Today's Datapoint

84% more stand-alone Medicare Part D Prescription Drug Plans will apply coinsurance next year to at least two of their highest formulary tiers, up from 32% of plans in 2014 to roughly two-thirds in 2015, according to an analysis by Avalere Health LLC.

Quote of the Day

“We’re big on shared decision making. Fully informed patients will choose less-expensive care and get better outcomes.”



— David Swieskowski, M.D., senior vice president and chief accountable care officer for Mercy Medical Center and the CEO of Mercy ACO — a successful participant in the Medicare Shared Savings Programs and operator of a 4.5-star Medicare Advantage plan — told attendees at a recent Accountable Care Congress in Los Angeles.

CMS Announces Next Phase in Medicare DMEPOS Competitive Bidding

CMS NEWS

 

FOR IMMEDIATE RELEASE                                     Contact: CMS Media Relations

December 11, 2014                                                         (202) 690-6145 or press@cms.hhs.gov

 

CMS Announces Next Phase in Medicare DMEPOS Competitive Bidding

 

The Centers for Medicare & Medicaid Services (CMS) today announced the bidding timeline for Round 2 Recompete and the national mail-order recompete of the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program, as required by law. CMS also launched a comprehensive bidder education program. This program is designed to ensure that DMEPOS suppliers interested in bidding receive the information and assistance they need to submit complete bids in a timely manner.

 

The DMEPOS Competitive Bidding Program changes the amount Medicare pays for certain DMEPOS while maintaining beneficiary access to items and services and quality of care. The program replaces the outdated, inflated fee-schedule prices Medicare paid for these items with lower, more accurate prices to help Medicare and its beneficiaries save money while ensuring access to quality equipment, supplies, and services. This program also helps limit fraud and abuse in Medicare. 

 

“Today marks another step forward in ensuring access to quality health care for millions of Medicare beneficiaries,” said CMS Administrator Marilyn Tavenner. “The DMEPOS competitive bidding program has proven to be effective in obtaining fair prices for quality equipment like wheelchairs and walkers.”

 

The Medicare DMEPOS Competitive Bidding Program has saved more than $580 million in the nine markets at the end of the Round 1 Rebid’s 3-year contract period due to lower payments and decreased unnecessary utilization. Additional savings are being achieved as part of the Affordable Care Act’s expansion of the competitive bidding program—at the end of the first year of Round 2 and the national mail-order programs, Medicare has saved approximately $2 billion. Furthermore, the monitoring data show that the implementation is going smoothly with few inquiries or complaints and no changes to beneficiary health outcomes.  

 

CMS is required by section 1847(b)(3) of the Social Security Act to recompete contracts under the DMEPOS Competitive Bidding Program at least once every three years. Suppliers must then compete to become a Medicare contract supplier by submitting bids to provide certain items in competitive bidding areas. The new, lower payment amounts resulting from the competitions replace the fee schedule amounts for the bid items in these areas.

The Competitive Bidding Implementation Contractor (CBIC) is the official information source for bidders and the focal point for bidder education. The CBIC website, www.dmecompetitivebid.com, features an array of important and helpful resources for suppliers, including the bidding timeline, bidding rules, short instructional videos, user guides, fact sheets, checklists, and bid preparation worksheets. To sign up to receive important competitive bidding announcements and reminders, suppliers are encouraged to subscribe to E-Mail Updates on the CBIC website.

 

In addition to viewing the information on the CBIC website, suppliers are encouraged to call the CBIC customer service center toll-free at 1-877-577-5331 with their questions. During registration and bidding periods, the customer service center will be open from 9 a.m. to 9 p.m. Eastern Time.  

# # #

 

 

Also, today CMS issued a fact sheet on the timeline for the DMEPOS Competitive Bidding at:

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-12-11-3.html?DLPage=1&DLSort=0&DLSortDir=descending

 

According to a recent survey,

respondents had the following privacy concerns regarding their health records:

• 16% were concerned with health records held by their health insurer
• 14% were concerned with records held by their hospital
• 11% were concerned with records held by their physician
• 10% were concerned with records held by their employer
• 5% said they have been notified that their medical records were compromised or accessed without their permission

Source: "Health Poll, Data Privacy," Truven Health Analytics/NPR, November 2014, http://truvenhealth.com/Portals/0/NPR-Truven-Health-Poll/NPRPulseDataPrivacy_Nov2014.pdf 

Nearly 9% Of Medicaid Births Delivered Early For No Medical Reason

According to a study published by Health Affairs:

Elective Deliveries as a % of Medicaid Singleton Births (Gestational Age)

• Early elective deliveries (< 39 weeks) - 8.9%
• Early-term elective deliveries - 7.0%
• Preterm elective deliveries - 1.9%
• Full-term elective deliveries - 23.3%
• Non-elective deliveries - 67.7%
• All elective deliveries - 32.3%

Note: Data from 2010-2012.


