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ConferenceOHA Update
March 20, 2014
Charles CatalineVP Health Economics & Policy
Alyson DeAngeloDirector Health Economics & Policy
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Agenda• Federal Update
• Medicare CY 2014 OPPS Enhanced Packaging• ICD.10• Medicare RAC Re-Bid• “Two-Midnights Rule:” What’s Next?
• State Update• Medicaid Expansion Kicks in
• Electronic Eligibility Rollout• Hospital- Based Presumptive Eligibility • 2014 HCAP Formula Updated to Respond to Eligibility Expansion
• DSH Audits: FFY 2011 Report & FFY 2012 Recommendations• OHT SIM Grant & Episodic Payments• MyCare Ohio Rollout• Medicaid Telemedicine Coverage• Medicaid Modernization II• APR-DRG Conversion: FFY 2015 = Conversion Year Two
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CY 2014 Medicare OPPS • Started Jan. 1, Regardless of Delay - Overall 1.7% increase• Changed E&M Reimbursement in Clinics
Just One Reimbursable “G” Code Paid at APC Level Does Not Affect Medicaid in CY 2014
Good News on Medicare ED E&M (for now?)• Big Movement Toward Additional APC Packaging & “Comprehensive
APCs” Is This the Slow Start of Real Outpatient Encounter- Based Reimbursement?• Packaging addl. Diagnostic & Surgical Drugs/Biologicals, Diagnostic
Tests, Add-on Codes & Device Removal• Comprehensive APCs for “Device-Dependent” APCs
• Additional Quality Standards• Tighter Supervision Standards at CAH’s
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ICD.10• CMS Says Oct. 1, 2014 is Hard Deadline
• Ohio Medicaid & BWC on board, too!• Commercial payers and trading partners ?????• Congress would have to intervene to change date
• Medicare, Medicaid, BWC Testing Underway• Limited Medicare Provider Bill-to-Payment Testing Scheduled
• MACs converting LCDs & opening web-based test site• Instructions on split bills out (DOS 10/1/14); See CR 7492
• No formal word from commercials !
• Effects on 2015 DRGs, IPPS Update & Budget Neutrality?• Initial Medicaid results are troubling!!• Clinical documentation more important than ever!
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Medicare RAC Re-Bid• RAC Contract Rebid on Hold Until June 1 (?)
• New Regions Drawn to Re-Weigh Claims Volume• Existing Region B Subdivided – at the Very Least Some States in
Region B Must Switch Contractors
• CMS will “Pause” Medicare RAC Activity Until New Contracts are in Place• Feb. 21 – Last Day a RAC can Issue Post-Payment ADR• Feb. 28 – Last Day a MAC can Issue ADR for RAC Pre-Pay Review Demo• June 1 – Last Day a RAC Can Send Denied Claims to MAC for Recovery
• Once New RACs are in Place ADRs will be Released Retro to Start of Program “Pause”
• In the Interim, CMS will Continue to “Refine” Medicare RAC Program, Starting with…
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Medicare RAC Map – Old v. New
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CMS: Five Medicare RAC Improvements
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Medicare “Two Midnights Rule”• Biggest Reason for New Policy is Huge Backlog of Short-Stay
Appeals at ALJ, but “Two Midnight Rule” Still Controversial• CMS Re-Extended Partial Enforcement Delay Through Sept. 30
• RACs and MAC Cannot (Ever) Perform Post-Pay Reviews of Short Stays with Dates of Admission from 10/1/13 – 9/30/14
• Medical Necessity and Coding Reviews can Continue
• MAC Pre-Payment “Probe & Educate” Reviews Continue on Claims from Same Period, With Additional CMS Guidelines • Jan. 30 - Admission Guidelines; Feb. 24 - Review Guidelines, Updated
FAQs, and P&E Project Status Update with Common Denials• MACs Ordered to Re-Review Earlier P&E Rejections to Ensure They
Abide by Latest Clarifications
• AHA Surveying MAC Activity, Claims Volume and Results
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Medicaid Expansion Kicks In• Started Jan 1. 2014
• Ohio Supreme Court : Controlling Board-Based Expansion is Constitutional!!
