For more information about this blog post, please contact Khaled J. Klele, Ryan M. Magee, Labinot Alexander Berlajolli, or Daniel J. Parziale.

Centers for Medicare &
Medicaid Services ("CMS") Issues Advisory Alert to Qualifying
APM Participants for Incentive Payment Information

85 FR 57980 – CMS
issued a payment advisory to alert certain clinicians who are Qualifying APM
participants ("QPs") and eligible to receive an Alternative Payment
Model ("APM") Incentive Payment that CMS does not have the current
billing information needed to disburse the payment. Specifically, CMS has
identified those eligible clinicians who earned an APM Incentive Payment in CY
2020 based on their CY 2018 QP status. When CMS disbursed the CY 2020 APM
Incentive Payments, CMS was unable to verify current Medicare billing
information for some QPs and was therefore unable to issue payment. CMS
compiled a list of QPs that have unverified billing information and issued
instructional letters to those qualifying APM participants on September 11,
2020.  QPs, and any others who anticipated receiving an APM Incentive
Payment but have not, should follow the instructions to provide CMS with
updated billing information using this information collection form.

New CMS Alternative Payment Models and
Guidance to Medicaid Agencies on Implementing Models

CMS Announces new ET3 Payment
Model for Ambulance Care Teams

On September 16, 2020 CMS issued new guidance on its new Emergency Triage,
Treat, and Transport (“ET3”) model. The ET3 model is a voluntary, five
year payment model that is designed to provide greater flexibility to ambulance
care teams to address emergency healthcare needs for Medicare Fee-for Service
(“FFS”) beneficiaries following a 911 call. As part of the new ET3 mode,
CMS will pay participating ambulance suppliers and providers to: (i) transport
an individual to a hospital emergency department (“ED”) or other destination
covered under the regulations; (ii) transport to an alternative destination
partner (such as a primary care doctor’s office or an urgent care clinic); or
(iii) provide treatment in place with a qualified healthcare partner, either
on the scene or connected using telehealth. The ET3 model will be
effective January 1, 2021.

CMS Finalizes Specialty Care
Models

On September 18, 2020, CMS
finalized its end-stage renal disease ("ESRD") treatment choices
("ETC") model and radiation oncology payment ("RO")
model. The ETC model focuses on encouraging greater use of home dialysis
and kidney transplants to reduce Medicare expenditures. The RO model
imposes a mandatory payment and testing model and makes prospective episode
payments to hospital outpatient departments ("HOPD") and freestanding
radiation therapy centers for radiotherapy episodes of care. It also seeks
to reduce Medicare program spending through enhanced financial accountability
for RO Model participants. The final rule, which includes both payment
models, can be found here.

CMS Announces New Guidance
Expanding Value-Based Care Strategies for Medicaid

On September 15, 2020, CMS issued
new guidance to state
Medicaid directors designed to advance the adoption of value-based care
strategies across their healthcare systems and align provider incentives across
payers (the “Roadmap”). Value-based care can be defined as being one in
which providers are reimbursed based on their ability to improve quality of
care in a cost-effective manner or lower costs while maintaining standards of
care, rather than the volume of care they provide. As part of its Roadmap,
CMS encourages states to consider the adoption of payment models in the context
of their individual circumstances such as: advanced payment methodologies under
fee-for-service, bundled payments, and total cost of care
models.  CMS issued a fact sheet on the
guidance.

CMS Proposes Payment Changes to Medicare
Advantage and Part D

On Tuesday, September 15, 2020,
CMS issued part one of its proposed 2022 Medicare Advantage Advance,
which updates payment methodologies to Medicare Advantage and Part D plans. CMS
released the first part of the proposed rule three months ahead of schedule to
give insurers more time to prepare bids for 2022 in light of uncertainty
brought by the COVID-19 pandemic. CMS proposes to change how it will
calculate Medicare Advantage risk adjustments for 2022, and wants to fully
phase in a model that adds variables to count conditions in the risk adjustment
model. It includes additional conditions for mental health, substance use
disorder and chronic kidney disease. Under the proposed rule, the Medicare
Advantage risk score used to calculate payment in 2022 would rely entirely on
encounter data as the source of diagnoses. In the past, CMS used a blend of
encounter data and diagnoses submitted to its risk adjustment processing
system. CMS also plans to discontinue its policy of supplementing diagnoses
from encounter data with diagnoses from inpatient records that are submitted to
the risk adjustment processing system for determining risk scores. CMS said
both parts of the Advance Notice will be finalized in the 2022 rate
announcement set to publish by April 5, 2021.

CMS Withdraws Proposed Medicaid Fiscal
Accountability Rule

The Medicaid Fiscal Accountability
Rule, first proposed last November, has been withdrawn by CMS as of September
14. The rule aimed to promote transparency and fiscal integrity by
establishing new reporting requirements for state supplemental payments to
Medicaid providers. However, several hospital associations, including
America's Essential Hospitals and the American healthcare Association, argued
that finalizing the Medicaid fiscal integrity rule would introduce unnecessary
restrictions on states at a time when hospitals are facing challenges and an
uncertain future due to the COVID-19 pandemic.

The New
Jersey State Legislature Passes Bill to Establish the New Jersey Task Force on
Long-Term Care Quality and Safety

On August 27, 2020 the New Jersey
Legislature passed a bill (A4481/S2787)
directing the establishment of the New Jersey Task Force on Long-Term Care
Quality and Safety (the “Task Force”), which will be tasked with developing
recommendations to make changes to the long-term system of care to drive
improvements in person centered care, resident and staff safety, improvements
in quality of care and services, workforce engagement and sustainability, and
any other appropriate aspects of the long-term system of care in New Jersey as
the task force elects to review. The Task Force would be comprised of 27
members.