Starting 2014, requires 85% medical loss ratio (MLR) for MA plans, with plans effectively required to return to CMS the portion of their revenue attributable to the difference between their MLR and 85%. After three consecutive years failing to meet the MLR requirement, plans may not enroll new beneficiaries. After five years of violation, plans will be terminated.
Phases down incentive payments for reporting of quality measures under the Physician Quality Reporting System (PQRS) by 2015, at which time penalties for non-reporting begin, increasing to 2% of physician payments by 2016. Authorizes physicians to submit quality data to approved Maintenance of Certification (MOC) programs, with an extra 0.5% bonus for physicians who complete an MOC practice assessment.
Makes changes to the feedback program to provide reports to individual physician regarding their resource utilization rates. Requires development of episode grouper software to aggregate clinically related claims and report to physicians on their resource use by episode.
As revised by section 10301 of the Senate Manager's Amendment, stipulates that CMS develop and submit plans to Congress by January 1, 2011, for implementation of VBP programs for SNFs, HHAs and ambulatory surgical centers (ASCs). On July 8, 2013, CMS released its CY14 hospital outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) payment system proposed rule in which it contemplates...
Requires phase-in of a physician payment modifier using a composite of quality and efficiency measures. Payment adjustments begin for some physicians on January 1, 2015, and for all doctors by January 1, 2017.
Establishes a Federal Interagency working group with the goals of disseminating the national priorities under section 3011, avoiding duplication of quality improvement efforts and assessing the alignment of public and private quality-related initiatives.
Revised by sections 10303 and 10304 of the Senate Manager's Amendment, authorizes (but does not delineate a separate Congressional appropriation) $75 million per year to HHS to develop quality metrics that fill gaps in existing measure sets and include outcomes measures.
Gives new responsibilities to the National Quality Forum (NQF) to make recommendations regarding the national quality strategy (see section 3011) and to endorse quality metrics. Requires periodic review of measures by CMS. Appropriates $20 million per year for FYs 2010-2014 for these purposes.
Creates CMMI to test and evaluate new delivery and payment models with the intent of improving quality or reducing costs. Gives CMS authority to expand these programs, if successful, without additional congressional action. Appropriates $10 billion for this purpose. Provides several examples for CMMI to consider in establishing pilot programs.
Creates an accountable care organization (ACO) program within traditional Medicare that will allow integrated healthcare organizations to share in savings they can achieve through quality improvements and efficiency of care.
Establishes, by January 1, 2013, a new pilot program to test bundling of Medicare payments for CMS-identified episodes of care spanning three days prior to a hospital admission to 30 days after discharge. Services delivered at a variety of settings can be bundled into these episodic payments. Allows CMS to expand the program after 2016 if it is successful in...
Establishes a new program whereby inpatient hospital service payments are reduced if their preventable readmission rates exceed certain levels. Payments may be reduced by up to 1% in FY13 phasing up to 3% in FY15 and thereafter.
Requires CMS to allocate funding to hospitals with high readmission rates or community-based organizations that have arrangements in place with such hospitals to manage the care of high-risk patients as they are discharged from a hospital into the community. Authorized for five years, starting in 2011, though CMS may extend the program if it is successful.
Provides for an extension of the 1.0 work geographic practice cost index (GPCI) floor through 2010 and limits variations in the practice expense (PE) GPCI with a hold harmless for areas that would otherwise lose funding.
Extends the rural ground ambulance add-on (1%), the super rural ambulance add-on (2%) and the air ambulance add-on and reclassifications through 2010. On July 8, 2013, CMS released its CY14 Medicare Physician Fee Schedule (MPFS) proposed regulation, which delineates proposed payment changes to physician payments, in addition to effectuating ACA-authorized requirements consistent with these statutory provisions of the law. Comments on the underlying proposed...
Authorizes the exemption of pharmacies with less than 5% of revenues coming from durable medical equipment from accreditation requirements until pharmacy-specific standards are developed. Pharmacies participating in the competitive bidding program do not qualify for the exemption.
