Tags Posts tagged with "CMS"



Hello ANCOR Members,

Earlier this afternoon, POLITICO Pro Health Care reported that, in a tweet today, Centers for Medicare and Medicaid Services (CMS) Director Seema Verma announced that the agency is officially withdrawing the Medicaid Fiscal Accountability Regulation (MFAR) from the Federal Register.

Verma wrote, “While we support its intent, further work is needed to ensure accountability for states while protecting critical safety-net care for vulnerable patients.”

As you recall, the American Network of Community Options and Resources (ANCOR), like many of you, submitted comments when the MFAR was originally proposed about a year ago, and we have continued to track its progress since. We are pleased to notify you of this update.

Donna Martin
American Network of Community Options and Resources
Alexandria VA

The Centers for Medicare and Medicaid Services (CMS) issued guidance to state health officials designed to drive the adoption of strategies that address the social determinants of health (SDOH) in Medicaid and the Children’s Health Insurance Program (CHIP) so that states can further improve beneficiary health outcomes, reduce health disparities, and lower overall costs in Medicaid and CHIP. SDOH describe the range of social, environmental, and economic factors that can influence health status—conditions that can often have a greater impact on health outcomes than the actual delivery of health services. The new guidance describes how states can leverage existing flexibilities under federal law to tackle adverse health outcomes that can be impacted by SDOH. It also supports states in designing programs, benefits, and services that can more effectively improve population health and reduce the cost of caring for our nation’s most vulnerable and high-risk populations.

The United States spends more on health care than almost any other country yet often underperforms on key health indicators, including life expectancy, reducing chronic heart disease, and maternal and infant mortality rates. According to the CMS Office of the Actuary, national health spending is projected to grow rapidly and reach $6.2 trillion by 2028. For its part, in 1985, Medicaid spending consumed less than 10 percent of state budgets and totaled just over $33 billion dollars. In 2019, that number had grown to consume 29 percent of total state spending at a total cost of $604 billion dollars.[1]

To address the contradiction between rising costs and low health outcomes, CMS has committed to accelerating the industry’s shift from traditional fee-for-service payment models to value-based models that hold clinicians accountable for cost and quality. As part of its continued efforts to advance value-based care, CMS recently issued guidance to state Medicaid directors to encourage the incorporation of value-based strategies across their health-care systems, allowing states to provide Medicaid beneficiaries with efficient, high-quality care while lowering cost and improving health outcomes. The guidance also noted that the adoption of value-based care arrangements could better provide opportunities for states to address SDOH as well as disparities across the health-care system.

“The evidence is clear: social determinants of health, such as access to stable housing or gainful employment, may not be strictly medical, but they nevertheless have a profound impact on people’s wellbeing,” said CMS Administrator Seema Verma. “Unfortunately, our fee-for-service system inherently limits the doctor-patient relationship to what can be accomplished inside the four walls of a clinician’s office. Today’s letter to state health officials highlights strategies by which states can promote a value-based system that fosters treatment of the whole person and lowers health-care costs. Patients are more than a bundle of medical diagnoses, and it’s time our health-care system treated them as such.”

With the release of today’s SDOH guidance, CMS acknowledges that an understanding of the social, economic, and environmental factors that affect the health outcomes of Medicaid and CHIP populations can be an integral component of states’ efforts to realign incentives, reduce costs, and advance value-based care in their health systems.

The guidance recognizes that Medicaid and CHIP beneficiaries face challenges related to SDOH, including but not limited to access to nutritious food, affordable and accessible housing, quality education, and opportunities for meaningful employment.

Growing evidence indicates that these challenges can lead to poorer health outcomes for beneficiaries and higher health-care costs for Medicaid and CHIP programs. They can also exacerbate health disparities for a broad range of populations, including individuals with disabilities, older adults, pregnant women, children and youth, individuals with mental health and/or substance use disorders, and individuals living in rural communities.

SDOH can affect health-care utilization and cost, health outcomes, and health disparities. For example, the on-going COVID-19 pandemic has exacerbated long-understood disparities in health outcomes among low-income populations, particularly children. Recent Centers for Disease Control and Prevention (CDC) data indicate that counties with greater social vulnerability, including high poverty rates and crowded housing units, were more likely to become COVID-19 hotspots, potentially putting those who experience economic and housing constraints at a higher risk of contracting the virus. Additionally, with many schools closed for in-person learning due to COVID-19 restrictions, some low-income children have less access to free non-academic supports that affect their health and well-being, including food assistance, counseling services, and homelessness and maltreatment interventions. According to CMS’s own data, some children are also forgoing key services they might receive such as child screens and vaccinations prior to the start of the school year or in-school services such as speech therapy, physical therapy, and occupational therapy, demonstrating the influence that social networks and physical environment can have on children’s health.

Current research indicates that some social interventions targeted at Medicaid and CHIP beneficiaries can result in improved health outcomes and significant savings to the health-care sector. These investments can also prevent or delay beneficiaries needing nursing facility care by offering services to facilitate community integration and participation and help keep children on normative developmental trajectories in education and social skills.

