Quote of the Month
“Advocacy can be – and often is – a messy business. It is not for the faint of heart and it can’t be half-hearted.” – Bill Benson. (FromAging Advocacy and the Older Americans Act in the January/February 2016 issue of Aging Today)
New CMS Prior Authorization Rule for DMEPOS
The Centers for Medicare & Medicaid Services (CMS) released a new rulerequiring prior authorization for some durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) for Medicare beneficiaries to help prevent fraud while ensuring access to medically necessary equipment and supplies. These regulations are effective February 29, 2016. There is a list of 135 items (see Table 5) that are specifically identified in the final rule. CMS plans to “issue specific prior authorization guidance in subregulatory communications” and will update the list each year. Items on the DMEPOS prior authorization list will have an average purchase cost of $1,000 or more, or an average rental fee of $100 or more, and be the subject of an OIG or GAO report of a national scope or a future “CERT DME Service Specific Report.” Items requiring prior authorization will be published in the Federal Register with 60 days’ notice before prior authorization begins for those items.
The new rule is another example of CMS moving away from the “pay and chase” model of reimbursement in its effort to prevent fraud. Physician documentation to meet authorization requirements for DMEPOS will not change but will be needed earlier in the process to get needed items, such as motorized wheelchairs and certain prostheses.
According to the CMS fact sheet, “Medicare or its review contractor will make a reasonable effort to render an initial prior authorization determination within 10 business days and will make a reasonable effort to render a resubmission prior authorization determination within 20 business days. These are maximum timeframes and will be adjusted downward for items that require less time for making a determination. An expedited review process will be available to address circumstances where applying the standard timeframe for making a prior authorization decision could seriously jeopardize the life or health of the beneficiary. The request for an expedited review must provide rationale supporting the request.”
Advocates have expressed concern that the final rule may delay access for needed DMEPOS items compromising consumers’ health or well-being, and it doesn’t provide beneficiaries a way to access a high appeal level if an item is denied. It is critical that the initial documentation be complete and accurate to avoid any denials. For more information see the Center for Medicare Advocacy’s alert, CMS Final Rule for Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).
Medicare Quality Measures
CMS released additional physician and hospital quality measures to help consumers make informed choices. Physician Compare’s new measures focus on the quality of care provided by Medicare physicians and other health care professionals. Hospital Compare now includes information on more than 100 quality measures and over 4,000 hospitals.
CMS’ Home Health Compare now posts star ratings, ranging from one to five stars, based on patients’ surveys. The information is in addition to the Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey measures.
The National Quality Forum (NQF) Measure Applications Partnership (MAP) released its final recommendations to the Department of Health and Human Services (HHS) on measures under consideration for the 2015-2016 pre-rulemaking cycle. The recommendations include into two components, a report that describes the approach to recommending measures as well as a sortable, searchable spreadsheet (XLSX) of all recommendations, and public comments provided throughout this process.
Fiscal Year 2016 Budget Update
Congress passed a final fiscal year (FY) 2016 omnibus budget bill (H.R. 2029, the Consolidated Appropriations Act), a $1.149 trillion package of all 12 annual appropriations bills, to provide funding for federal government operations through September 2016. In short, there were proposed major cuts to services for older adults but the final bill averted those cuts and even provided some much needed increases.
Here is a summary of items of interest to older Americans in the final agreement.
- The legislation increases funding from FY 2015 levels by $2 billion for the National Institutes of Health. Alzheimer’s disease research is increased by $350 million. This is the largest increase ever for federal Alzheimer’s research funding. It also includes specific increases for the BRAIN Initiative research to map the human brain by $85 million, antibiotic research, and the Precision Medicine Initiative.
- Alzheimer’s Disease Demonstration and Initiative has an increase of $1 million above FY 2015. This funding supports competitive grants to expand the availability of evidence-based interventions and long-term care services for individuals with Alzheimer’s disease. The funds also support an Alzheimer’s disease outreach campaign to educate caregivers about community resources.