Creates a 2-year demonstration program to assess the affect on Medicare quality and costs of direct payments for certain complex laboratory tests. Requires CMS to report its findings to Congress by June 30, 2015.
Directs the Medicare Payment Advisory Commission (MedPAC) to study the adequacy of Medicare payments made to rural healthcare providers and the impact on beneficiary access to care in these areas. Includes the impact of changes made under the Affordable Care Act (ACA).
Makes clear that CAHs can receive their 101% of costs-based payments regardless of the billing methodology they use. Also clarifies that this payment methodology applies to CAH-delivered ambulance services.
Directs CMS to rebase Medicare home health agency (HHA) payments by 2014. Creates a 10% limit on the portion of an HHA’s reimbursement that may come from outlier payments from April 1, 2010 through 2015. Requires CMS to submit a report to Congress by March 1, 2011 making recommendations to improve the home health payment system and beneficiary access to...
Directs CMS, by January 2, 2011, to update Medicare hospice cost reports and claims forms and mandate a face-to-face encounter between a doctor (or nurse practitioner) and the patient to determine the need for recertification after 180 days, and to implement reforms to the payment system to improve payment accuracy by no earlier than FY14.
Requires CMS to adjust Medicare DSH payments to improve the accuracy in accounting for uncompensated care beginning FY14. DSH payments are to be reduced to reflect expected increases in coverage under the ACA.
Effective January 1, 2011, sets the utilization rate assumption for advanced diagnostic imaging services (ADIS) at 75% for the practice expense portion of Medicare physician payment. Excludes non-advanced services like x-rays and EKGs. Increases the discount to the technical component of payment for imaging performed on a contiguous body part during the same session from 25% to 50%, effective July...
Repeals the option for Medicare to purchase power-driven wheelchairs with a lump sum payment, requiring that payments be made under the traditional 13-month rental period for durable medical equipment. Does not apply to complex, rehabilitative power wheelchairs.
Extends so-called Medicare section 508 hospital reclassifications through FY10, with a requirement that CMS make recommendations to Congress by the end of 2011 regarding comprehensive reforms to the geographic wage index system. From FY11 to FY13, requires CMS to restore the thresholds used for determining hospital reclassifications to the percentage used in FY09. Clarifies that CMS may only use wage...
Mandates a CMS study regarding the degree to which inpatient prospective payment system (IPPS) exempt cancer hospitals have outpatient costs that exceed those of other hospitals. Authorizes HHS to make any appropriate adjustments to reflect those higher costs effective for services furnished on or after January 1, 2011.
Repealed and replaced by section 1102 of HCERA, summarized here. Sets MA payments in 2011 at 2010 levels. Phases in plan reimbursement reductions over three, five or seven years, depending on the depth of the cuts to the plan region, with final benchmarks set at 95% in high-cost areas up to 115% in low-cost areas. Areas with high-quality plans receive...
Repealed and replaced by section 1102 of HCERA. Requires CMS to implement reductions to MA plan reimbursement to account for increases in coding intensity patterns, with cuts ramped up beginning in 2014 and again in 2019. In years 2015-2019, the cut may be no less than the previous year plus 0.25%.
Reauthorizes the MA SNP program through 2013 for beneficiaries with chronic conditions. Requires transition of non-chronically ill MA SNP enrollees to non-SNP plans or traditional Medicare by 2013. Extends SNP plans for dual eligible beneficiaries through 2012. Requires all SNPs be accredited by the National Committee for Quality Assurance (NCQA) by 2012.
Extends the employer waiver from private fee-for-service plan network requirements, effective CY11. In a Mar. 23 letter to CMS, House Ways and Means Committee Chairman Kevin Brady (R-TX) and Energy and Commerce Committee Chairman Fred Upton (R-MI), along with other members of the Republican leadership, requested more transparency in the process for rate setting for MA Employer Group Waiver Plans...
As amended by section 1101 of HCERA, effective 2011, phases in closure of the Part D “donut hole” by requiring 50% discounts on brand name and generic drugs to enrollees in that component of the benefit. Discount increases to 75% by 2020. Provides $250 rebate for all Medicare Part D enrollees in the donut hole in 2010.