The SDOH guidance details how state Medicaid and CHIP programs can utilize a variety of delivery approaches, benefits, and reimbursement methodologies to improve beneficiary outcomes. States can use different federal authorities that can provide them with flexibility to design an array of services to address SDOH and that can be tailored, within the constraints of certain federal rules, to address state-specific policy goals and priorities, including the movement from volume-based payments to value-based care, and the specific needs of states’ Medicaid and CHIP beneficiaries.

While states have flexibility to design a number of different services to address SDOH, the guidance focuses on a set of services and supports that states can cover under current law, including housing-related services and supports, non-medical transportation, home-delivered meals, educational services, and employment supports. CMS remains committed to partnering with states to address beneficiaries’ SDOH. When used in accordance with statutory and regulatory requirements, the Medicaid and CHIP programs are uniquely positioned to help states lower health-care costs, improve health outcomes, and increase the cost-effectiveness of health-care services and interventions for its beneficiaries.

CMS has placed an emphasis on addressing SDOH across all of its programs in its continued efforts to move toward a value-based model of care delivery.


The Centers for Medicare and Medicaid Service (CMS) has approved the Office of Long-Term Living’s (OLTL) Community HealthChoices (CHC) Waiver amendment, which became effective on January 1, 2021.

Some of the changes in the approved amendment include:

  • Revised service definitions, service limitations, and/or provider qualifications for the following CHC waiver services:
    • Assistive Technology;
    • Career Assessment;
    • Cognitive Rehabilitation Therapy Services;
    • Community Transition Services;
    • Home Adaptations;
    • Job Coaching;
    • Job Finding;
    • Nutritional Consultation;
    • Participant-Directed Community Supports;
    • Participant-Directed Goods and Services;
    • Personal Assistance Services;
    • Personal Emergency Response System (PERS);
    • Respite;
    • Specialized Medical Equipment and Supplies; and
    • Vehicle Modifications.
  • Amended responsibilities of the fiscal/employer agent
  • Revised waiver performance measures

Questions about the 2021 CHC amendment can be submitted here.

The Centers for Medicare and Medicaid Services (CMS) has released an Interim Final Rule with Comment Period that will establish a new COVID-19 treatments add-on payment (NCTAP) under the Medicare Inpatient Prospective Payment System (IPPS), which is effective from November 2, 2020, until the end of the Public Health Emergency (PHE) for COVID-19. To mitigate potential financial disincentives for hospitals to provide new COVID-19 treatments during the COVID-19 PHE, the Medicare program will provide an enhanced payment for eligible inpatient cases that involve the use of certain new products with current Food and Drug Administration (FDA) approval or emergency use authorization to treat COVID-19. Comments will be accepted until the close of business on January 4, 2021.

New opportunity offers a more holistic approach to care for individuals while aiming to reduce overall spending across both programs.

The Centers for Medicare and Medicaid Services’s (CMS) Center for Medicare and Medicaid Innovation is announcing a new opportunity to enable Medicaid Managed Care Organizations (MCOs) to better serve enrollees who are dually eligible for Medicare and Medicaid. This new model opportunity is the first CMS initiative designed to harness the power of Medicaid MCOs to coordinate Medicare and Medicaid services and improve health outcomes for the population of dually eligible beneficiaries who are in both Medicaid managed care and Medicare fee-for-service (FFS).

Currently, Medicaid MCOs do not have an incentive to coordinate care in a way that reduces Medicare FFS costs for dually eligible beneficiaries. By better aligning incentives, the new opportunity for MCOs to participate in the global and professional options of the direct contracting model seeks to encourage Medicaid MCOs to partner with providers and suppliers and implement care coordination programs that can improve quality and reduce Medicare FFS costs.

“Beneficiaries eligible for both Medicare and Medicaid are some of our most vulnerable neighbors and friends, and the COVID-19 pandemic has made this abundantly clear as this population has had some of the highest rates of hospitalizations for COVID-19,” said CMS Administrator Seema Verma. “For too long, we have struggled to deliver acceptable outcomes for this vulnerable population, but today’s model is a game changer. It represents a significant step toward addressing these long-standing issues and ensuring that they receive the coordinated care that they rightfully deserve.”

Some examples of the actions MCOs and their affiliates serving as MCO-based Direct Contracting Entities (DCEs) – organizations that participate in direct contracting via a participation agreement with CMS – can take to better serve dually eligible beneficiaries include:

  • Establishing processes to connect aligned beneficiaries to a primary care provider, particularly high-value Medicare fee-for-service health-care providers;
  • Risk-stratifying and targeting care coordination resources toward aligned beneficiaries at risk of high Medicare spending;
  • Deploying care coordinators or in-home aides who provide Medicaid long-term services and supports to also actively promote flu vaccines, preventive screenings, evidence-based falls prevention, and diabetes management activities;
  • Having care coordinators or in-home aides who provide Medicaid long-term services and supports assist enrollees with managing Medicare-covered medical appointments to help reduce missed treatments;
  • Training in-home aides – who often cook meals for their clients – in meal preparation for individuals with nutrition-sensitive conditions such as diabetes; and
  • Entering into value-based purchasing arrangements with nursing facilities that factor in facilities’ hospitalization rates.