Source: Kaiser Health News

What 2015 means for PPACA

By Nathan Solheim

December 10, 2014

 

In many ways, 2014 was a pivotal year for PPACA, as most major reforms came online in the past 11 months. Among the facets implemented were the Health Insurance Tax, subsidies, state and federal exchanges, minimum standards, health care co-ops, Medicaid expansion and new rules for wellness programs, minimum waiting periods and several market reforms.

 

There were lots of problems, and the government tacked on plenty of last-minute changes and extensions in an effort to smooth the implementation. It all resulted in a flood of negative press for PPACA. Public perception has fallen so far that polls now consistently show that around 60 percent of Americans don't favor the law.

 

It's fair to say that health care workers, insurance brokers and agents, consumers, government regulators and President Obama hope 2015 will unfold more smoothly. On tap for next year is a relatively minor facet of PPACA set to start on Oct. 15 — a 23 percent increase in the Children's Health Insurance Program match rate up to a cap of 100 percent, according to the Kaiser Family Foundation.

The main issues for Obamacare in 2015 revolve around how employers and benefits professionals handle the employer mandate and related compliance issues. Also on their plate will be working with employers and employees struggling with canceling policies or canceled policies as extensions lapse. And there are tweaks coming for the state and federal exchanges, too.

Already delayed multiple times, the employer mandate — a critical part of the law's success — is set to begin in 2015. That means employers with more than 100 employees must offer health insurance by January or pay a fine of $2,000 per worker. Companies that employ 50–99 workers have until January 2016 to begin offering health insurance. (Companies with less than 50 employees are exempt.)

 

“The employer mandate is coming in 2015, and employers need to be preparing for it,” says Jessica Waltman, senior vice president of government affairs at the National Association of Health Underwriters in Washington, D.C. “Employers need to be acting right now and making coverage offers for Jan. 1. Those decisions need to be made now.”

Compliance

With new employers entering the health care marketplace because of the mandate and because the time frame to phase out noncompliant plans will expire, benefits professionals in 2015 will increasingly be called upon to help clients come into compliance with PPACA.

“Most of the requirements were effective for 2014, but because of the way the administration allowed states and carriers to continue with noncompliant plans for another year, there's variability across the country,” Waltman says. “So you have some employers who are compliant and other employers working on becoming compliant. They have to document. It's not just ‘I don't have to do it this year’; it's ‘I have to fill out and document it.’ A lot of employers were already offering coverage, but the new systems in place are a compliance burden that may be as much work as offering coverage in the first place.”

But compliance hasn't been easy, some industry insiders say, as employers have been fearful over the law's penalties and continuing changes. Aaron Davis, president of NextLogical Benefit Strategies in Westminster, Maryland, says brokers have been busy working to educate clients — as well as ease their concerns.

“What's happening is PPACA is just loaded with fear-inducing issues. So employers are freaking out,” Davis says. “Plus the law has changed 30–40 times so far, so everyone is asking if they’re in compliance. In health care, we call it the worry well. It creates stress, so brokers use that and deluge people with information. Within 24 hours of a change, we get the information. We keep up on it, but clients continue to freak out because they’re scared of missing something. The IRS went out and hired a bunch of new auditors last year and started auditing health plans. And those penalties can be huge. People are going to continue to peddle fear and offer hope.”

Exchanges

Benefits professionals and consumers will continue to see change in the federal and state exchanges as well. Some exchanges were really clunky and inefficient, like Oregon's Cover Oregon. Others seemed to work better, like Kentucky's Kynect. And no one needs to bring up the subject of the federal exchange on HealthCare.gov. Still, benefits professionals working with state-run exchanges question whether the marketplaces will continue to improve in the next year.

 “I haven't had a new training on the new exchange website in Kentucky,” says Zach Zinser of Zinser Benefit Service in Louisville, Ky. “We’ve just been told, ‘You’ll want to re-enroll your clients in it.’ I’ve contacted my clients, and I’m telling them I’m aware of what's going on. I don't know how much they believe me or I believe myself, but I’m doing what I can.”

NAHU's Waltman adds that some states will complete their exchanges in 2015, while other states, such as Idaho and New Mexico, will launch completed state exchanges to take the place of federal-state hybrids created for 2014.

According to the federal government, another 2015 change will be an increased number of carriers offering plans on the exchanges. The U.S. Department of Health and Human Services said in a September statement that the number of issuers will increase by 25 percent — with 77 new issuers. The federal exchange will have 57 more issuers by itself.

 

“When consumers have more choices, we all benefit,” HHS Secretary Sylvia Burwell said in a press release. “In terms of affordability, access and quality, [the news of more carrier participation] is very encouraging. It's a real sign that the Affordable Care Act is working.”

