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CMS

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The Centers for Medicare and Medicaid Services (CMS) has launched the Jimmo Settlement Agreement web page. This web page provides access, in one location, to various public documents and resources related to the Jimmo Settlement Agreement, including a Frequently Asked Questions (FAQs) link.

 

Background on Settlement Agreement:

On January 24, 2013, the US District Court for the District of Vermont approved a settlement agreement in the case of Jimmo v. Sebelius, in which the plaintiffs alleged that Medicare contractors were inappropriately applying an “Improvement Standard” in making claims determinations for Medicare coverage involving skilled care (e.g., the skilled nursing facility (SNF), home health (HH), and outpatient therapy (OPT) benefits). The settlement agreement sets forth a series of specific steps for CMS to undertake, including issuing clarifications to existing program guidance and new educational material on this subject. The goal of this settlement agreement is to ensure that claims are correctly adjudicated in accordance with existing Medicare policy, so that Medicare beneficiaries receive the full coverage to which they are entitled.

 

The Jimmo Settlement Agreement may reflect a change in practice for those providers and contractors who may have erroneously believed that the Medicare program covers nursing and therapy services under these benefits only when a beneficiary is expected to improve. The Settlement Agreement is consistent with the Medicare program’s regulations governing maintenance nursing and therapy in skilled nursing facilities, home health services, and outpatient therapy (physical, occupational, and speech) and nursing and therapy in inpatient rehabilitation hospitals for beneficiaries who need the level of care that such hospitals provide.

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On Thursday, June 29, 2017, the Centers for Medicare and Medicaid Services (CMS) and the Office of Medicare Hearings and Appeals (OMHA) will host a call from 1:00 pm to 3:00 pm that will focus on the recent regulatory changes to the Medicare claims appeals process. There will also be discussion surrounding the Medicare Appeals Final Rule that was published in the January 17, 2017 Federal Register, as well as the changes that are intended to streamline the administrative appeals processes, reduce the backlog of pending appeals, and increase the consistency in decision making across appeal levels.

To participate in the call, registration is required by 12:00 pm on June 29, or until the event is full. Following the presentation, time will be allocated to a session for questions and answers.

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In the May 13, 2017 PA Bulletin, the Department of Human Services (Department) made available for public review and comment the Medical Assistance Quality Strategy for Pennsylvania.

The Department is complying with Centers for Medicare and Medicaid Services’ (CMS) requirement that states draft and implement a written quality strategy for assessing and improving the quality of health care and services furnished by managed care organizations that have a contract with the Department. As a result, the Department has developed the Medical Assistance Quality Strategy for Pennsylvania, which discusses the various quality improvement initiatives the Department has implemented to increase the quality of care for individuals receiving services through its managed care programs. The Medical Assistance Quality Strategy for Pennsylvania is not intended to comprehensively describe all the activities that the Department undertakes to assure the quality of care rendered to individuals who are receiving services through managed care programs.

The Department’s quality strategy will be used to assure that the contractors that are implementing the Department’s managed care programs are in compliance with the terms of their agreements with the Department and have committed resources to meet the following: to perform monitoring and ongoing quality improvement; to contribute to the improvement of health for the populations they serve; and to incorporate new programmatic changes to assure that the individuals they serve have timely access to high-quality care.

The Medical Assistance Quality Strategy for Pennsylvania will include programs and initiatives within the following:

  • The Office of Medical Assistance Programs, Bureau of Managed Care Operations;
  • The Office of Mental Health and Substance Abuse Services;
  • The Office of Long-Term Living Community HealthChoices;
  • CHIP; and
  • Adult Community Autism Program (ACAP).

The Medical Assistance Quality Strategy for Pennsylvania can be viewed here and interested persons are invited to submit comments regarding the Medical Assistance Quality Strategy for Pennsylvania to the Department via email. Comments received within 30 days must be reviewed and considered before the Quality Strategy is submitted to CMS for review.

Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at 800-654-5984 (TDD users) or 800-654-5988 (voice users).

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The Centers for Medicare and Medicaid Services (CMS) published a final rule; delay of effective date notice in the February 17, 2017 Federal Register that delays the effective date of the rule, “Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement (CJR) model.” This notice clarifies that, in accordance with the White House’s regulatory freeze, provisions of CMS’ bundled payment final rule that were to become effective on February 18, 2017, are now delayed until March 21, 2017.

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On February 23, 2017, from 1:30 pm to 3:00 pm, the Centers for Medicare and Medicaid Services (CMS) will host a call, “Looking Ahead: The IMPACT Act in 2017,” focusing on the Improving Medicare Post-Acute Care Transformation (IMPACT Act) of 2014. The IMPACT Act requires the reporting of standardized patient assessment data by post-acute care (PAC) providers, including inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), home health agencies (HHAs), and long-term care hospitals (LTCHs). Agenda topics during this call will include the requirements, goals, progress to date, and key milestones for 2017. CMS will also convene a question and answer session following the presentation. To participate in the call, registration is required.

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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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The Centers for Medicare and Medicaid Services (CMS) recently approved five new employment-related services in the Office of Long-Term Living’s (OLTLs) CommCare and Independence waivers. The services offer providers an opportunity to expand their profiles, particularly those who have been providing prevocational services and supported employment. Listed below are the new services, their credentialing and certification requirements, and rates that will be paid for the services.

  • Benefits Counselors must hold a Certified Work Incentives Counselor (CWIC) certification that is accepted by the Social Security Administration for its Work Incentives Planning and Assistance program. To learn more about CWIC, visit this web page.
  • Employment Skills Development (replaces Prevocational Services), Job Coaching (replaces Supported Employment), Job Finding, and Career Assessment workers must hold one of the following:
  1. A Certified Employment Support Professional (CESP) credential from the Association of People Supporting Employment First (APSE); and
  2. A Basic Employment Services Certificate of Achievement or Professional Certificate of Achievement in Employment Services from an Association of Community Rehabilitation Educators (ACRE) organizational member that has ACRE-approved training. Individuals without one of these certifications must be supervised by an individual holding the above certification until certification is achieved. Certification must be achieved within 18 months of employment.

