Biden-Harris Administration approves crucial eligibility extensions for Medicaid and CHIP in five states.

In a significant development, the Biden-Harris Administration has approved amendments that allow Colorado, Hawaii, Minnesota, New York, and Pennsylvania to extend Medicaid and CHIP eligibility. This policy update aims to ensure that eligible children and adults, especially those recently incarcerated, maintain uninterrupted access to healthcare services without the need for frequent eligibility reassessment.

Extensive Approval Features:

• Affected States: The states of Colorado, Hawaii, Minnesota, New York, and Pennsylvania have been granted these extensions, reflecting a strategic focus on regions with significant needs for sustained healthcare coverage.
• Target Demographics: The extensions primarily benefit children and recently incarcerated individuals who are particularly vulnerable to disruptions in their healthcare coverage.
• Strategic Objectives: By reducing the frequency of eligibility verifications, these amendments aim to minimize administrative burdens and enhance the stability of healthcare access for underrepresented populations.
• Expected Outcomes: The initiative is expected to facilitate better healthcare continuity, reduce administrative costs, and improve overall health outcomes for the targeted groups by maintaining continuous coverage.

For further details on the Medicaid and CHIP eligibility extensions, visit the CMS press release.

Virginia Medicaid launches $100 incentive for completing Obstetrical Risk Assessments.

To enhance maternal health outcomes, Virginia Medicaid is now offering a $100 incentive for healthcare providers who complete the Obstetrical Risk Assessment Form (OBRAF). This initiative targets the improvement of prenatal care quality through comprehensive risk assessments at the outset of prenatal care. The program stipulates that providers must submit these forms electronically, encouraging a systematic approach to maternal healthcare.

Detailed Program Overview:

• Eligibility and Participation: All enrolled providers performing obstetrical assessments are eligible for this incentive. The program seeks to encompass a wide range of healthcare professionals to ensure broad participation and impact.
• Program Goals: The primary goal is to enhance the initial assessment of pregnant patients, enabling healthcare providers to identify and manage potential health risks early. This proactive approach is expected to lead to better health outcomes for both mothers and their infants.
• Process and Implementation: Providers are required to submit completed OBRAF via designated electronic channels. This digital submission process is designed to streamline operations and improve the efficiency of data collection and processing.
• Financial Incentive: The incentive of $100 per completed and approved assessment is aimed at motivating providers to conduct thorough and detailed evaluations, thus elevating the overall standard of prenatal care.

For more information, providers can access the full details through the official UHCprovider website.

New Requirement Effective December 1, 2024

Starting December 1, 2024, healthcare providers in Louisiana and Pennsylvania must submit Medicaid medical reconsiderations and appeals electronically. This mandate impacts both primary care and ancillary service providers associated with UnitedHealthcare Community Plans.

The transition to electronic submissions is aimed at enhancing operational efficiency and ensuring faster processing of appeals and reconsiderations. Providers must use designated online tools available through the UnitedHealthcare Provider Portal to comply with this new requirement.

How to Submit Electronically:

• Pre-Service Appeals: Utilize the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.
• Claim Reconsiderations and Post-Service Appeals: Submit through the Claims & Payments section of the portal or via the Application Programming Interface (API) for automated transactions.

For assistance with the portal or technical support, providers can contact UnitedHealthcare Web Support or use the real-time chat feature on the Provider Portal.

This change requires providers to adapt their current processes and possibly coordinate with external revenue cycle management vendors to ensure compliance with the new electronic submission standards.

Exclusions: The requirement does not apply to behavioral health professionals and facilities or home- and community-based services.

For detailed guidance on navigating these changes, providers can visit the UnitedHealthcare Provider Portal.

Ensure Compliance to Continue Receiving Payments Without Interruptions

Under the 21st Century Cures Act, all healthcare providers participating in Medicaid Managed Care (MMC) and Children’s Health Insurance Program (CHIP) networks in New York must be enrolled with the state's Medicaid programs. This mandate is critical to avoid disruptions in claim processing.

Enrollment Details: To prevent claim denials, providers must verify their current enrollment status or complete their enrollment with the New York Medicaid. This process is essential as Managed Care Organizations, including UnitedHealthcare, are required to deny claims from providers who are not registered.

Steps to Enroll or Verify Status: Providers can check their enrollment status or begin the enrollment process by accessing the New York State Department of Health's provider portal. Detailed steps and links for enrollment are provided on the website to facilitate easy compliance.

