share of people in grandfathered plans reduces, very few privately insured individuals will have financial barriers to clinical preventive care. The big question remains: will this new benefit increase use of preventive services and, ultimately, what will be the law’s impact on the public’s health and health care costs.
1. The Patient Protection and Affordable Care Act, Sec. 2713, Coverage of Preventive Services.
2. Maciosek, Michael V. “Greater Use Of Preventive Services In U.S. Health Care Could Save Lives At Little Or No Cost.” Health Affairs 29.9 (2010): 1656-660.
3. Note that the rules described in this fact sheet apply to private insurers, self-insured employer plans, and are separate from preventive requirements for public programs like Medicare or Medicaid.
4. Kaiser Family Foundation, Health Research and Educational Trust, Employer Health Benefits 2014 Annual Survey.
5. Federal Register, Vol. 75, NO. 137, July 18, 2010.
6. Institute of Medicine, Clinical Preventive Services for Women: Closing the Gaps, July 19, 2011.
7. Federal Register, Vol. 75, NO. 137, July 18, 2010.
8. Federal Register, Vol. 75, NO. 137, July 18, 2010.
9. KFF, Coverage of Colonoscopies under the Affordable Care Act’s Prevention Benefit.
10. Centers for Medicare and Medicaid Services, Affordable Care Act Implementation FAQs – Set 26.
11. CMS, Affordable Care Act Implementation FAQs – Set 12.
12. Department of Labor, FAQs about Affordable Care Act Implementation (Part XVIII) and Mental Health Parity Implementation.
13. CMS/CCIIO, Affordable Care Act Implementation FAQ’s Set 12.
14. The ACA requires that all FDA-approved contraceptive methods and services, as prescribed by a clinician, must be covered without cost-sharing. At least one version of each method must be covered, including brand-name versions if no generic option is available. However, religious institutions defined as “houses of worship” are exempt from the requirement. Women covered by these plans do not receive contraceptive coverage. Furthermore, the case of Hobby Lobby v. Burwell reached the Supreme Court, which ruled that closely-held for-profit employers may exclude contraceptive coverage if they hold religious objections and receive a court order affirming that they have a sincerely held religious belief against providing contraceptive coverage. Religiously affiliated nonprofit organizations that object to contraceptives are eligible for an accommodation, and do not have to pay for contraceptive coverage offered by their employer-sponsored plans. In these cases, the insurer or third party administrator of these plans must pay for the cost of coverage, assuring that women covered by these plans receive contraceptive coverage. For more information see “How Does Where You Work Affect Your Contraceptive Coverage?”
15. ASPE, The Affordable Care Act is Improving Access to Preventive Services for Millions of Americans, May 14, 2015
16. KFF, Kaiser Health Tracking Poll, March 2014.
The Michigan Business and Professional Association (MBPA) needs your help! Recently, the U.S. Senate Health, Education, Labor, and Pensions Committee held a hearing on S. 30, the Forty Hours is Full Time Act, a bill that would change the definition of full-time employee under the Patient Protection and Affordable Act (ACA).
This action was preceded by a U.S. House vote in early January on a companion bill, H.R. 30, the Save American Workers Act. Both bills redefine “full employment” back to its original 40 hours, from the current ACA defined 30 hours.
This historic change from the traditional 40 hour work week to the 30 hour work week has given the business community no other choice than to restructure their workforce and reduce employees’ hours to save them from closing their front doors.
MBPA has already been in contact with our Michigan Delegation in Washington D.C. and we are asking you to do the same. Please see the links below that will guide you to your U.S. elected officials at our nation’s Capitol. They need to hear from you!!
U.S. House of Representatives (scroll down to Michigan section): http://www.house.gov/representatives/#state_me
Thank you for your continued support!! Please contact our government relations team for any questions/comments/concerns, by phone: (888) 277-5029, by email: email@example.com.
The Michigan Business and Professional Association (MBPA) strives to keep you updated on all things related to healthcare reform, namely the Affordable Care Act (ACA). This March 4th, 2015 the U.S. Supreme Court intends to hear oral arguments on a case that could affect the sustainability of the ACA public exchange system and its insurance underwriting rules.