Requires CMS to permit Part D plans to waive the monthly premium for low-income subsidy (LIS) individuals. Such plans will be included in the auto-enrollment program for LIS beneficiaries starting in 2011.
Effective 2011, requires CMS to provide LIS enrollees assigned to a new plan because their previous plan no longer qualified with information regarding changes in their Part D formulary and their right to request coverage reconsideration.
Provides funding from 2010 through 2012 for state health insurance programs (SHIPs), Area Agencies on Aging (AAAs), Aging and Disability Resource Centers (ADRCs) and the National Center for Benefits and Outreach and Enrollment. Up to $45 million per year is allocated for these purposes.
Mandates development of a system to collect complaints against Part D plans and requires CMS to deliver an annual report to Congress summarizing such complaints. CMS must develop a model complaint form that must be prominently displayed on the home page for Medicare.gov.
Mandates that all Part D plan sponsors utilize a single, uniform exceptions process for coverage determinations and provide instant access to decisions via toll-free phone number or the Internet by 2012.
Directs the OIG to study and report to Congress by July 1, 2011 (and annually after that), on the extent to which Part D formularies include drugs commonly used by dual eligibles. Also requires a report by October 1, 2011, regarding the prices for covered Part D drugs with an accounting of any discrepancy in price and the impact on...
Amended by sections 10319 of the Manager’s Amendment and 1105 of HCERA. Revises payment updates in Medicare fee-for-service as follows: Inpatient and outpatient hospitals, inpatient rehab facilities and psychiatric hospitals: -0.25% in 2010 and 2011, -0.1% in 2012 and 2013, -0.3% in 2014, -0.2% in 2015 and 2016 and 0.75% from 2017-2019. Productivity adjustment applied beginning in 2012. Long-term care...
Amended by section 10320 of the Manager’s Amendment. Establishes a new entity that, starting in 2014, will make recommendations and develop proposals to reduce Medicare spending to meet certain targets and improve quality. The IPAB is also required to make recommendations regarding the private healthcare sector every two years, starting in 2015. Prior to 2018, target Medicare spending growth is...
Builds on the Center for Quality Improvement and Patient Safety at AHRQ to support research, technical assistance and process implementation grants. Authorizes but does not fund $20 million for grants to develop innovative approaches for quality improvement practices.
Modified by section 10321 of the Manager’s amendment. Creates a new grant program to establish health teams that support care coordination services delivered at primary care practices. No funding allocated.
Expands an existing trauma center grant program for Indian tribal, urban Indian and Indian Health Service operated trauma centers to defray costs and improve quality. No funding appropriated for this expansion.
Establishes a new grant program at AHRQ to provide grants to health professional training institutions for the development and implementation of academic programs that integrate quality improvement and patient safety in the clinical education of health professionals. No funding allocated.
Extends an existing program to provide assistance to patients facing barriers in access to health services. Under these programs, patients can receive referrals, assistance with identifying support organizations, background on clinical trials and targeted outreach if in a population suffering from health-related disparities. No funding allocated.
Establishes Medicare eligibility for persons in Libby, Montana who were exposed to asbestos hazards prior to 6/17/09. Additional eligibility may be extended to individuals in other areas when a public health emergency is declared under the Comprehensive Environmental Response, Compensation and Liability Act of 1980.
By plan year 2013, requires Part D plans to include MTM services for certain enrollees. MTM programs must include annual, comprehensive, in-person medication reviews and a process for auto-enrollment (with opt-out). Part D plans must also assess medication use of non-MTM-enrolled individuals on a quarterly basis.
Effective January 2012, authorizes HHS to provide standardized extracts of Medicare claims data by geographic area to public and private entities that meet certain criteria for provider performance evaluation purposes.
Transfers the Office of Minority Health to the Office of the Secretary and establishes new minority health offices at the CDC, HRSA, SAMHSA, AHRQ, FDA and CMS, and elevates the existing office at the NIH.