Information on APSE credentialing can be found here.
Information on how to receive a certificate of achievement from ACRE can be found here.

(NOTE: Employment Skills Development services that are provided in vocational rehabilitation facilities that fall under 55 PA Code Chapter 2390 are not required to have the above credential or certification. Employment Skills Development services provided in the community do require the above credential or certification.)

A complete description of these services and provider qualifications can be found in the CommCare and Independence waivers here.

NOTE: OLTL has scheduled a webinar on Friday, November 18, 2016 at 1:00 pm to review and discuss these new services. Registration is required to participate.

Listed below are the rates for the new employment services:

 
Service PT/Spec CC IW Procedure Code Modifier Region 1 Region 2 Region 3 Region 4 Unit
Benefits Counseling 59/502 X X W1740 $9.78 $10.21 $10.54 10.87 15 mins
Career Assessment 59/503 X X W1732 $11.12 $12.12 $12.39 12.67 15 mins
Employment Skills Development (1:1) 59/505 X X W1728 $9.44 $11.22 $10.07 10.12 15 mins
Employment Skills Development (1:2 to 1:3) 59/505 X X W1729 $3.77 $4.49 $4.03 4.05 15 mins
Employment Skills Development (1:15) 59/505 X X W1741 $6.29 $6.50 $6.96 6.54 15 mins
Job Coaching 1:1 (Follow-Along) 59/504 X X W1733 U5 $9.78 $10.21 $10.54 10.87 15 mins
Job Coaching 1:2 to 1:4 (Follow-Along) 59/504 X X W1734 U5 $3.26 $3.40 $3.51 3.62 15 mins
Job Coaching 1:1 (Intensive) 59/504 X X W1733 U4 $9.78 $10.21 $10.54 10.87 15 mins
Job Coaching 1:2 to 1:4 (Intensive) 59/504 X X W1734 U4 $3.26 $3.40 $3.51 3.62 15 mins
Job Finding 59/530 X X W1735 $11.15 $12.11 $11.98 12.34 15 mins

 

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In July 2016, the Centers for Medicare and Medicaid Services (CMS) proposed new bundled payment models to shift Medicare payments from rewarding quantity to rewarding quality by creating strong incentives for hospitals and clinicians to deliver better care to patients at a lower cost. These proposed new bundled payment models focus on heart attacks, heart bypass surgery, and hip fracture surgery, and would reward hospitals that work together with physicians and other providers to avoid complications, prevent hospital readmissions, and speed recovery. This proposal follows the implementation of the Comprehensive Care for Joint Replacement (CCJR) Model that began earlier this year which introduced bundled payments for certain hip and knee replacements.

CMS just released the second annual evaluation report for Models 2–4 of the Bundled Payments for Care Improvement (BPCI) Initiative, which include both retrospective and prospective bundled payments that may or may not include the acute inpatient hospital stay for a given episode of care. This report describes the characteristics of the participants and includes quantitative results from the first year of the initiative. Key highlights include:

  • 11 out of the 15 clinical episode groups analyzed showed potential savings to Medicare. Future evaluation reports will have more data to analyze individual clinical episodes within these and additional groups;
  • Orthopedic surgery under Model 2 hospitals showed statistically significant savings of $864 per episode while showing improved quality as indicated by beneficiary surveys. Beneficiaries who received their care at participating hospitals indicated that they had greater improvement after 90 days post-discharge in two mobility measures than beneficiaries treated at comparison hospitals; and
  • Cardiovascular surgery episodes under Model 2 hospitals did not show any savings yet but quality of care was preserved. Over the next year, we will have significantly more data available, enabling CMS to better estimate effects on costs and quality.

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The Centers for Medicare and Medicaid Services (CMS) has announced that the inpatient rehabilitation facility (IRF) quality reporting program (QRP) provider preview reports are currently available until September 30, 2016. Members are encouraged to preview the performance date on each quality measure prior to public display on the IRF Compare website. While corrections to the underlying data will not be permitted during this timeframe, members can request a CMS review during the 30-day preview period if you feel the data is inaccurate. Additional information, including instructions on how to access preview reports, is available from the IRF Quality Public Reporting web page.

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RCPA members are reminded to consider soliciting nominations for a Technical Expert Panel (TEP) that will provide input on two new quality measures in development for post-acute care providers (including inpatient rehabilitation facilities, skilled nursing facilities, long-term care hospitals, and home health agencies).

The Centers for Medicare & Medicaid Services (CMS) has contracted with RTI International and Abt Associates to develop and refine a cross-setting, post-acute care transfer of health information and care preferences quality measure as required by the Improving Medicare Post-Acute Care Transformation Act of 2014. The two new quality measures include:

  • Transfer of Information at Post-acute Care Admission, Start, or Resumption of Care from Other Providers/Settings; and
  • Transfer of Information at Post-acute Care Discharge or End of Care to Other Providers/Settings.

In alignment with the CMS and National Quality Strategy objectives and goals, the purpose of this project is to develop, maintain, re-evaluate, and implement measures that will drive high quality in post-acute care through CMS’ quality reporting programs. This includes the inpatient rehabilitation facility, skilled nursing facility, long-term care hospital, and home health quality reporting programs.

CMS is seeking technical experts with expertise in care transitions and information transfer during transitions, admission and discharge planning, and care coordination, among other areas of knowledge. The call for technical expert panel members is open through August 21, 2016.

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