Guidance

4/24/12 HHS/CMS issued a final rule "Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreements." The rule finalizes program integrity provisions under ACA §6402 and §6405 that CMS estimates will prevent fraud in Medicare and save taxpayers almost $1.6 billion over 10 years. The rule requires all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs. According to CMS, this will allow the agency and states to match specific claims with the ordering or certifying physician or eligible professional and to check for suspicious ordering activity. In addition, it requires physicians and other professionals who are permitted to order and certify covered items and services for Medicare beneficiaries to be enrolled in Medicare. According to CMS, the rule will also help ensure beneficiaries receive quality care because the agency will verify the credentials of a provider who is ordering or certifying equipment and supplies.

Read the rule at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2012-09994.pdf

Prior guidance can be viewed at www.healthcare.gov

News

4/23/12 The Board of the Medicare Trustees released the 2012 Annual Report which shows that Medicare's Hospital Insurance Trust Fund is projected to remain solvent until 2024, the same estimate from last year's report. According to the report, without the cost control tools and payment reform initiatives in the ACA, the Hospital Insurance Trust Fund would expire 8 years earlier, in 2016. The trustees said that Medicare spending continues to rise and, although the financial projections for Medicare reflect substantial cost savings resulting from the ACA, further action is needed to address the program's continuing cost growth.

In fact, the report states that the ACA contains approximately 165 provisions that affect the Medicare program by "reducing costs, increasing revenues, improving certain benefits, combating fraud and abuse, and initiating a major program of research and development to identify alternative provider payment mechanisms, health care delivery systems, and other changes intended to improve the quality of health care and reduce its costs to Medicare."

The Medicare Trustees are Treasury Secretary and Managing Trustee Timothy F. Geithner, HHS Secretary Kathleen Sebelius, Labor Secretary Hilda L. Solis, and Social Security Commissioner Michael J. Astrue. Two other members are public representatives who are appointed by the President, subject to confirmation by the Senate. Charles P. Blahous III and Robert D. Reischauer began serving on September 17, 2010. CMS Acting Administrator Marilyn B. Tavenner is designated as Secretary of the Board.

Read the report at: http://www.treasury.gov/resource-center/economic-policy/ss-medicare/Documents/TR_2012_Medicare.pdf

4/23/12 CMS released a report called "The Affordable Care Act: Lowering Medicare Costs by Improving Care" which shows that CMS expects various ACA initiatives to result in more than $200 billion in savings to the Medicare Program through 2016 and almost $60 billion in lower out-of-pocket costs to beneficiaries in traditional Medicare. According to the CMS Office of the Actuary, the over $200 billion in short-term savings to the Medicare program is because of measures that include ending excessive payments to private insurers that offer Medicare Advantage plans and implementing anti-fraud measures.

The report also highlights several of the ACA's delivery system reforms that CMS is implementing. According to CMS, the reforms will: strengthen the role of primary care providers; reward better-coordinated care through Accountable Care Organizations; improve the quality and coordination of care for "duals" (individuals who are enrolled in both Medicare and Medicaid); and pay for the quality of care provided to patients rather than just the quantity of services or tests that are done.

Read the report at: http://www.cms.gov/apps/files/ACA-savings-report-2012.pdf

4/19/12 The Medicaid and CHIP Payment and Access Commission (MACPAC) met to discuss Medicaid's research agenda, Medicare-Medicaid coordination, access to care for non-elderly adults, data for measuring access and Medicaid and CHIP statistics. MACPAC was established by the Children's Health Insurance Program Reauthorization Act and later expanded and funded through §2801 and §10607 of the ACA. MACPAC is tasked with reviewing state and federal Medicaid and CHIP access and payment policies and making recommendations to Congress, the HHS Secretary, and the states on a wide range of issues affecting Medicaid and CHIP populations, including health care reform. 

View the agenda at: http://www.macpac.gov/home/meetings/agenda-april-2012-meeting

View the presentations and materials from the meeting at: http://www.macpac.gov/home/meetings/2012_04

4/19/12 The Commonwealth Fund released a report called "Gaps in Health Insurance: Why So Many Americans Experience Breaks in Coverage and How the Affordable Care Act Will Help." The survey found that 25% of adults experienced a gap in their health insurance in 2011, with a majority remaining uninsured for one year or more. According to the report, gaps in health insur­ance coverage are most often caused by changes in employer-based health insurance eligibility due to a job change or loss, or due to a change in Medicaid eligibility because of a change in income or age. The survey authors conclude that the ACA will help close such gaps by making it easier for people to buy insurance on their own when they don't have access to an employer-based policy. As authorized under by the ACA, beginning in 2014 new affordable health insurance options available through expanded Medicaid programs and state insurance exchanges will enable adults to more easily find and purchase insurance without being dependent on their employment status. The report found that because of the implementation of ACA §1001(2714) that requires health plans that offer dependent coverage to allow children to stay on their parents' insurance policies until age 26, millions of young adults who might oth­erwise lose their health benefits upon high school or college graduation are maintaining their health insur­ance. The survey finds that almost half of young adults ages 19 to 25 reported that they had stayed on or joined a parent's insurance policy in the last 12 months. Another provision already in effect, the preexisting condition insurance plans (PCIPs, ACA §1101) for people with health problems who have been uninsured for at least six months, is starting to bridge the coverage gap for the uninsured. While enrollment in PCIPs is low, in 2014 the ACA's "guaranteed issue" and "community rating" provisions will bring further relief to people with chronic health problems when insurers are prohibited from excluding those with preexisting conditions from coverage.

Read the issue brief at: Commonwealthfund