Even with all those new issuers, though, benefits professionals may not be getting all the information they need from insurance companies to help service their clients correctly and efficiently.

“As of right now, I’m pretty disappointed in the insurance companies,” Zinser says. “On the individual side, we’ve had one meeting with them. We’ve gotten some guidance from Anthem on what they’re doing and moving people to plans. But who's going to be gone and who's not going to be gone? Last year, we had a lot of renewals. In some of my states, like Indiana, they’re discontinuing some plans and rolling them into a new plan. Humana — one of the major carriers in the individual market in Kentucky — hasn't told us anything at all. I’m hugely disappointed. There's been no guidance. We had a webinar and they let us know renewals are coming soon. That's where I stand right now.”

Rates

There's no easy way to sum up what will happen to rates — they’re going to go up for some consumers and they’re going to go down for others.

 

“My guess is that employers will continue to reveal to employees what the law is costing them,” Davis says. “We’ve got clients right now — midsize clients — that are paying $100,000 per year in fees. One of our clients went back and said, ‘We want to tell our employees what it's costing us.’ The singles were paying an extra $150 per year for single coverage and around $650 per year for a family. Employers are saying, ‘We want people to know what this is costing.’

“My customer-service people spend more than half their time on [PPACA] issues,” Davis adds. “You take a broker business that used to be profitable, and you take that staff and 50 percent of their time is spent on compliance. You have to ask yourself what's not getting done — and that's all the really important stuff we do to help our clients control spending.”

Cancellations

Throughout 2014, there were plenty of stories concerning plan and policy cancellations. Politifact even called President Obama's sales pitch — “If you like your plan, you can keep your plan” — the lie of the year in 2013. In 2015, the tide of cancellations isn't likely to subside as prices increase or employers stop offering health insurance altogether.

“All of these people right now are getting renewal prices for 2015, and the rate increases are enormous,” Waltman says. “Since small employers and large employers are starting to comply, employers are also making switches. They may no longer offer coverage to spouses or they may no longer offer coverage to part-time employees.”

Davis agrees, saying he thinks cancellations are going to continue.

“That's part of what's going to drive individuals to the exchanges,” he says. “Now, while it's a minimal fine for not doing it, that's going to increase over time. The IRS is going to look at that over time, too. I would say you’re going to see more cancellations and groups getting out of the business of providing health care.”

 

http://www.benefitspro.com/2014/12/10/what-2015-means-for-ppaca?eNL=5488bb01160ba04535c8082c&utm_source=BenefitsProDaily&utm_medium=eNL&utm_campaign=BenefitsPro_eNLs&_LID=144817897

Medicare and Medicaid Program; Revisions to Certain Patient’s Rights Conditions of Participation and Conditions for Coverage Overview

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to revise selected conditions of participation (CoPs) for providers, conditions for coverage (CfCs) for suppliers, and requirements for long-term care facilities, to ensure that certain requirements are consistent with the Supreme Court decision in United States v. Windsor, 570 U.S. 12, 133 S.Ct. 2675 (2013) and U.S. Health and Human Services policy.



Background



In United States v. Windsor, the Supreme Court held that section 3 of the Defense of Marriage Act (DOMA) is unconstitutional because it violates the Fifth Amendment (See Windsor, 133 S. Ct. 2675, 2695). Section 3 of DOMA provided that in determining the meaning of any Act of the Congress, or of any ruling, regulation, or interpretation of the various administrative bureaus and agencies of the United States, the word “marriage” meant only a legal union between one man and one woman as husband and wife, and the word “spouse” could refer only to a person of the opposite sex who was a husband or a wife (1 U.S.C. § 7).



Proposed Requirements



For all Medicare and Medicaid provider and supplier types, we conducted a review of the Code of Federal Regulations (CFR) for instances in which our regulations defer to state law for purposes of defining “representative,” “spouse,” and similar terms in which reference to a spousal relationship is explicit or implied. We have identified several provisions that we believe should be revised in light of the Windsor decision. These provisions have been interpreted to support the denial of federal rights and privileges to a same-sex spouse if their state of residence does not recognize same-sex marriages.

This proposed rule would revise these regulations governing Medicare and Medicaid participating providers and suppliers by proposing to clarify that where state law or facility policy provides or allows certain rights or privileges to a patient’s opposite-sex spouse under certain provisions, a patient’s same-sex spouse must be afforded equal treatment if the marriage is valid in the jurisdiction in which it was celebrated.



These revisions would promote equality and ensure the recognition of the validity of same-sex marriages when administering the patient rights and services at issue.

The proposed rule [CMS-3302-P] can be viewed at: https://www.federalregister.gov/public-inspection/2014/12/11.



This link will change once the proposed rule is published in the Federal Register on December 12, 2014.