- The Elder Justice Initiative doubled its first time appropriation from last FY and will receive $8 million in funding. In addition, funding for the Victims of Crime Act (VOCA) Crime Victims Fund will see an almost $700 million increase in the cap for FY 2016 to $3 billion, and after allowing for a transfer of some of these funds, it will leave funding of $2.65 billion for VOCA, which is an increase of $302 million for state VOCA assistance programs over FY 2015.
- The Office of Medicare Hearings and Appeals (OMHA) received an increase of $20 million above FY 2015 for the Medicare appeals process to add more Administrative Law Judge (ALJ) teams to combat the considerable backlog of Medicare appeals currently pending at OMHA.
- Older Americans Act Caregivers Support Formula Grants are funded at $6.5 million more than FY 2015.
- Older Americans Act Senior Nutrition Program is funded at $20.1 million above FY 2015.
Funding for these programs was held level at FY 2015 levels:
- Long Term Care Ombudsman Program at $20.6 million
- OAA Title VII Elder Rights Support Activities at $3.8 million
- Social Services Block Grant at $1.7 billion
Pennsylvania continues to move forward with its Managed Long Term Services and Supports (MLTSS) proposal, now called Community HealthChoices (CHC). (Please see CARIE Connection archives for more background information.) The Department of Human Services (DHS) released the draft CHC Request for Proposal (RFP) and draft program requirements for public comment on November 16, 2015 that were due on December 11. Additional draft agreement sections were released for comment in December that were due on January 8, 2016. All CHC related drafts and other information may be found on DHS’ CHC webpage. CARIE submitted comments for both the (CHC) Draft Agreement Sections and theCHC program draft Request for Proposal (RFP) and program requirements. CARIE was successful in its “Freedom of Information Act” request to obtain the University of Pittsburgh Medical Research Center’s MLTSS concept paper commissioned by DHS. If you would like a copy of this research analysis, please contact Kathy at [email protected].
DHS plans to release the official RFP sometime during the week of February 22 and also plans to release another draft agreement at the same time. While the RFP will be final, DHS is planning to accept comments on the new draft agreement to obtain additional feedback. The implementation in Southwestern Pennsylvania is still on target to begin in January 2017.
DHS is accepting comments on Pennsylvania’s revised proposed statewide transition plan for Home and Community-Based Settings. On September 16, 2015, the Centers for Medicare and Medicaid Services (CMS) issued a letter regarding the statewide transition plan submitted by the Department on April 1, 2015. The Department revised the statewide transition plan to address CMS’ recommendations and provide updated information on the progress made in implementing the plan. Comments must be submitted by February 16, 2016. Recently, a coalition of national aging and disability advocacy organizations posted a toolkitto help advocates push for the strongest implementation of CMS’s home and community-based setting regulations.
DHS is delaying its RFP for the Independent Enrollment Broker (IEB) for its Home and Community-Based waiver (HCBS) programs. The current contract with Maximus will continue until November 2016 with additional requirements, including a 60-day enrollment process to mirror the goals of the RFP and mandatory performance measures. Starting April 1, Maximus will expand its IEB role to include the Aging Waiver shifting this responsibility from the Area Agencies on Aging (AAA).
Webinars and Videos
On February 16, from 2:00 to 3:30 PM, Justice in Aging is conducting a free webinar, Elder Financial Abuse in Medicaid Denials.
On February 29 from 12:00 to 1:30 PM, The PA Behavioral Health and Aging Coalition will present a free webinar, LGBT Older Adults: Unique Issues and Healthcare Needs.
The University of Maine Center on Aging is offering a new online certificate Grandfamilies Leadership program for those who work with grandfamily caregivers. The first online series will be free and will accept registrations on a first come first served basis. The course begins February 29 and includes 9 modules over a 12-week period. (Course ends on May 23.)
A new MLN Connects video (23 minutes) provides an overview of theImproving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014that requires patient assessment data used in post-acute care settings be standardized to improve quality of care. Visit the IMPACT Act website for more information.
