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Policy Areas

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On January 17, 2017, the Centers for Medicare and Medicaid Services (CMS) published the final rule in the Federal Register that finalizes changes to the Medicare benefit claim appeals processes that were proposed on July 5, 2016. This final rule is part of the Department of Health and Human Services (HHS) approach for addressing the increasing number of appeals and the current backlog of claims waiting to be adjudicated. This final rule includes new and revised rules that expand the pool of available Office of Medicare Hearings and Appeals (OMHA) adjudicators; increase decision-making consistency among the levels of appeal; and improve efficiency by streamlining the appeals process so less time is spent by adjudicators and parties on repetitive issues and procedural matters. These regulations become effective on March 20, 2017.

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The Centers for Medicare and Medicaid Services (CMS) conducted a national provider call on January 12, 2017, that focused on therapy information data collection for the inpatient rehabilitation facility patient assessment instrument (IRF-PAI). The therapy information section on the IRF-PAI was finalized in the fiscal year (FY) 2015 IRF prospective payment system (PPS) final rule. The call included a review of examples of each type of therapy and how to accurately code and complete the therapy information section on the IRF-PAI. To assist with the call, CMS utilized a PowerPoint presentation for providers to refer to. The written transcript and audio recording of the national provider call will be posted in approximately two weeks.

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In recent months, Pennsylvania’s Learning Community has focused on challenges to financing and payment for mental health care in the primary care and collaborative care settings. The SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) has provided the field with an array of information, presentations, and other resources related to the financing of mental health services in primary care and integrated care settings. Below are some of the resources that CIHS has made available to us here in Pennsylvania.

  • The ability to bill for both behavioral health and primary care services on the same day is an essential part of integrating care. The Center for Medicare and Medicaid Services (CMS) created the Billing Properly for Behavioral Health Services booklet to help providers understand the laws and regulations that govern billing for behavioral health services.
  • The resource also includes a checklist to help evaluate your billing procedures and identify potential errors, as well as a resource guide for your billing staff to review current guidelines, billing and coding, covered services, and compliance information.
  • Learn ways you can enhance and streamline your billing process through Improving Your Third-Party Billing System, a self-paced online course from SAMHSA’s BHbusiness initiative.

CIHS continually updates its website to present the best and newest resources and information relevant to integrated primary and behavioral health care.

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From: “HS, Secretary’s Office”
Date: January 5, 2017 at 1:01:56 PM EST
To: “DHS-STAKEHOLDERS@LISTSERV.DPW.STATE.PA.US”
Subject: [DHS-STAKEHOLDERS] DHS Awards Medicaid Agreements

Department of Human Services (DHS) Secretary Ted Dallas announced that DHS has agreed to move forward and negotiate agreements with six managed care organizations (MCOs) to deliver physical health services to Pennsylvanians through HealthChoices, Pennsylvania’s mandatory Medicaid managed care program since 1997.

“These agreements will be the most significant changes to Pennsylvania’s Medicaid program since we moved to managed care two decades ago,” said Dallas. “Over the next three years, MCOs will be investing billions of dollars in innovative approaches that reward high-quality care that improves patient health rather than just providing services for a fee.”

The $12 billion, three-year contracts include a 30 percent target for payments based on value received or outcomes, rather than on the quantity of services provided.

The MCOs were selected based on several criteria, including their current performance, the level of customer service delivered, member satisfaction, and their value-based performance plan. Performance criteria measured, among other things, management of chronic conditions such as high blood pressure, diabetes, and asthma; frequency of prenatal and post-partum care; and access to preventive services.

“The average performance ratings of the selected organizations are consistently higher than the current averages in every region. This transition will result in higher levels of quality care for the 2.2 million Pennsylvanians served by Medicaid,” said Dallas.

To drive Pennsylvania’s Medicaid system towards these better outcomes, the three-year agreements set gradual targets for all MCOs to increase the percentage of value-based or outcome-based provider contracts they have with hospitals, doctors, and other providers to 30 percent of the medical funds they receive from DHS. The result will be that billions in funds that would have otherwise been spent on traditional payment arrangements will instead be invested in outcome or value-based options such as:

  • Accountable care organizations (voluntary networks of hospitals, doctors, and other providers that work together to provide coordinated care to patients);
  • Bundled payments (increases value-based purchasing);
  • Patient-centered medical homes; and
  • Other performance-based payments.

“We’re going to reward folks for providing the right services, not just more services. You get what you pay for so we’re shifting the focus of Pennsylvania’s Medicaid system toward paying providers based on the quality, rather than the quantity of care they give patients,” said Dallas. “In addition, by focusing on improving the health of consumers, we will drive down the cost of care and ultimately save the taxpayer funds we spend on health care in Pennsylvania.”

HealthChoices delivers quality medical care and timely access to all appropriate services to 2.2 million children, individuals with disabilities, pregnant women, and low-income Pennsylvanians.

For more information, visit www.HealthChoicesPA.com or www.dhs.pa.gov.

DHS has selected the following MCOs to proceed with negotiations to deliver services in Pennsylvania beginning in June 2017. The agreements are awarded in five geographic regions:

Southeast Region Gateway Health
Health Partners Plans
PA Health and Wellness
UPMC for You
Vista–Keystone First Health Plan
Southwest Region Gateway Health
PA Health and Wellness
UPMC for You
Vista—AmeriHealth Caritas Health Plan
Lehigh/Capital Region Gateway Health
Geisinger Health Plan
Health Partners Plans
PA Health and Wellness
Northeast Region Gateway Health
Geisinger Health Plan
UPMC for You
Northwest Region Gateway Health
UPMC for You
Vista—AmeriHealth Caritas Health Plan

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Registration is now open for the 2017 Social and Emotional Learning (SEL) Conference: Building Skills for Lifelong Success, to be held Monday, March 13, 2017, at the Hilton Harrisburg.