• Electronic and Expedited Application Software went Live Dec. 9 at “benefits.ohio.gov” • Linked to Federal Data Hub• No CPJFS Visit Required • Utilize MAGI Standards• No Documentation Required
• Presumptive Eligibility Roll- Out Continues - Watch for Quality Standards• OHA Advocating for Additional Direction on Overall Process &
Preparing “Intake” Tool Kit. Stay Tuned!!
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Potential Medicaid Expansion by County
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Medicaid On-line Eligibility System• benefits.ohio.gov Live as of Dec. 9, 2013• Designed to Interact with the Federal “Data Hub” to Provide a “No
Touch” Application Experience • However, Most Cases Currently Still Need to be Completed by
Follow-up with a County JFS Case Worker• Expansion as of February…
– 23,156 have enrolled– 9% of estimated 275,000– About 90,000 Medicaid applications are stuck between federal and state
systems – county JFSs are working to resolve– State expects to enroll 500,000 in next 18 months – about 231,000 from
“woodwork• Direct people to benefits.ohio.gov even if they tell you they’ve
completed an application through healthcare.gov
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Medicaid Presumptive EligibilityPE Today•Pregnant women and children only•Entered through MITS•Currently 44 hospitals are Qualified Entities•Coverage is for outpatient pregnancy related services and all services for childrenPE in the Near Future•All Medicaid populations•PE portal through the integrated eligibility system•All hospitals can become qualified entities•We are waiting for the state to finish the PE portalThe Hospital is Responsible for Following Through with Patient to get Full Medicaid Application Completed
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2014 HCAP Distribution Formula • Concerns:
• (OHA) The Combination of Retroactive FFY 2014 Medicaid DSH Audits (Myers & Stauffer) with the CY 2014 Medicaid Expansion Could Cause big Medicaid DSH Payment Recoveries from Some Hospitals
• (ODM) CMS is increasingly Demanding Medicaid DSH Programs Follow Uninsured & Medicaid Losses
• But… How Valid is the Expansion Projection for 2014?• Many Hospitals Currently Reporting Lower than Projected Medicaid
Eligibility “Uptake”
• Finance Committee Recommends 2014 Compromise for HCAP Distribution Model• Assume 50% of Projected Medicaid Expansion Uptake for FFY 2014• Protect Existing Special Allocations (Pots)• Merge Some $$ for High DSH, UC<FPL & UC>FPL ; Link to OBRA Cap• Reexamine in 2015
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DSH Audits: FFY 2011 Report & FFY 2012 Recommendations
OHA Task Force on Medicaid DSH Audits Recommendations
•Limit New Data Elements for SFY 2014 Cost Reports / Logs•Revive Medicaid Paid Claims Report (“PS&R”)•Consider Permanent Delay to Cost Report Due Date•Report All Charges (CR & LOGS) Based on Date of Service; All Payments Based on Date of Payment / Recovery•Clarify Whether ODM Wants all Payments Reported in Schedule F or Just Uncompensated Payments•Revise Schedule F Data Review “Agreed-Upon-Procedures”
• Eliminate DA• Revise Sample Size to Increased Hospital Revenue
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OHT SIM Grant & Episodic PaymentsState Innovation Models – Episodic Payments
• State Seeking CMS Grant• Governor’s Advisory Council on Health Care Innovation 5-
Year Plan• Develop Comprehensive Primary Care Initiative• Create Payment System for Selected Clinical Episodes
• Episodic Payments Involve the Assignment of a “Primary Accountable Provider” to be Responsible for Managing “Costs” in the Treatment of Selected Episodes Using a Retrospective Risk/Gain Sharing Program.• OHA Meeting with Medicaid & Office of Health
Transformation
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Ohio Medicaid/Medicare Dually Eligible Integrated Delivery System Demonstration
(AKA “MyCare Ohio”) • Target Population
o Full-Benefit Dual Eligible Enrollees Excluding:• Those Eligible for the Medicare Savings Program• Dual Eligibles with Intellectual and Developmental Disabilities
Served Through an IDD 1915(c) HCBS Waiver or an ICF-IDD. – Those Not Under Waiver can Opt In
• Dual Eligibles Enrolled in PACE• Dual Eligibles under 18
o Duals With “Severe or Persistent Mental Illness” will be Includedo Individuals with SPMI in the Demonstration do not Have to Change
Providers for Behavioral Health Services.
