5/17/13 CMS/HHS issued an interim final rule regarding the Pre-Existing Condition Insurance Plan (PCIP) Program. The interim final rule sets the payment rates for covered services beginning on June 15, 2013 for individuals enrolled in the PCIP program. In addition, the rule prohibits facilities and providers from charging a PCIP enrollee an amount greater than cost-sharing amount calculated by the PCIP plan for the covered service.

The PCIP program, established under ACA §1101, is a temporary federal program designed to cover uninsured Americans with pre-existing conditions until 2014. In 2014, individuals will be able to purchase health insurance through the Exchange where they cannot be denied coverage because of a pre-existing condition. The ACA provides $5 billion in funding for this program. On February 16, 2013, the PCIP suspended new enrollment to ensure that funding would be available to current PCIP enrollees through the end of 2013. According to HHS, since enrollment began in July 2010, the PCIP provided insurance to over 135,000 people with high-risk pre-existing conditions nationwide.

Massachusetts participates in the federally-administered PCIP program because it is a guarantee-issue state where existing commercial plans already offer guaranteed coverage at premiums comparable to PCIP so the need for such a program is not as high as in other states. As a result, enrollment in Massachusetts has been very low. The most recent data indicates that 24 people in Massachusetts are enrolled in PCIP.

Comments are due on July 22, 2013.

Read the interim rule (which was published in the Federal Register on May 22, 2013) at: http://www.gpo.gov/fdsys/pkg/FR-2013-05-22/pdf/2013-12145.pdf

Prior guidance can be viewed at: www.healthcare.gov

News

5/20/13 The U.S. Preventive Services Task Force (USPSTF) issued a draft recommendation statement on the use of fluoride in children to help prevent dental decay. USPSTF recommends that clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride, and apply fluoride varnish to the primary teeth of infants and children starting at the age of primary tooth eruption. According to the Task Force's research, tooth decay is the most common chronic disease in children in the United States.

The USPSTF is an independent panel of non-federal government experts that conduct reviews of scientific evidence of preventive health care services. The USPSTF then develops and publishes recommendations for primary care clinicians and health systems in the form of recommendation statements. As part of their recommendations process, the USPSTF will assign definitions to the services they review based on the certainty that a patient will receive a substantial benefit from receiving the benefit. Services that are graded "A" and "B" are highly recommended and the USPSTF believes there is a high certainty that patient will receive a substantial or moderate benefit. Under ACA §1001, all of the recommended services receiving grades of "A" or "B" must be provided without cost-sharing when delivered by an in-network health insurance provider in the plan years (or, in the individual market, policy years) that begin on or after September 23, 2010.

The USPSTF issued a "B" rating for the recommendation to provide fluoride supplementation beginning at age 6 for those children whose water supply doesn't have enough fluoride in it. According to the USPSTF, approximately 42% of children ages 2 to 11 years have dental decay in their primary teeth. The USPSTF also stated that the current evidence is insufficient to recommend that clinicians screen for tooth decay in children from birth to age 5. This recommendation received an "I" rating so it will not be a covered benefit under the ACA without cost-sharing.

Comments on the draft are due June 17, 2013 and can be submitted at: uspreventiveservicestaskforce

Read the USPSTF's recommendations at: http://www.uspreventiveservicestaskforce.org/draftrec.htm

Learn more about the USPSTF and the ACA at: Healthcare.Gov 

5/16/13 CMS/HHS announced an open period for additional organizations to be considered for participation in Model 1 of the Bundled Payments for Care Improvement (BPCI) Initiative under ACA §3021. The funding opportunity is open to acute-care hospitals paid under the inpatient prospective payment systems (IPPS) and organizations that wish to convene acute care hospitals in a facilitator convener role are also eligible to be considered for participation in Model 1.

The initiative is designed to test how bundling payments for episodes of care can lower costs for Medicare and improve outcomes for beneficiaries. Under the BPCI models, organizations enter into payment arrangements that include performance and financial accountability for episodes of care. The program aligns payments for services delivered across an episode of care, such as heart bypass or hip replacement, rather than paying for services separately as Medicare currently does. Bundled payments are intended to give doctors and hospitals new incentives to coordinate care, improve the quality of care and save money for Medicare.

The BPCI initiative outlines 4 models of care. Models 1-3 involve a retrospective bundled payment, with a price for a defined episode of care, and Model 4 would be paid prospectively. Model 1 includes an episode of care focused on the acute care inpatient hospitalization. Model 1 awardees agree to provide a standard discount to Medicare from the usual Part A hospital inpatient payments. Medicare will continue to pay physicians separately for their services under the Medicare Physician Fee Schedule. Under certain circumstances, hospitals and physicians will be permitted to share gains arising from the providers' care redesign efforts. Participation will begin as early as April, 2013 but no later than January, 2014.

Applications are due July 31, 2013.

Read the Federal Register Notice at: GPO.Gov

Read more about the BPCI Initiative at: http://innovation.cms.gov/initiatives/Bundled-Payments/index.html