RegWatch


Public charge rule uncertainty remains – As the Administration considers enforcing regulations designed to reduce costs of immigration, the impact of changes to the rule are being quantified. A study published in JAMA estimates about 8M children could lose CHIP and/or SNAP benefits. The Department of Homeland Security sent the rule to OMB for scoring on July 12.

Further reading

https://psmag.com/news/millions-of-kids-could-lose-health-insurance-and-food-assistance-under-trumps-public-charge-rulehttps://www.natlawreview.com/article/dhs-completes-public-charge-rule-forwards-to-omb

New CMS guidance to states on Medicaid eligibility- After several high profile reports of states failing to properly use Medicaid eligibility criteria, CMS issued new guidance late June. The new guidance includes checklists that focus on program integrity functions, continual assessment of eligibility criteria and improvements of systems. Statements from the Administrator emphasize that the explosive enrollment growth under ACA overwhelms current eligibility verification practices, and a renewed push for monitoring is warranted.

Further reading

https://www.fiercehealthcare.com/payer/cms-issues-guidance-aimed-at-ensuring-states-are-appropriately-vetting-medicaid-eligibility

CMS comprehensive review of nursing homes regulation – As part of the continued push to improve nursing home quality, Administrator Verma announced a new, comprehensive review of regs, guidance and oversight. Key components of the next phase include more CMS coordination with State Survey Agencies (SSAs) that report on nursing home issues, increased use of Medicare claims to identify adverse outcomes (including possible use of AI for identifying predictive indicators), and adding improper antipsychotic use to publicly reported measures. CMS will spend $440M on new efforts along these lines, with $45M more this year for enforcement efforts tied to SSA reviews.

Further reading

https://skillednursingnews.com/2019/04/cms-chief-verma-orders-review-of-federal-nursing-home-regulations-defends-progress-so-far/

https://www.healthleadersmedia.com/strategy/cms-launches-comprehensive-review-nursing-homes-regulation

PACE regulations get updated- CMS released (June) an update to the overall Program for All-Inclusive Care for the Elderly (PACE) regulatory framework which touched on various areas, including: Corporate structure, compliance, and participants rights. On the clinical side, the new regs allow more use of non-physicians on the interdisciplinary care teams assigned to each member.

Further reading

https://www.natlawreview.com/article/cms-updates-pace-regulations-elderly-care

https://www.healthleadersmedia.com/nursing/final-pace-rule-allows-non-physicians-fill-pcp-shoes-some-services

New CMS rules on Duals plans- CMS finalized a rule (April) to implement several provisions of the Bipartisan Budget Act of 2018 related to Medicare Advantage Special Needs Plans. In addition to revised definitions for certain types of SNPs, CMS also provided comments that it may consider dual eligible “look alike” plans for further scrutiny in the near future. CMS also released guidance (also in April) via a State Medicaid Director letter describing ways to improve integration across the Medicare and Medicaid benefit designs in duals.

Further reading

https://www.modernhealthcare.com/insurance/cms-may-start-cracking-down-dual-eligible-look-alike-plans

https://www.modernhealthcare.com/care-delivery/cms-invites-states-test-new-dual-eligible-care-models

Reactions to the Interoperability Rule- The rule was released in February, and comments continued to come in through June (CMS extended the window for comments by 30 days). Most responses were positive, including 6 former heads of the Office for the National Coordinator for Health Information Technology (ONC) who weighed in via a Health Affairs article. Most commenters lauded the expanded use of APIs and the adoption of HL7 as a tech standard for data sharing. The rule has important provisions (including potential penalties such as listing violators online) for providers or organizations (including health plans) who are found to be practicing “information blocking.” The enforcement of the rule can also leverage the Medicare conditions of participation for non-compliant providers and plans. Some analysts (and one Senator) have expressed concerns about needing more time to implement the rule.

Further reading

https://www.healthaffairs.org/do/10.1377/hblog20190604.428654/full/

https://www.modernhealthcare.com/government/top-gop-senator-calls-cms-delay-interoperability-rule

https://www.healthcareitnews.com/news/himss-onc-and-cms-open-apis-key-enablers-innovation-competition

Home health workers Medicaid payments and union dues- Some states allow unions to automatically deduct dues from home health workers paychecks. Recent efforts to stop this practice (on grounds that Medicaid monies can not be used to fund unions, since they are not a contracted healthcare provider) have met with lawsuits in several states. The CA Attorney General has led the charge to keep the union financing in place, and filed suit to block a new CMS rule aiming to stop the practice. The SCOTUS ruled (in 2014) that union dues for home health workers must be voluntary. A total of $1.4B in Medicaid funding has gone to union dues since 2000.

Further reading

https://www.modernhealthcare.com/government/california-sues-us-over-home-health-worker-union-dues

https://cei.org/blog/trump-administration-ends-homecare-providers-dues-skim

https://www.modernhealthcare.com/government/cms-stops-medicaid-paying-home-health-union-dues

Rural hospitals wage index changes- CMS announced changes to the hospital wage index. The changes will raise the index for hospitals with lower wages (mostly rural) and decrease it for higher-wage hospitals. If the plan goes through, rural hospitals will start seeing a 3.2% increase in wages this October. The total bill is expected to be about $4.7B for the increase.

Further reading

https://www.modernhealthcare.com/government/cms-throws-rural-hospitals-lifeline-wage-index-changes

Final telehealth rule issued (Medicare Advantage)- CMS finalized a new rule (April) to implement provisions of the Bipartisan Budget Act of 2018, including allowing MA plans to deliver care via telehealth. The rule relaxes requirements around where the telehealth visit occurs (moving beyond the legacy originating site / destination site model). Telehealth can now also be included in the basic benefits that MA plans use to bid proposals (previously it was included only as a supplemental benefit). CMS also clarified that certain CPT codes used for telehealth can now also be billed by auxiliary personnel and not just the physician (related to Medicare “incident to” billing policies). Plans may not replace in person services with telehealth services under the new rule (they must continue to offer in person services for the same services being provided via telehealth).

Further reading

https://www.natlawreview.com/article/cms-issues-final-rule-telehealth

https://mhealthintelligence.com/news/cms-tweaks-cpt-code-for-remote-monitoring-giving-mhealth-a-boost

https://www.thinkadvisor.com/2019/04/05/medicare-advantage-issuers-can-put-telehealth-in-2020-basic-benefits-cms/?slreturn=20190528092311

https://www.businessinsider.com/cms-loosens-medicare-advantage-telehealth-regulations-2019-4

CMS weighs in on various Rx issues, including PBM spread pricing- CMS guidance released in May clarified that plans must consider spread pricing in MLR calculation. CMS is concerned that MLR rates are artificially high because they include spread pricing PBM margins in the medical costs. In other Rx news, CMS also finalized a rule (May) that requires manufacturers to show list prices for drugs in TV commercials (for any drugs that cost more than $35 for a month’s supply).

Further reading

https://healthpayerintelligence.com/news/cms-addresses-prescription-drug-price-spreading-issues

https://www.modernhealthcare.com/government/drug-prices-must-be-tv-ads-under-cms-final-rule

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