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MyCare Ohio Dually Eligible Integrated Delivery Demo • Model Design
o At Least Two Competing Health Plans in each of Seven Regions Chosen for the Demonstration (Most Rural Areas Exempt)
o Enrollees can Choose Between the Health Plans in Their Region• All Regions Have at Least 3 Medicare Advantage Plans Currently
Serving Medicare Beneficiarieso The Demonstration will Auto-Enroll the Eligible Population With an
Option to Opt in for Medicare-Covered Benefits• If They Don’t Opt in for Medicare They Will Still be Enrolled in
Medicaid Managed Care• Enrollees Will Have the Option of Switching Plans and can Opt
into / out of Medicare at any Timeo Utilizes a “Payment Structure That Blends Medicare and Medicaid
Funding”
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MyCare Ohio Dually Eligible Integrated Delivery Demo
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•Approx. 196,000 Medicare-Medicaid Enrollees in Ohio Are Currently Receiving Benefits Primarily Through FFS•Approx. 115,000 Included in the Demonstration Program•Medicaid Enrollment Starts May1 and is Phased in Through June & July•Individuals have up to Eight Months to Decide Medicare Status•Starting Jan. 2015, Individual who Have not Chosen a Medicare Plan will be Enrolled in a MyCare Ohio Plan, but they still have the Option to Return to Medicare FFS or Medicare Advantage if they Choose
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MyCare Ohio Dually Eligible Integrated Delivery Demo • Draft Payment System
o Medicare and Medicaid will Contribute to the Blended Payments in a Manner that Expected Aggregate Savings are Proportionately Shared Between the two Programs
o The Blended Capitation Payment Structure is Expected to Provide Plans the Flexibility to Utilize the Most Appropriate Cost Effective Service for the Enrollee, Eliminating Incentives to Shift Costs Between Medicare and Medicaid
o Reimbursement will Include Pay-for-Performance Incentives
• OHA’s Concernso Can MCPs Really Integrate and Manage this Array of Providers,
Agencies and Services?o How Would This Affect Existing UPL Programso Is it Right to Limit Enrollees Freedom of Choice?
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Medicaid TeleHealth Coverage• Proposed Rule Out (OAC 5160-1-18)• “Originating” v. “Distant” Sites Defined
• Sites Must be at Least Five Miles Apart, Unless Emergency or when Travel Poses “Undue” Patient Hardship
• Coverage Limited to:• Originating = Dr. Office, Hospital, FQHC, Nursing Facility
• Distant = Consulting Practitioner• Payment = Lesser of Billed Charge or Fee Schedule
Amount• Originating =
• E&M (Only if Service is Separately Billable)• Telehealth “Originating” Fee
• Distant = Normal Professional Claim for Service
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Medicaid Modernization II
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APR-DRG Conversion: FFY 2015 = Conversion Year Two
SFY 2014 Policy Shifts •CMS Grouper 15 to 3M APR-DRG •Outliers Policy Changed to Mirror Medicare•New Peer Group Base Rates•Newly Calibrated Relative Weights•Stop Loss/Stop Gain Applications Within Peer Groups•Med-ed Payments Held Harmless
What’s Next for 2015 ? •New APR-DRG Starts Each Year with Discharges 10/1 and After •Stop Loss/Gain Transition Moves to Year Two•Accuracy of Payments & Projections – Rebalance to Come?•Additional Discussion Expected About:
– Peer Groups, Next Scheduled DRG Re-base & Re-Calibration, Medical Education Payments, HAC, Other?
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