Michigan is a federally facilitated exchange, (FFE), which means the federal government runs our public health care exchange. As written, the ACA requires those states’ utilizing the federal health care subsidies to have a state-based exchange. Michigan made several good attempts to secure such a status, but politically that goal was not achievable. In the meantime, before the individual mandate took effect, the Administration overrode that stipulation and allowed all state’s to participate and gain the subsidies for those individuals who qualified.
If the U.S. Supreme Court rules against the Administration, that would prohibit Michigan from participating and accepting the health care subsidies under the federal health care law. This action could destabilize the individual health care market, making insurance unaffordable for those that need it most. Michigan would then be charged with the decision and responsibility on how to move forward. An answer not easily made when politics is involved.
If the U.S. Supreme Court rules in favor of the Administration, Michigan’s health care subsidies remain status quo. The decision on the subsidy ruling does not impact our state’s decision of adopting the Healthy Michigan Plan, which was an expansion of our Medicaid recipients. Michigan has enrolled over 500,000 individuals in the Healthy Michigan Plan, which is quite an achievement.
We will continue to keep you up to date on the subsidy ruling. There is much speculation out there, but we truly will not know the outcome until the U. S. Supreme Court rules in late June of 2015. Please contact our government relations team if you have any questions or comments. All feedback is appreciated!
Contact information: By Email: firstname.lastname@example.org Phone: (888) 277-6464.
By Bonnie Bochniak
Vice President, Government Relations
A new report released by the United States Department of Health and Human Services (HHS) shows that consumers will have more options to choose from when they shop for health coverage on the Health Insurance Marketplace for coverage beginning in 2015. This is a direct effect from a 25% increase in the number of issuers offering coverage through the Marketplace for next year.
The Marketplace is adding 77 new health insurance issuers which allows consumers a greater selection and also increases competition throughout the market. The main purpose of the Marketplace was to increase competition and lower costs for consumers. In previous estimates HHS has found a correlation between greater competition and lower costs. For example, in a recent press release from HHS, they stated, “an increase of one issuer in a rating area is associated with a 4 percent decline in the second-lowest cost silver plan premium, on average. In 2014, consumers in regions with larger numbers of issuers were able to access a wider range of choices.”
HHS’s report studies preliminary data from 36 states run or fully supported by the federal government (Federal Marketplace) in addition to eight states operating State-based Marketplaces, and finds that a larger set of insurance issuers will offer plans in the Marketplaces in 2015.
•In the 44 states for which we have data, 77 issuers will be newly offering coverage in 2015.
•The eight State-based Marketplaces where data is already available will have a total of six more issuers in 2015, a ten percent net increase over this year.
•The Federal Marketplace states alone will have 57 more issuers in 2015; a 30 percent net increase over this year.
•Four of the 36 states in the Federal Marketplace will have at least double the number of issuers they had in 2014.
•In total, 36 states of the 44 will have at least one new issuer next year. And some of the nation’s largest insurance companies will be offering coverage in more than a dozen new states, joining the hundreds of insurance companies already participating in the Marketplace.
As always, please contact our government relations team with any questions or comments. We encourage your feedback! By email: email@example.com or by phone: 888-277-6464.
In a recent newsletter that goes out to exchange navigators and certified application counselors only, officials at the Centers for Medicare & Medicaid Services (CMS) discuss the rules that govern exchange assisters’ activities.
These rules apply directly to those assisters for the Affordable Care Act (ACA) exchanges run by the U.S. Department of Health and Human Services (HHS), the parent of CMS. Some rules may also impact those assisters in state-based exchanges.
As a fresher, a certified Navigator (in-person assisters) provide unbiased information, at no cost, to help customers decide which health insurance option is best for them. Under the ACA, Navigators cannot recommend a specific plan to consumers.
HHS exchange assisters are not allowed to solicit door-to-door per sae. The consumer must initiate or ask the assister to come into their home. Once these terms are met, the in-person assister can sell exchange plans and services door-to-door, as long as they use a low-key approach.
More specifically, in an unsolicited visit, an assister can go door-to-door to educate consumers about the exchange system and the exchange application process. Then, and only then, after the initial conversation with the consumer educating them about the exchange, if initiated by the consumer, the assister may at that time help with enrollment, the application process etc.
