2012 Master Medicare Guide

January 2012

2012 Master Medicare Guide

In the next day or so, the 2012 Master Medicare Guidewill be live on IntelliConnect to customers. The 2012 edition provides about 500 explanatory sections on all aspects of the Medicare program – from enrollment to reimbursement to compliance. The Master Guide also includes dozens of analysis pieces contributed by experts in the field.

The print version of the Master Guide will ship in March.

TheHealth Law Web Site & Blog

Do your customers know about the new Health Law web site and blog: If they don’t, make sure you tell them to check it out.

This web site is intended to serve as a community site for the Health Law market with access to a blog written by CCH and industry leading experts, twitter feeds, mobile apps, net news, new product and enhancement announcements, and a knowledge center. Updated daily, the content in the blog will focus attention on topics related to health care compliance, reimbursement, and food and drugs.

This is also the place to direct current customers for information on enhancements to their subscriptions, such as the Medicare and Medicaid Guide Toolkit Smart Charts, or new products, like the Health Care Compliance and Reimbursement Daily Smart Chart.

Both of these Smart Chart products allow customers to research various health care compliance and reimbursement issues. The Toolkit is built up from the Explanations sections of the Medicare and Medicaid Guide and provides links to laws, regulations, final rules and significant decisions. The Daily Smart Chart provides same-day links to Federal Register issuances, court cases, administrative decisions, new laws, and significant guidance documents issued by CMS.

News

Low-income drug subsidy eligibility rules confirmed. The Social Security Administration (SSA) has adopted, without change, its Interim final rule with request for comments (75 FR 81843, December 29, 2010) that changed the way it accounts for income and resources when determining eligibility for the Medicare Part D prescription drug subsidy provided by the low-income subsidy (Extra Help) program.

Income and resource exemptions

Section 116 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (P.L. 110-275) amended Soc. Sec. Act §1860D-14(a)(3) to exempt the value of life insurance and in-kind support and maintenance from income and resources determinations of Extra Help eligibility on or after January 1, 2010. The SSA applied these exemptions to applications filed and redeterminations initiated after that date.

As a result, SSA no longer counts as income the help a beneficiary receives when someone else provides food and shelter, or pays for food, mortgage, rent, heating fuel, gas, electricity, water, or property taxes. To reflect these statutory exemptions, SSA revised sections 20 C.F.R. §418.3335(b) and 20 C.F.R. §418.3350 and deleted 42 C.F.R §418.3345 of their regulations in the December 2010 interim final rule.

Section 3304 of the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148), extended the effective date of a determination or redetermination of an Extra Help subsidy due to the death of a spouse. Prior to the passage of this provision, any adjustment in the amount of Extra Help the beneficiary received was effective the month after the month in which SSA was notified of the death of a spouse. In some cases, the death of a spouse would result in a decrease in the amount of Extra Help or loss of Extra Help eligibility for the beneficiary.

Under the December 2010 interim final rule, effective January 1, 2011, if the death of the spouse would decrease or eliminate the subsidy provided by the Extra Help program, SSA extended the effective period for a determination or redetermination until one year after the date on which it would otherwise cease to be effective — that is, the month after the month SSA is notified of the death of the spouse. In order to reflect these changes, SSA revised sections 20 C.F.R. §418.3120 and 20 C.F.R. §418.3123 of their regulations in the December 2010 interim final rule.

Social Security Administration Final Rule, January 18, 2012

CMS sets appeals process for EHR incentives.CMS has released a guidance document detailing the steps that health providers must use to appeal a decision relating to applying for incentives to adopt electronic health records (EHR) technology. Under the Health Information Technology for Economic and Clinical Health (HITECH) Act, eligible health professional and hospitals can qualify for payment incentives to adopt EHR technology.

Incentive payments started being disbursed in 2011 and will be available to eligible providers under the Medicare program for four consecutive years until 2016. Eligible professionals may receive up to $44,000 if they meet the requirements to receive incentive payments during all five years of the program. If providers have not adopted EHR technology by 2015, they face reductions in their Medicare payments.

According to the CMS guidance, EHR incentive appeals will be handled by CMS’ Office of Clinical Standards and Quality (OCSQ). The OCSQ will manage a two-level appeal process, which includes an informal review and a request for reconsideration. Within that two-level appeal process, three types of appeal will be available—

(1) / an eligibility appeal, allowing a provider to show that all the EHR incentive program requirements were met and that he or she should have received a payment but could not because of circumstances outside of the provider’s control;
(2) / a meaningful use appeal, allowing a provider to show that he or she is using certified EHR technology and has met the meaningful use objectives and associated measures after a successful attestation; and
(3) / an incentive payment calculation appeal, allowing a provider to show that he or she provided claims data for inclusion that was not used in determining the amount of the incentive payment.

