CurrentMedicarePolicy N/A

Summary of CMS provisions from the Affordable Care Act

This document lists CMS provisions and implementing guidance/regulations related to the Patient Protection and Affordable Care Act as of December 10, 2010; it summarizes changes to insurance market rules, Medicare/Medicaid program provisions, payment adjustments, eligibility expansions, and related implementing documents that affect payers, providers, and state agencies.

Policy Summary

PayerMedicare

PolicySummary of CMS provisions from the Affordable Care Act

Policy CodePolicy N/A

Change TypeSummary / informational

Effective DateDec 10, 2010

Next Review DateN/A

Key ActionEnsure physicians who order items or services are enrolled in Medicare to comply with new ordering and screening requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~40+individual CMS provisions listed in this excerpt

2010-2015implementation years referenced

Multipleimplementing document types

nationalapplicability

Dec 10, 2010document date

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Coverage and Eligibility Changes

Insurance market coverage requirements

Insurance market reforms and required coverage provisions

ALL of the following

Prohibits lifetime limits and unreasonable annual limits on the dollar value of benefits; restricted annual limits allowed for plan years beginning prior to 1/1/2014
Prohibits rescission of coverage except in cases of fraud or misrepresentation
Requires coverage of preventive services and immunizations recommended by the U.S. Preventive Services Task Force, the CDC, and certain HRSA-recommended child preventive services without cost-sharing
Requires plans that offer dependent coverage to allow unmarried children to remain on parents' plans up to age 26

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Medicaid eligibility changes

Medicaid/eligibility and program changes

ALL of the following

Creates a mandatory Medicaid eligibility category for non-elderly, non-pregnant individuals with income at or below 133% of the Federal Poverty Level beginning January 1, 2014
State options
- Option for States to expand Medicaid above 133% FPL through a State plan amendment
- Optional categorically-needy eligibility group limited to family planning services for non-pregnant individuals up to the highest pregnancy-related income level (State option)

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Preventive and Part D MTM coverage provisions

Preventive services coverage changes described in the document include:

ALL of the following

Medicare covers an annual wellness visit including a personalized prevention plan and comprehensive health risk assessment; Secretary to establish publicly available guidelines for health risk assessments and standards for interactive telephonic or web-based programs used to furnish them
Medicare to waive beneficiary coinsurance (cover 100%) for personalized prevention plan services and for preventive services rated A or B by the USPSTF
Part D medication therapy management (MTM) programs must include comprehensive medication reviews with written summaries and provide quarterly enrollment opportunities for eligible beneficiaries; enrollment may be structured with opt-out allowed

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Payment policy changes

Payment and payment-adjustment provisions:

ALL of the following

Establishes a 10 percent cap on home health outlier payments and reinstates a rural home health add-on payment effective April 1, 2010 through 2015
Sets the assumed utilization rate at 75% for the practice expense portion of advanced diagnostic imaging services and adjusts the technical component discount on single-session contiguous imaging studies (from 25% to 50%)
Revises payment policy for power-driven wheelchairs by eliminating the lump-sum purchase option (payments made over 13 months), while maintaining purchase option for complex rehabilitative power wheelchairs
Incorporates productivity adjustments and specified market-basket reductions into updates for multiple provider types (IPPS, HH, SNF, hospice, IRF, LTCH) with additional reductions in specified fiscal years

Coding, Payment, and Measurement Impacts

Imaging payment/coding impactsmixed

Adjustment to assumed utilization rate for advanced diagnostic imaging practice expense (set to 75%) and adjustment to technical component discount for single session contiguous imaging studies.

DXA paymentsmixed

Restores payment for dual-energy x-ray absorptiometry (DXA) services furnished during 2010 and 2011 to 70 percent of the Medicare rate paid in 2006.

Physician fee schedule adjustmentsmixed

Modifications to practice expense assumptions and imaging technical component discounts referenced under Physician Fee Schedule rulemaking (including assumed utilization rate set at 75% and technical component discount adjustments).

SNF PPS revisionsmixed

Delays implementation of certain SNF prospective payment system 'RUGs-IV' changes by one year to October 1, 2011; implements therapy concurrent basis and look-back period adjustments beginning October 1, 2010 as specified.

SNF PPS RUGs-IV changesmixed

No codes listed

Physician Quality Reporting System bonusmixed

No codes listed

Medical Loss Ratio thresholds

Group market MLR threshold20% (group market) — reporting requirement; refunds required through 12/31/2013

Individual market MLR threshold25% (individual market) — reporting requirement; refunds required through 12/31/2013

Reporting vs. refund sunsetRequirement to report percentages continues beyond 12/31/2013; requirement to provide refunds expires 12/31/2013

Assumed utilization rate for advanced imaging

Assumed utilization rate75 percent (practice expense portion for advanced diagnostic imaging services)

Provider Responsibilities and Operational Requirements

Note

Physician feedback and reporting

Expands Medicare's physician feedback program to require development of individualized, risk‑adjusted utilization reports by 2012. Reports will compare physician (or physician group) utilization to peers who see similar patients and will be standardized to account for local health care costs. CMS to develop a public-domain episode grouper no later than 1/1/2012.

Individualized, risk-adjusted utilization reports by 2012
Public-domain episode grouper NLT 1/1/2012

Documentation Required

Hospice face-to-face encounter

Requires a hospice physician or nurse practitioner to conduct a face-to-face encounter with the patient to determine continued hospice eligibility prior to the 180‑day recertification and for each subsequent recertification. The provider must attest that the visit occurred as established by the Secretary.

