CMS Issues Alert to Providers Regarding Incentive Payments, New CMS Models and Other CMS Action, and New Jersey Establishes Task Force on Long-Term Care

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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 health care 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 health care 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 Health Care 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.