The guidance provides information on who providers must contact to make an appeal, general filing requirements for an appeal filing, and issues precluded from review.

CMS Guidance, January 24, 2012

MedPAC recommends reducing hospital supervision payments. The Medicare Payment Advisory Commission (MedPAC) has recommended setting the payment rate for supervision services provided in hospital outpatient departments to be the same as it is in physician’s offices. The recommendation is to be phased in over three years and capped at no more than 2 percent for any particular hospital. This recommendation to reduce this payment was accepted at a MedPAC meeting on January 12 and 13, 2012.

MedPAC estimates that if this policy is fully phased in, it would reduce hospitals' overall Medicare revenue by 0.6 percent and outpatient Medicare revenue by 2.8 percent.

CCH Chicago Bureau, January 19, 2012

Changing Medicare eligibility age will reduce health spending. Increasing the eligibility age for Medicare and Social Security would decrease federal spending on health care, increase gross domestic product, and decrease the federal budget deficit, according to a report from the Congressional Budget Office (CBO). The downside for individuals is that it would likely lead to an increase in the number of people who are uninsured in the year or so before they are eligible for Medicare.

The report–"Raising the Ages of Eligibility for Medicare and Social Security"–examined possible changes to:

• the Medicare eligibility age (MEA), currently 65;
• the early eligibility age (EEA) under Social Security, at which participants may first claim retirement benefits, currently 62; and
• the full retirement age (FRA) under Social Security, at which participants are eligible to receive full benefits, currently 66 but scheduled to increase to 67 for people who were born after 1959.

The CBO noted that if the MEA was increased to 67, annual federal spending on Medicare would decrease by about 5 percent per year.

Most people affected by an increase in the Medicare eligibility age would obtain health insurance coverage other ways, although there would be a slight increase in the number of uninsured people.

According to the report "of the 5.4 million people who would be affected by the higher MEA in 2021, about 5 percent would become uninsured, and approximately half of the group would obtain insurance from their or their spouses’ employers or former employers. The remainder (about 2.3 million people in 2021) would…receive coverage through Medicaid, receive coverage through Medicare because they would qualify for [disability insurance] benefits, or purchase insurance either through the health insurance exchanges that will become available in 2014" under the health reform law. Increasing the MEA this way also would reduce Medicare spending by $148 billion from 2012 through 2021.

Raising the Ages of Eligibility for Medicare and Social Security, Congressional Budget Office, January 10, 2012

Retiree drug subsidy provisions and waiver authority finalized. CMS has finalized the retiree drug subsidy (RDS) language as specified in the January 12, 2009 Final rule with comment period (74 FR 1494) and the proposed regulatory changes for Part 423 Subpart J (Coordination of Part D Plans With Other Prescription Drug Coverage) in the Proposed rule (74 FR 1550) published the same day. These changes are effective March 12, 2012.

As a result, CMS has finalized the definitions of “actually paid,” “administrative costs,” “allowable retiree costs,” “gross covered retiree plan-related prescription drug costs, or gross retiree costs,” as they were published in the January 12, 2009, Final rule with comment period (see 42 C.F.R. §423.882). CMS, however, specifically declined to adopt the Part D definition of “negotiated price,” which would have required RDS sponsors, like Part D sponsors, to report pass-through pricing and retained rebates.

CMS has also finalized the revision of 42 C.F.R. §423.888(b)(5)(i) so that it references the term “gross covered plan-related retiree prescription drug costs,” which is a term defined in Part 423 Subpart R (Payments to Sponsors of Retiree Prescription Drug Plans), rather than “gross prescription drug costs,” which is not. Finally, CMS has made one technical change to the definition of “actually paid” to make it clear that direct and indirect remuneration can be from any source, as opposed to only from manufacturers or pharmacies.

CMS has also finalized the regulatory waiver language set out for 42 C.F.R. §423.458(c) in the January 2009 Proposed rule. While CMS believes the Part D and RDS programs are mutually exclusive programs, both are established under the Part D – Voluntary Prescription Drug Benefit Program, and implemented under 42 C.F.R. Part 423. Therefore, CMS believes it is best to interpret parallel statutory language in the same manner, but use their waiver authority to waive RDS requirements that, if interpreted consistently with parallel Part D requirements, would hinder the offering of, design of, or enrollment in, RDS plans.

Final rule, 77 FR 1877, January 12, 2012