Impact of Non-Compliance: During the COVID-19 Public Health Emergency, there was leniency allowed for claims processing for providers who were not enrolled but had retroactively completed their enrollment. As of April 1, 2024, this leniency has ceased, and claims from non-enrolled providers will be outright denied.

How to Handle Claim Denials: In cases where claims have been denied due to enrollment issues, providers have the option to submit a payment reconsideration request. It is imperative that the enrollment dates be prior to the date of service on the claim to qualify for reconsideration.

Support and Assistance: For further assistance, providers can utilize the UnitedHealthcare Provider Portal to access support resources, including chat and direct links to enrollment pages.

Staying compliant with the state's enrollment requirements is paramount to ensuring that your claims are processed without delay. Check your enrollment status today to avoid unnecessary claim denials and ensure continuous payment for services rendered.

Claims involving sterilization procedures submitted to UnitedHealthcare Community Plan of New Jersey must include a completed Consent Form-7473-M ED 3-81. This requirement applies to all providers (hospital, operating physician, anesthesiologist, clinic, etc.) per state guidelines. Claims submitted without a fully completed, signed consent form will be denied.

Steps for Submission:

For sterilization claims submission, make sure to complete the consent form attached as follows:

• Paper Claims: Make sure to attach the consent form directly to the mailed claim.
• Electronic Claims: Strictly follow clearinghouse instructions to include the consent form with the submission.

For more information on this healthcare providers can consult with UnitedHealthcare via their 24/7 chat feature available in the UnitedHealthcare Provider Portal.

On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) released the CY 2025 Medicare Physician Fee Schedule (PFS) final rule. The updates focus on enhancing the Medicare Shared Savings Program (Shared Savings Program) to advance value-based care, equity, and growth, with an emphasis on expanding support for Accountable Care Organizations (ACOs) in underserved areas. CMS aims to have all Traditional Medicare beneficiaries in accountable care arrangements emphasizing quality and cost management by 2030.

Key Highlights of the CY 2025 PFS Final Rule

• Prepaid Shared Savings
  CMS introduces “prepaid shared savings” for high-performing ACOs, providing advance payments to support direct beneficiary services and healthcare infrastructure, especially in underserved areas. At least 50% of these funds must go toward medically appropriate services not covered by Traditional Medicare, addressing the specific needs of vulnerable populations.
• Health Equity Benchmark Adjustment (HEBA)
  To incentivize participation in underserved areas, CMS is implementing the HEBA, which adjusts ACOs' financial benchmarks based on the number of low-income or dual-eligible beneficiaries they serve. ACOs with at least 15% of such beneficiaries are eligible, supporting equitable access to quality care.
• APP Plus Quality Measure Set
  Shared Savings Program ACOs will adopt the APP Plus quality measure set by 2025, aligning with CMS’s Universal Foundation measures for streamlined, clinically relevant quality reporting. This measure set will gradually expand from six to 11 measures by 2028.
• Digital Quality Measurement Transition
  To improve interoperability and data accuracy, CMS is prioritizing digital quality measurement via electronic Clinical Quality Measures (eCQMs). CMS will incentivize ACOs to adopt eCQMs, supporting efficient data collection and reporting, with incentives extended through 2025.

CMS is finalizing the Complex Organization Adjustment for the CY 2025 performance period and 2027 MIPS payment year to address reporting challenges for virtual groups and APM entities, including Shared Savings Program ACOs.

1. Complex Organization Adjustment

Virtual Groups and APM Entities will receive one measure achievement point for each compliant eCQM submitted, capped at 10 points per measure. Total points cannot exceed 10% of the total available for the MIPS quality performance category.

2. Mitigating SAHS Billing Impact

To reduce the effect of Significant, Anomalous, and Highly Suspect (SAHS) billing on Shared Savings Program calculations starting in CY 2024, CMS will exclude Medicare Parts A and B payments from financial assessments related to SAHS billing. Ongoing monitoring will identify and address any irregular billing trends.

3. Reopening ACO Payment Determinations

Finalized modifications will allow CMS to adjust calculations for improper payments. ACOs can request the reopening of payment determinations to account for identified overpayments or improper amounts, ensuring fair financial assessments.

4. Other Modifications

• Eligibility Requirements: ACOs that fall below 5,000 assigned beneficiaries can regain eligibility before renewal.
• Beneficiary Assignment Methodology: The definition of primary care services will be updated to reflect recent Medicare PFS changes.
• Beneficiary Notification Requirements: ACOs must now provide follow-up notifications within 180 days of initial communications, rather than at the next primary care service.