The National Quality Forum posted a video, Quality Measures at Work. (3 minutes)
The Training Resources on Elder Abuse (TREA) site is a collaboration between the Keck School of Medicine of USC and the NCEA. The site provides a wide range of training materials for a variety of audiences.
Just the Links
“MedNexus is a medical search engine for patients – think “Google for Medicine”. Through our search engine, you can find the most relevant content from a variety of sources: medical journals, patient forums, government health sites, etc. We want to empower patients to educate themselves and cut through the noise and pseudo-science of typical online health information. No more WebMD scares, no more endless Googling. Whether you are looking for the latest evidence, or to learn from fellow patients, you can find actionable and reliable answers atMedNexus.”
The National Academy of Social Insurance posted a white paper, The Aging Network in Transition: Hanging in the Balance.
The Bipartisan Policy Center posted its Initial Recommendations to Improve the Financing of Long-Term Care.
The U.S. Senate Committee on Finance released its Bipartisan Chronic Care Working Group Policy Options Document.
The White House has released the final report for the 2015 White House Conference on Aging.
Easter Seals and the National Association of Area Agencies on Aging launched the National Aging and Disability Transportation Center.
2014-2015 Alzheimer’s Disease Progress Report: Advancing Research Toward a Cure is now available online.
The Kaiser Family Foundation posted Medicaid and Long-Term Services and Supports: A Primer.
The Congressional Research Service completed an analysis, Medicaid Financing and Expenditures.
ASA’s recent edition of Generations includes an article,Family Caregiving: Looking to the Future, that describes key principles for caregiver assessment among other needs.
The Medicare Payment Advisory Commission and the Medicaid and CHIP Payment and Access Commission released updated data, Beneficiaries Dually Eligible For Medicare And Medicaid: Data Book.
Medicare updated its publication, Medicare Limits on Therapy Services, for 2016.
Medicare Learning Network revised its publication, Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program.
An article in Forbes, How Aging Affects Financial Decision-Making, describes research about the impact that the aging process has on people’s cognitive ability to make financial decisions. Here is a link to related research, Sources of Lower Financial Decision-making Ability at Older Ages.
“Identity theft victims can now go online and get a free, personalized identity theft recovery plan as a result of significant enhancements to the Federal Trade Commission’s IdentityTheft.gov website. The new one-stop website is integrated with the FTC’s consumer complaint system, allowing consumers who are victims of identity theft to rapidly file a complaint with the FTC and then get a personalized guide to recovery that helps streamline many of the steps involved.”
EDDIE is a new online self-service tool to be utilized by data users for accessing and analyzing Pennsylvania health statistics.
Philadelphia’s Senior Hunger Task Force released a Senior Hunger Relief Toolkit. (It has useful information for those beyond Philadelphia.)
Just for Fun
Pete Souza, Chief Official White House Photographer, released the most memorable photographs from the White House for 2015.
Save the date! CARIE’s annual auction and benefit reception will be held at WHYY studios on April 20, 2016. Come and have a wonderful evening while supporting CARIE’s vital elder advocacy. This year’s theme, From Generation to Generation, celebrates favorite family traditions. The evening will honor two outstanding advocates as recipients of this year’s Spirit of CARIE Award, Philip Marshall and Beryl Goldman. Purchase tickets, become a sponsor and get lots more information at www.501auctions.com/carie. Hope to see you there! For more information contact Michele Mathes at (267) 546-3436 or[email protected]
CARIE Connection Archives
Are looking for a past issue of CARIE Connection? Click here to access past newsletters.
Public Policy Meeting Announcement
The next Dorothy S. Washburn Legislative Committee meeting will be held from 9:30 to 11:30 on Thursday, February 4, 2016 at CARIE’s office at Two Penn Center – Suite 1500. Please click here for February’s agenda. All are welcome. Hope you can join us.
As always, please contact me if you have any questions.
267-546-3438 or 1-800-356-3606, ext. 3438