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Policy Areas

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ODP Announcement 049-16: QM Certification Fall Registration Now Open and Fall 2016 registration; ODP has been offering training on quality management practices on an ongoing basis since 2003. In order to support moving the system forward in partnership and collaboration, ODP is now offering its staff and stakeholders an opportunity to become ODP QM Certified. In November 2015, ODP announced (Announcement 105-15) the availability of the ODP QM Mailbox. ODP staff and stakeholders were encouraged to send their interest in becoming certified to ODP and begin to complete the prerequisites. Since that time, ODP has heard from over 160 interested parties and the list continues to grow. This announcement includes information about the fall 2016 classes, the registration process, and the deadline for submission of the application, which is August 15, 2016. A registration form is available as well.

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The Centers for Medicare and Medicaid Services (CMS) published a proposed rule in the August 2, 2016 Federal Register that proposes to implement three new Medicare Parts A and B episode payment models under section 1115A of the Social Security Act, which are meant to improve quality and lower cost. The proposed rule includes a new mandatory bundled payment model for cardiac care in 98 geographical markets for patients who have a heart attack or undergo bypass surgery. The rule would also extend the existing bundled payment model for hip and knee replacements – the Comprehensive Care for Joint Replacement model – to include hip and femur surgeries. Also proposed are new incentive payments designed to increase the use of cardiac rehabilitation. Additionally, new pathways are outlined for physicians participating in bundled payment models to qualify for payment incentives under the proposed Quality Payment Program, which implements the Medicare Access and CHIP Reauthorization Act (MACRA). CMS issued a fact sheet to provide more detailed information on the key provisions of this proposed rule. Comments are due by October 3, 2016.

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The Department of Human Services (DHS), in collaboration with the Insurance Department, will be implementing updated physical health and behavioral health autism spectrum disorder (ASD) related procedure and diagnosis codes as a key element of the state’s Medicaid (MA) cost avoidance initiative, effective September 30. These changes will reflect a more complete and updated array of ASD related procedure and diagnostic codes that will be recognized by commercial insurance plans as well as MA. The goal of these changes is to identify the service array that is covered by commercial health insurance plans, reduce the financial burden on the MA system, and to improve the uniformity of coding and billing for services. The September 30 implementation date will allow additional time for the state, in collaboration with RCPA, to provide outreach and training to providers of services for children with an ASD. As a member of the state’s Act 62 External Work Group, RCPA will be meeting with DHS to develop materials and plan for informational webinars to prepare providers for these changes. RCPA will provide information and updates as they become available.

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A recent news release from the American Psychiatric Association reports that diagnosis of autism spectrum disorder before the age of 4 means that a child is more likely to get effective, evidence-based treatment, such as behavioral therapy. When children are diagnosed after that threshold, they are less likely to receive such treatment, but they are more likely to be treated with medication, according to research published online in the August 1 release of Psychiatric Services in Advance. The strongest evidence for effective treatment for autism is for behavioral intervention therapy directed at core autism symptoms, such as social skills and inflexible behaviors. Early intensive treatments may have long-term benefits for children’s functioning. Other therapies, including complementary and alternative medicine and medication treatments for autism, are more controversial and are not as strongly supported by scientific studies. Psychiatric Services in Advance articles have been peer reviewed but have not yet appeared in the print journal. Publication ahead of print allows articles to become available in a rapid and timely manner.

The American Academy of Pediatrics recommends that all children be screened for autism at 18 months and again at 24 months. Current information suggests that only about half of primary care practitioners screen for autism. The average age at diagnosis in the United States is more than 4 years old.

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ODP Announcement 047-16; Frequently Asked Questions for Targeted Services Management Bulletin Now Posted

On January 20, 2016, ODP issued bulletin 00-16-01 entitled Targeted Services Management for Individuals with an Intellectual Disability. The purpose of the bulletin was to communicate and clarify the requirements for targeted services management that were approved by the Centers for Medicare and Medicaid Services on April 15, 2015.

Since the release of the bulletin, ODP has received many inquiries from stakeholders. To address these inquiries, ODP has developed a document entitled Frequently Asked Questions (FAQs) Targeted Services Management Bulletin. Updates will be made to the FAQ document as more questions are received.

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In June, the Behavioral Health Rehabilitation Service (BHRS) Regulations Work Group completed a series of conference calls with RCPA members and other providers, managed care representatives, and advocacy groups. Meeting notes provided by the Office of Mental Health and Substance Abuse Services and the Bureau of Autism Services from the several work group conference calls are available below. While these notes don’t fully reflect the active and thoughtful discussions that were evident in each of the work group’s conference calls, they may provide some insight into those conversations. The Department of Human Services will be working throughout the month of July to put together a document based on the BHRS Regulation Work Group’s feedback, and ideas for review and comments by work group members, in early August.

Meeting documents are below:

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The Department of Human Services (DHS) is implementing a number of measures related to services for children and adolescents with behavioral health needs. The full text of their announcement is available for review and a summary of key elements of the DHS action plans are highlighted below:

 

Behavioral Health Rehabilitation Services (BHRS)

  • Concentrating efforts on the development of appropriate regulatory guidance for BHRS.
  • Established a work group that will review existing policies, bulletins, and data that will be used to draft the regulations by November 2016.

 

Applied Behavioral Analysis (ABA)

  • Developed a two-year action plan to enhance access and quality of ABA services.
  • Will develop new requirements for the training, qualifications, skills, and experience of practitioners.
  • Issued bulletins clarifying the training requirements for TSS workers and newly licensed behavior specialists who use BSC-ASD services to provide ABA.
  • Issued a bulletin that provides guidelines to assess the medical necessity of ABA.