In 2019, 12.2 million Americans were concurrently enrolled in both Medicare and Medicaid. Dually eligible individuals are an especially high needs population with 70 percent of dually eligible individuals having three or more chronic conditions and more than 40 percent having at least one mental health diagnosis. These dually eligible individuals must navigate two separate programs for their health care: Medicare for the coverage of most preventive, primary, and acute health-care services and drugs and Medicaid for coverage of long-term services and supports, certain behavioral health services, and for help with Medicare premiums and cost sharing. A lack of alignment and cohesiveness between Medicare and Medicaid can often lead to fragmented and episodic care for dually eligible individuals. This can result in reduced quality of care for these individuals as well as increased costs to both the Medicare and Medicaid programs. Dually eligible individuals account for approximately 20 percent of all Medicare enrollees but more than one-third of Medicare costs.

CMS believes that dually eligible individuals can benefit from more integrated systems of care that meet all of their needs – primary, acute, long-term, behavioral, and social – in a high quality, cost-effective manner. This new opportunity to participate in direct contracting creates the incentives and flexibilities for Medicaid MCOs to better integrate care for these beneficiaries.

To ensure that the participation of MCO-based DCEs in direct contracting aligns with states’ plans to better serve dually eligible beneficiaries, MCO-based DCEs will be required to obtain a letter of support from their state Medicaid agency to participate in the model. CMS will track both Medicare and Medicaid expenditures in order to ensure that there is no cost-shifting from Medicare to Medicaid or vice versa.

In early 2021, the Innovation Center expects to release a request for applications (RFA) for all professional and global DCE types, including MCO-based DCEs. This will be the first direct contracting RFA to include MCO-based DCEs. MCO-based DCEs will begin participating in the model in January 2022.

For more information, please visit this webpage.

The Centers for Medicare and Medicaid Services (CMS) issued Medicare Learning Network (MLN) Matters article MM12063 entitled “Calendar Year (CY) 2021 Update for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule”. It becomes effective on January 1, 2021. This article includes material on the data files, update factors, and other information related to the update of the fee schedule. The DMEPOS fee schedule is updated on an annual basis. For CY 2021, an update factor of 0.2 percent is applied to certain DMEPOS fee schedule amounts. Additional details specific to supplies are provided in the article.

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To further support clinicians during the COVID-19 Public Health Emergency (PHE), the Centers for Medicare and Medicaid Services (CMS) has extended the 2020 Merit-Based Incentive Payment System (MIPS) Extreme and Uncontrollable Circumstances Exception application deadline until February 1, 2021.

For the 2020 performance year, MIPS eligible clinicians, groups, and virtual groups can submit an application requesting for CMS to reweight one or more performance categories to zero percent due to the current COVID-19 PHE. If members have concerns about the effect of the COVID-19 PHE on your performance data, including cost measures, submit an application and cite COVID-19 as the reason for your application.

For additional information, consult the following resources:

  • MIPS Extreme and Uncontrollable Circumstances Exception Application User Guide and Fact Sheet
  • How to Submit an Extreme and Uncontrollable Circumstances Exception Application Video
  • Extreme and Uncontrollable Circumstances Exception Webpage
  • Quality Payment Program Exceptions Application Fact Sheet

The Centers for Medicare and Medicaid Services (CMS) has announced that they will hold a call on December 10, 2020 from 1:30 pm – 3:00 pm Eastern Time (ET) that will focus on the calendar year (CY) 2021 Medicare Physician Fee Schedule (MPFS) final rule that was recently released. This call will focus specifically on four key areas within this final rule, including:

  • Extending telehealth and licensing flexibilities beyond the public health emergency (PHE);
  • Updating Evaluation and Management (E/M) coding guidance;
  • Updating the Quality Payment Program and Merit-Based Incentive Payment System Value Pathways; and
  • Updating opioid use disorder and substance use disorder provisions.

During the call, CMS experts will briefly cover provisions from the final rule and address any questions. Members are encouraged to review the final rule prior to the call. To participate, please register here.

The Centers for Medicare and Medicaid Services (CMS) has planned a special open-door forum to discuss the final rule that was released on November 20, 2020. This final rule clarified the regulations that interpret the federal physician self-referral law (known as the Stark Law). It supports CMS’s “Patients Over Paperwork” initiative by reducing unnecessary regulatory burdens on physicians and other health care providers. It also reinforces the Stark Law’s goal of protecting patients from unnecessary services and the practice of being led to less convenient, lower quality, or more expensive services because of a physician’s financial self-interest. This final rule will be published in the December 2, 2020 Federal Register.

Agenda topics for this special call include:

  • Exceptions that Facilitate the Transition to Value-Based Care Delivery and Payment Arrangements
  • New Guidance and Clarifications Related to Key Terminology of the Stark Law
  • Flexibilities to Enhance Compliance and Reduce Burden

This open-door forum will be held on December 2, 2020 from 2:00 pm – 3:00 pm Eastern Time. To participate, use the information below:

Dial-In Number: 1-888-455-1397

Participant Passcode ID #: 2037400

A transcript and audio recording of this open-door forum will be posted to the Podcast and Transcripts webpage.