Face-to-face encounter required prior to 180-day recertification and for each subsequent recertification

Definitions and Named Provisions

Preventive services

Cost-sharing for preventive servicesMedicare covers preventive services with no coinsurance or deductible when recommended by USPSTF (A or B) or as personalized prevention plan services

Annual wellness visitIncludes an annual wellness visit with a personalized prevention plan and comprehensive health risk assessment

Implementation guidanceSecretary to establish publicly available guidelines for health risk assessments and standards for telephonic/web-based programs

Rescission prohibition

Rescission ruleProhibits plans from rescinding coverage except in cases of fraud or misrepresentation

ApplicabilityExtends prohibition on rescissions to existing health plans beginning six months after enactment

Policy Summary

PayerMedicare

PolicySummary of CMS provisions from the Affordable Care Act

Policy CodePolicy N/A

Change TypeSummary / informational

Effective DateDec 10, 2010

Next Review DateN/A

Key ActionEnsure physicians who order items or services are enrolled in Medicare to comply with new ordering and screening requirements.

SourceLink

On This Page

ScopeApplies to practice expense component of advanced imaging under Physician Fee Schedule rules

Related adjustmentImplemented alongside adjustments to technical component discounts for single-session contiguous studies

Medicare primary care payment bonus

Primary care payment bonus10% Medicare payment bonus for primary care practitioners (and general surgeons in HPSAs) for five years beginning 2011

Duration and startFive-year bonus period starting in 2011; half of the cost offset across other services

Eligibility noteApplies to primary care practitioners and general surgeons practicing in health professional shortage areas (HPSAs)

Attestation that the visit took place required

Billing Rule

Provider enrollment requirement for ordering

Requires that physicians who order durable medical equipment, home health services, or other Medicare items/services be enrolled in Medicare. The Secretary has authority to extend the enrollment requirement to other items and services to reduce fraud, waste, and abuse.

Ordering physicians must be Medicare‑enrolled for DME and home health certifications
Secretary may extend enrollment requirement to additional items/services

Prior Authorization

Provider screening and enrollment

Requires the Secretary, in consultation with the OIG, to establish risk‑based provider and supplier screening procedures for Medicare, Medicaid, and CHIP. Screening levels must be set according to fraud/waste/abuse risk and may include fingerprinting, criminal background checks, multistate database checks, and random or unannounced site visits. The Secretary may impose additional screening measures for higher‑risk categories.

Risk‑based screening levels for all provider/supplier categories
Possible measures: fingerprinting, criminal background checks, multistate database inquiries, random/unannounced site visits

Denial Risk

CMP reduction and escrow for appeals

Authorizes the Secretary to reduce civil monetary penalties (CMPs) by up to 50% for facilities that self‑report and correct deficiencies within ten calendar days of imposition. For CMPs cited at the level of actual harm or immediate jeopardy, the Secretary may place CMPs in escrow following informal dispute resolution or 90 days after imposition (whichever is earlier). If an appeal is successful, funds (with interest) are returned; if unsuccessful, proceeds may be used for activities benefiting facility residents.

CMP reduction up to 50% for timely self‑reporting and correction (within 10 days)
Escrow provision for CMPs cited for actual harm or immediate jeopardy pending appeal
Successful appeals return CMP plus interest; unsuccessful appeals may direct funds to resident‑benefit activities

Implementing documentsImplemented via Omnibus Health Insurance Market Interim Final Rule (Preventive Services) and guidance

Dependent coverage up to age 26

Dependent coverage ageUnmarried individuals may remain on parents' coverage up to age 26 for plans that offer dependent coverage

Effective timingExtension applied to existing plans starting six months after enactment

ImplementationImplemented via Omnibus Health Insurance Market Interim Final Rule (Coverage Up to Age 26)

Annual wellness visit

Annual wellness visit contentsIncludes comprehensive health risk assessment and personalized prevention plan with 5–10 year screening schedule, identified risks, health advice, and referrals

Coverage statusPersonalized prevention plan services are covered and coinsurance/deductible waived under Medicare

StandardsSecretary to establish guidelines for health risk assessments and standards for telephonic/web-based programs

Provider screening

Screening levels based on riskSecretary to determine screening level for each provider/supplier category according to fraud, waste, and abuse risk

Possible screening measuresMeasures may include fingerprinting, criminal background checks, multi-state database inquiries, and random or unannounced site visits

Authority and consultationSecretary establishes procedures in consultation with the OIG; applies to Medicare, Medicaid, and CHIP providers/suppliers

Elder Justice (6703)

Mandatory crime reportingOwners, operators, and certain employees of long-term care facilities required to report suspected crimes committed at the facility

Closure notificationOwners/operators must submit written notification of impending facility closure at least 60 days prior, including a resident transfer/relocation plan

ScopeProvision enacted under Elder Justice (Section 6703) with grant and training activities to protect long-term care residents

Medicaid waiver transparency (10201)

Regulatory requirementSecretary required to promulgate regulations for Medicaid demonstration application and renewal processes to increase transparency

Public participationRegulations must provide for a process for public hearings regarding demonstration projects

PurposeAims to increase transparency at State and federal levels for waiver development and approval

Medicare data availability (10332)

Authorized data releaseAuthorizes release and use of standardized extracts of Medicare claims data for provider and supplier performance measurement

Privacy and requirementsUse of data authorized in ways that protect patient privacy and in accordance with other requirements

Implementing actionImplemented through Federal Register notices and listening sessions regarding Medicare data availability (CMS-0031-N)