 

Behavior Specialist Licensure

  • Will send out guidance to accredited colleges and universities that are interested in developing graduate-level coursework or programs.
  • Will provide guidance for students on how they can satisfy the coursework and experience requirements while working towards their degree.

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A recent edition of the Pittsburgh Post-Gazette focused on the planning efforts by Highmark Insurance to assure health care parity and the economic and health care value of integrated health care.

The Post-Gazette article notes that “behavioral health care is still provided under a “separate and unequal” system, eight years after enactment of a federal law that meant to curb such disparity,” noted Patrick Kennedy in a meeting with a group of Pittsburgh-area health insurance caseworkers. “But that may start to change by fall when employer compliance monitoring is expected to begin for the Mental Health Parity and Addiction Equity Act,” the 49-year-old former Rhode Island congressman told about 20 case managers at Highmark Health. Mr. Kennedy was upbeat, saying a renaissance was at hand as employers and insurers learn about the cost-saving value of behavioral health coverage. “The business model isn’t there yet. This is going to take time,” he said. “Let’s find the value so it makes sense for insurance companies.”

In a related effort, the Pennsylvania Parity Coalition will be meeting this week with the Pennsylvania Insurance Department, to discuss the implementation and monitoring of commercial insurance plans as part of the federal parity requirements in the move toward integrated health care. RCPA, along with leading provider and consumer advocacy groups and representatives of ParityTrack, supported by the Kennedy Forum, make up the core leadership of the Pennsylvania Parity Coalition.

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The Centers for Medicare and Medicaid Services (CMS) issued the calendar year (CY) 2017 Medicare Physician Fee Schedule Proposed Rule, which was published in the July 15, 2016 Federal Register. Some of the key provisions proposed include:

New Physical Therapy and Occupational Therapy Codes

CMS is proposing new CPT codes for physical therapy and occupational therapy evaluative procedures. The new codes are listed on Page 350 of the proposed rule in table 19 and include: 97X61, 97X62, 97X63, 97X64, 97X65, 97X66, 97X67, and 97X68. These codes are deemed “always therapy” regardless of the type of provider who bills for the service, and thus are subject to the statutory therapy caps.

Misvalued Therapy Codes

As part of the continued misvalued code initiative, CMS identifies ten potential therapy codes that fall under the “codes that account for the majority of spending under the physician fee schedule” statutory category. The ten codes that CMS requests comment on include the following: 97032 electrical stimulation; 97035 ultrasound therapy; 97110 therapeutic exercises; 97112 neuromuscular reeducation; 97113 aquatic therapy/exercises; 97116 gait training therapy; 97140 manual therapy 1/regions; 97530 therapeutic activities; 97535 self-care management training; and G0283 electrical stimulation other than wound.

Physician Value-based Modifier

The Value-based Payment Modifier (VM) provides for differential payments under the PFS to self-employed physicians, groups of physicians, and other eligible professionals (EPs) based on the quality and cost of care they furnish to beneficiaries enrolled in the traditional Medicare Fee-for-Service (FFS) program. Under the VM Program, performance on quality and cost measures can translate into payment incentives for EPs who provide high quality, efficient care, while EPs who underperform may be subject to a downward adjustment. This program is set to expire on January 1, 2019, as a new comprehensive program required by the Medicare Access and CHIP Reauthorization Act, called the Merit-based Incentive Program, begins in CY 2019. For CY 2017, CMS requests feedback on four scenarios that aim to help physician groups and solo practitioners better predict the outcome of their final VM adjustment and to minimize claims reprocessing.

Medicare Shared Savings Program

Within the Medicare Shared Savings Program, CMS proposes to introduce beneficiary protections related to the use of the skilled nursing facility (SNF) 3-Day Waiver, currently limited to beneficiaries in a Track 3 Accountable Care Organization (ACO). CMS estimates the first SNF 3-day rule waiver applications from Track 3 ACOs to be accepted later this summer. The following additional beneficiary protections are proposed in order to ensure proper use of the SNF 3-day rule waiver:

  • Establishment of a 90-day grace period that would permit payment for SNF services provided to beneficiaries who were initially on an ACO’s prospective assignment list for a performance year, but subsequently excluded during the performance year;
  • Requirement that a beneficiary who was never prospectively assigned to a waiver-approved ACO is not subject to non-covered SNF services; and
  • Misuse of a waiver may result in CMS taking remedial action against an ACO. CMS has indicated they will develop a process for ACOs to confirm that they have met all the SNF 3-day rule waiver requirements and requests comments on the proposed beneficiary protection policies.

Medicare Advantage Provider Enrollment

CMS proposes to require Medicare Advantage (MA) organization providers and suppliers to also be enrolled in Medicare in an approved status. The statutory definition of a “provider of services” includes a hospital, critical access hospital, SNF, a comprehensive outpatient rehabilitation facility, a home health agency, or a hospice. According to CMS, this requirement is needed to ensure that MA enrollees receive appropriate or medically necessary items or services from health care providers and suppliers that fully comply with Medicare enrollment requirements and have not had their privileges revoked. The Medicare enrollment requirement would be part of CMS contracts with MA plans, and those failing to meet this requirement could be subject to contract actions ranging from sanctions to termination. This proposal would create consistency with the provider and supplier enrollment requirements for all other Parts of Medicare (i.e., Medicare Part A, Part B, and Part D), and would also parallel requirements for providers participating in Medicaid managed care organizations.

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