These updates enhance the Shared Savings Program's fairness and functionality, ensuring ACOs are not unfairly penalized for factors beyond their control. Effective January 1, 2025, these rules aim to promote equitable access to quality care and strengthen value-based payment systems.

The Centers for Medicare & Medicaid Services (CMS) has unveiled new health and safety standards specifically designed for hospitals and Critical Access Hospitals (CAHs) that provide obstetrical services. This initiative aims to enhance the safety of care for expectant mothers during pregnancy, childbirth, and postpartum recovery, addressing the pressing maternity care crisis in the U.S. This announcement is part of the final rule for the 2025 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC).

Key Highlights of the Announcement:

• New Maternal Health Standards:
  CMS is for the first time setting standards for maternal health and safety in hospitals. These standards will establish basic standards for staffing, organization, and care delivery in obstetrical care units. Further, CMS will revise the quality assessment and performance improvement (QAPI) program to address the need to meet these standards for all staff members; training on EB maternal health practices will also be implemented.
• Payment Rate Increase:
  The final rule also addresses a net change in payment rates of 2.9% which is equivalent to $2.2 billion in hospitals in 2025 based on the previous year. This financial assistance is to help hospitals in providing quality healthcare services to their clients.
• Expanded Access to Behavioral Health Services:
  The new regulations also address the expansion of access to behavioral health services and reductions in barriers to acquiring costly cancer treatment drugs, especially for tribes. CMS is adding new codes for more payment for non-opioid therapies and devices, a move the agency says is aimed at addressing the opioid epidemic and enhancing pain management.
• Support for Formerly Incarcerated Individuals:
  To increase access to care for all those who have been previously incarcerated, CMS is eliminating Medicare work requirements for those on bail, parole, or probation. The special enrollment periods will be liberalized to help such persons as they are readjusted back into society.
• Promoting Health Equity:
  CMS's initiatives aim to address health disparities and improve access to care for underserved communities. Dr. Meena Seshamani, Deputy Administrator of CMS, emphasized that these new policies are designed to ensure that all patients, including those transitioning from incarceration, have access to critical services like pain management and cancer treatment.
• Medicaid Service Expansions:
  The final rule will also improve Medicaid coverage by allowing states to provide clinic services outside traditional settings, including Indian Health Services (IHS) and tribal clinics. Furthermore, it requires a 12-month continuous eligibility period for children enrolled in Medicaid and the Children’s Health Insurance Program (CHIP).

The recent announcements from CMS represent a significant step forward in enhancing maternal health and expanding access to healthcare across the United States. By implementing comprehensive standards for obstetrical care and focusing on the needs of underserved populations, CMS is committed to building a healthier future for all Americans.

The U.S. Department of Health and Human Services (HHS) has finalized new policies in the 2025 Medicare Physician Fee Schedule (PFS) to enhance primary care, expand access to preventive services, and support whole-person care, including behavioral and oral health. This initiative aligns with the Biden-Harris Administration's commitment to affordable healthcare.

Key points include:

• Strengthening primary and preventive care and improving behavioral health access.
• Leveraging the Inflation Reduction Act to ensure equitable care.
• Encouraging participation in the Medicare Shared Savings Program, particularly for rural and underserved areas.
• A 2.93% reduction in payment rates resulted in a new conversion factor of $32.35 for 2025.

Advancing High-Quality, Accountable Care

CMS is solidifying primary care as an anchor for the future of the US healthcare system by completing new codes and payment for advanced primary care services such as availability of care during evenings, weekends, and holidays and personal patient-centered care that targets their medical as well as social needs. These updates build on experience from value-based care models, which define the architecture of accountable care within Medicare.

Whole-person care amalgamates physical health, behavioral health, oral health, and social determinants of health with the aim of improving the well-being of the patient, according to CMS deputy administrator for operations and affairs, Dr. Meena Seshamani. ‘This final rule enhances primary care teams and ACOs – helping improve care for Medicare beneficiaries.’

New policies include strategies for enhancing cardiovascular health based on the Million Hearts® model and changes in the Medicare Shared Savings Program to allow eligible ACOs to receive early savings for additional services and infrastructure, with modifications for promoting health in ACOs serving underrepresented populations.

CMS improves payment accuracy in relation to anomalies in billing practices as well. Moreover, six new MIPS Value Pathways are added to improve the quality of care in such niches as ophthalmology and dermatology.