There is an amazing lineup of national experts who will present workshops on SEL policy and practice. The keynote speaker will be Dave Levin, Co-Founder of the Knowledge is Power Program (KIPP). When registering, be sure to pre-select the workshops that are of most interest to you. Selecting workshops may be difficult, considering the number of great topics and presenters available, so bring along a few colleagues and gather as much information as you can.

Participants are responsible for their own travel and lodging arrangements/costs. A limited block of rooms has been reserved at a discounted rate of $139 single/double occupancy per night plus tax at the Hilton Harrisburg until Monday, February 20, 2017. Make reservations online or call 717-233-6000 and reference group code “SEL” in order to obtain the discounted rate. Rooms are available on a first-come, first-served basis.

Find workshop descriptions, additional conference information, and registration on the conference website. For additional questions, feel free to contact Amy Moritz, Youth Development Coordinator, Center for Schools and Communities, at 717-763-1661.

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The Alliance of Community Health Plans (ACHP) invites our Learning Community to discuss the innovative approaches that not-for-profit, community-based health plans are using to integrate primary care and behavioral health on Wednesday, January 18, at 1:00 pm. The presentation and discussion of innovative examples of integrating primary care and behavioral health features Dr. Judith Feld (Independent Health), Dr. James Schuster (UPMC), and Dr. Mason Turner (Kaiser Permanente), and focuses on:

UPMC Health Plan is integrating primary care and behavioral health with programs such as co-locating behavioral health specialists at primary care sites, placing care managers within primary care practices to assist with care coordination, and reverse co-locating primary care physicians in behavioral health settings.

Independent Health has fully integrated behavioral health consultants within nine patient-centered medical homes, resulting in high patient satisfaction and significantly increased use of screening rates for mental health and substance abuse.

Kaiser Permanente’s evidence-based collaborative care approach to depression treatment helps adult members who have been newly diagnosed with mild-to-moderate depression and who have started an antidepressant.

Registration for this webinar is required.

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CESP Exam Logo

Earn the Designation of Certified Employment Support Professionals (CESP™)
by Passing the National CESP™ Examination

Hawley, PA Exam (information/registration links)
Wednesday, February 15, 2017

Wyomissing, PA Exam (information/registration links)
Wednesday, April 19, 2017

WHO SHOULD TAKE THE CESP™ EXAM?

Job Coaches • Job Developers • Transition Employment Specialists • Job Placement Specialists • Employment Specialists/Consultants • Employment Managers and/or Directors

What is CESP™ Certification?

  • CESP™ certification is a national credential for Employment Support Professionals who assist people with disabilities in finding and maintaining regular, community-based employment.
  • The CESP™ credential is earned by passing a comprehensive examination based onnational standardized competencies.
  • CESP™ certification is a complement to program certification and licensing, demonstrating a level of professionalism has been achieved.
  • The CESP™ certification is a national, portable, individual credential that remains valid for three years.

What are the Benefits of EARNING THE CESP™ Credential?

  • CESP™ certification opens the door to: improved professional advancement & job opportunities, increased income opportunities, and enhanced credibility with employers
  • Become a member of a rapidly growing, elite group of professionals:

• Reduced APSE membership fee
• National networking opportunities
• Exclusive access to CESP ™ publications & webinars
• A professional credential — not just a certificate of completion
• CESP™ Meet-ups
• CESP™ LinkedIn Group
• Your name listed on the APSE website
• Recognized as a leader in your field

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On December 20, 2016, the Centers for Medicare and Medicaid Services (CMS) announced the release of a final rule that will implement three new Medicare Parts A and B episode payment models, a Cardiac Rehabilitation Incentive Payment model and modifications to the existing Comprehensive Care for Joint Replacement (CJR) model under Section 1115A of the Social Security Act.

The finalization of these new Innovation Center models will continue the shift of Medicare payments from rewarding quantity to rewarding quality by creating incentives for hospitals to deliver better care to patients at a lower cost. The models will reward hospitals that work together with physicians and other providers to avoid complications, prevent hospital readmissions, and speed recovery.

The announcement finalizes significant new policies that:

  • Improve orthopedic care: One new payment model will support clinicians in providing care to patients who receive surgery after a hip fracture, other than hip replacement. In addition, CMS is finalizing updates to the CJR Model, which began in April 2016.
  • Improve cardiac care: Three new payment models will support clinicians in providing care to patients who receive treatment for heart attacks, heart surgery to bypass blocked coronary arteries, or cardiac rehabilitation following a heart attack or heart surgery.
  • Provides an accountable care organization (ACO) opportunity for small practices: The new Medicare ACO Track 1+ Model will have more limited downside risk than Tracks 2 or 3 of the Medicare Shared Savings Program in order to encourage more practices, especially small practices, to advance to performance-based risk.

The final rule makes several modest adjustments to the CJR Model that are largely conforming changes for consistency with the other episode payment models. These include refinements for use of the skilled nursing facility waiver, exclusion of beneficiaries participating in selected ACOs, and revising target pricing methodology to include reconciliation and repayment amounts for performance years 3, 4, and 5. CMS is finalizing revisions to the quality adjustment to incorporate improvement as well as absolute performance, and also finalized changes to align CJR with the episode payment models around financial arrangements and beneficiary engagement incentives, compliance enforcement, appeals processes, and beneficiary notifications.

The final rule is scheduled to be published in the Federal Register on January 3, 2017, and is effective on February 18, 2017.

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