As more information becomes public we will continue to keep you up to date as this unfolds. As always, we welcome your feedback and/or questions. Please feel free to contact our government relations staff at BBochniak@michbusiness.org
Note: The CMS exchange helper newsletter is not readily available to the public.
Prior to the open enrollment in 2013 and especially the weeks leading up to the very first day of available healthcare on the Affordable Care Act (ACA) healthcare exchange January 1, 2014, there was much discussion of the safety of individuals personal information on such a massive website, and also much discussion of individuals falsifying information in order to qualify for a much richer subsidy in their healthcare plan.
In order to help deter giving false information when individuals sign up to one of the new public health insurance exchange programs, the U.S. Department of Health and Human Services (HHS) could impose a maximum penalty of $250,000 per exchange application “for any person who knowingly and willfully provides false information.”
In principle, HHS could also levy a $25,000 penalty on “any person who fails to provide correct information, where such failure is attributable to negligence or disregard of any rules or regulations of the HHS secretary,” and on any person who “knowingly or willfully uses or discloses” private exchange data.
Officials at the Centers for Medicare & Medicaid Services (CMS), an arm of HHS, review the ACA civil monetary penalty (CMP) rules in a new presentation (link below) directed at assisters or people who help consumers apply for coverage through the exchange system.
Link to summary of ACA civil monetary penalty: http://marketplace.cms.gov/help-us/market-standards-rule.pdf
On a deadline to circumvent any major problems on the next round of open enrollment on the Affordable Care Act’s (ACA) healthcare exchange, major sections of the Healthcare.gov website are getting totally redone. There is also a possibility that some parts of this website dedicated to helping individuals navigate the ACA may be scratched. Open enrollment for 2015 kicks off this November 15th, 2014.
Due to a somewhat tight deadline to achieve a more seamless enrollment process with far less flaws, officials are meeting with carriers to hash out potential fixes. If problems are not fixed ahead of the November 15th date this year, consumers may again face obstacles when attempting to enroll on the federal market place.
The Healthcare.gov website last year endured slow load-times, site crashes, and troublesome registration requirements, which is not enticing to potential consumers. There already have been ongoing fixes which include coordinating customer information and insurance payments. An automatic payment to carriers is one specific area that still needs repair.
Additional changes to HealthCare.gov include: replaced software and repairs to the application consumers use to sign up for coverage and the comparison tool for shoppers looking for plans. The administration will rely on cloud technology from Amazon for many of these functions.
Please contact our government relations team with any questions or comments. Feedback is always welcomed! Email: firstname.lastname@example.org or by phone: (888) 277-6464, ext. 401.
In early May, the Internal Revenue Service (IRS) has provided the new public health insurance exchanges rules for reporting on the private health coverage they have sold. This new batch of final regulations titled, “Information Reporting for Affordable Insurance Exchanges,” dictates how the exchanges will communicate whether they have enrolled consumers in individual qualified health plans (QHPs).
The exchanges will report the facts every month on Form 1095-A, and the IRS could set the due date for the first reports on or after June 15, 2104, but no earlier. Health plans, exchanges, governmental agencies and QHP enrollees will use this information on form 1095-A in connection with the new premium subsidy tax credit program created by the Affordable Care Act (ACA). Consumers may use the ACA tax credit to pay for health coverage during the tax year, essentially a year or more before filing their tax forms.
Come 2015 when consumers file their 2014 tax forms, the IRS will use Form 1095-A information to determine the amount of the advance tax credits paid to the consumers’ QHP issuers with the amount of tax credits given to consumers. IF the IRS paid out more in tax credits to the QHP’s than the consumers were supposed to get, many consumers will be asked to find the money to pay back the surplus credits.
This collection of “missing” credits might prove to be tricky when asking individuals to pay more as their records didn’t match the feds. We plan to learn more about this issue as the IRS continues to publish these final regulations.
MBPA will keep you up to date as we learn more about this batch of new rules in addition to any other changes relating to the ACA. Please contact our Government Relations team with any questions at (586) 393-8800 or by email at BBochniak@michbusiness.org.
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