Increasing Access to Behavioral Health, Oral Health, and Caregiver Training

CMS is working towards offering more extensive health solutions through policies on behavioral, oral, and caregiver health. For the first time, CMS is proposing payment codes for FDA-cleared digital mental health devices, suicide and overdose prevention planning, and improving behavioral health/primary care integration. OTPs now also offer support services such as social health assessment, patient navigation, and recovery services.

The rule now extends to dental services for patients who have end-stage renal disease and who are on dialysis, in addition to those receiving cancer treatment and transplants. Also, CMS is approving payments for virtual caregiver training services, as part of the caregiving support programs by the Biden Administration.

Expanding Preventive Services: Hepatitis B Vaccine, Cancer Screening, and PrEP

To boost preventive care, CMS is extending hepatitis B vaccine coverage for Medicare recipients, allowing access at pharmacies at no cost. Colorectal cancer screening access is also broadened, especially for rural and underserved communities. CMS now includes payment for HIV prevention via Pre-Exposure Prophylaxis (PrEP) under Medicare Part B.

Telehealth Flexibility Preservation

With temporary telehealth provisions set to expire at the end of 2024, CMS is preserving select flexibilities to allow virtual supervision by certain practitioners and virtual teaching for medical residents. Starting January 2025, many pre-COVID restrictions will resume, limiting telehealth to rural medical facilities except for behavioral health, which may continue at home.

Implementing the Inflation Reduction Act

CMS is building on the IRA’s prescription drug provisions that require drug makers to give back to Medicare when drug prices increase beyond inflation so that beneficiaries can sustainably afford the drugs they need.

The TRICARE West Region health plan, administered by TriWest Healthcare Alliance, will be part of the multi-payer platform known as Availity Essentials starting on 1 January 2025. It aims to eliminate as much administrative burden as possible among providers in healthcare. As part of Availity Essentials, routine items, including eligibility and benefits check-ups, claim status queries, and other standard practices will be done quicker on the part of the provider.

This is achieved by rendering the Availity Essentials user from today's easy work provider with the TRICARE West beneficiary. To make preparations ready for the go-live date, TriWest has put up a set of learning materials that can be accessed at the TriWest Learning Center. It is a resource meant for providers. There they can take classes so as to know the nitty-gritty of working on TRICARE West on Availity Essentials.

For those looking to expand their knowledge, the TriWest Learning Center offers a Provider Readiness Designation, which is a prerequisite for listing in the TRICARE provider directory. The designation is acquired by completing courses from the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences.

The coursework includes military culture and evidence-informed mental health treatments most frequently utilized among Armed Forces personnel.

Live support training webinars are available starting in December via Availity and TriWest professionals. Providers can also personalize their Availity Essentials by saving frequently used apps for easy access and auto-populating provider information to minimize errors on input screens.

This integration with Availity Essentials marks a pivotal development for TRICARE West Starting with Availity Essentials or upcoming training, providers can visit the TriWest Learning Center.

The Consumer Financial Protection Bureau (CFPB) and the Centers for Medicare & Medicaid Services (CMS) announced a joint action that will protect low-income Medicare beneficiaries from improper billing practices. As a result, the QMB group of about one in eight Medicare beneficiaries nationwide will no longer be subjected to unlawful charges, such as co-pays and deductibles, prohibited by federal law.

CFPB Director Rohit Chopra said this improper billing can have such a financial cost on low-income families, and this is why the CFPB and CMS are really committed to preventing illegal debt collection for these beneficiaries. CMS Administrator Chiquita Brooks-LaSure also emphasized their commitment to affordable healthcare, making sure that no American experiences financial ruin over essential medical services.

The agencies made clear that Medicare providers, including those in Medicare Advantage plans, cannot legally charge QMB enrollees for cost-sharing amounts. Violators may face CMS sanctions and potential legal liability. This guidance accompanies CMS's issuance of new resources to assist healthcare providers with accurate verification of QMB status and timely refunds of improper charges, particularly where misinformation comes from Medicare Advantage plan administrators.

Improper billing practices normally are against QMB, and hence, it fosters a tendency to move into debt collection actions as well as affecting their credit reports. According to the CFPB, there was a report of QMB status among 17 percent of Medicare-related complaints, including 11 percent who actually claimed attempts to collect by either providers or debt collectors. Reports of debts can have some effects on low-income recipients' access to shelter, among other services.

CMS recommends that QMB recipients whose bills are illegally charged contact Medicare to obtain assistance. Consumers can also report related debt collection issues on the CFPB website or by hotline.

For more information, visit CFPB’s website or call (855) 411-CFPB.