By: Susan Sumrell
CMS recently published an updated version of its Federally Qualified Health Center Fact Sheet. Check it out to learn more abouton Medicare covered services at FQHCs, Medicare FQHC payments, including vaccinations, and other helpful resources. The fact sheet also lists the regional contacts at CMS, which are always good to have handy.
In December HHS issued the final rule for the Consumer Operated and Oriented Plan program (“CO-OP”), created by Section 1322 of the Affordable Care Act (“ACA”), to provide federal loans to foster the creation in every state of private consumer-run nonprofit health insurers (“CO-OP”) to offer qualified health plans in the Affordable Insurance Exchanges (“Exchanges”). 76 Fed. Reg. 77392 (December 13, 2011). The proposed rule was issued in July 2011. 76 Fed. Reg. 43237 (July 20, 2011).
In the final rule HHS rejected one suggestion that the rule explicitly require that FQHCs be included in the provider network of all CO-OPs on the ground that section 1311(c)(1)(C) of the ACA governs the inclusion of safety net providers for issuers that participate in the Exchanges. 76 Fed. Reg. at 77407.
On March 11, 2011 NACHC offered comments on some of the questions posed by HHS concerning this proposed rule. As discussed below, the final rule and the proposed rule – while not otherwise specifically mentioning FQHCs – address some of the matters discussed by NACHC. The following is a summary of the comments NACHC provided, with the responses, when applicable, in the final rule.
NACHC urged HHS to recognize that individual FQHCs, health center-controlled networks, and state or regional primary care associations could act as sponsors of a CO-OP. The proposed rule does not mention (at 43242) FQHCs as examples of entities that could be sponsors (the examples given are entities that received an insurance license after July 16, 2009, self-funded and Taft-Hartley group health plans, church health plans, and “three-share or multi-share” programs not licensed by a state health insurance regulator). The final rule does not address this matter.
NACHC said it thought that it would take a new CO-OP between 12 and 24 months to become operational. The proposed rule required (at 43244) the applicant become an operational CO-OP within 54 months of the first drawdown of a start-up loan or 18 months following the initial drawdown of a solvency loan. The final rule extends these periods to 60 months and 36 months respectively (at 77403).
NACHC said an applicant should be required to submit qualifications and business plans similar to those applying for section 330 grants. Neither the proposed rule nor the final rule mentions this matter.
NACHC said that roughly a minimum of $5-8 million would be required to establish an administrative and claims processing information technology system. Neither the proposed rule nor the final rule mentions this matter.
NACHC said that the amount necessary to capitalize and fund a new CO-OP would depend in part on the solvency requirements established by the state. The proposed rule agrees (at 43244).
NACHC said that there should be preemption of state requirements that hinder the creation of CO-OPs. Neither the proposed rule nor the final rule mentions this matter.
NACHC said that a CO-OP should be allowed to participate in Medicaid or CHIP. The proposed rule provides (at 43243) for such participation; the final rule does not mention this matter.
NACHC said that NACHC and primary care associations would be willing to coordinate training and assistance for CO-OPs and urged that HHS provide funds for such assistance. Neither the proposed rule nor the final rule mentions this matter.
NACHC said that HHS should provide a way for a new CO-OP to gain access to hospitals and specialists at the lowest price charged by these entities to other insurers. Neither the proposed rule nor the final rule mentions this matter.
NACHC said that CO-OPs are more likely to be successful in rural areas. Neither the proposed rule nor the final rule mentions this matter.
NACHC said that the care provided by FQHCs is “integrated care” within the meaning of section 1332. Neither the proposed rule nor the final rule mentions this matter.
NACHC said that the term “significant private support” in section 1332 should include support from local business and labor. Neither the proposed rule nor the final rule mentions this matter.
NACHC said that FQHCs meet all of the priority criteria of section 1322. Neither the proposed rule nor the final rule mentions this matter.
NACHC said that HHS could offer planning grants to a primary care association, a CO-OP in another state, or NACHC if there is no CO-OP in a particular state. Neither the proposed rule nor the final rule mentions this matter.
NACHC said that HHS could follow the CMS criteria for Medicare Advantage Organizations in order to distinguish marketing activities from educational activities; private funds or program income from premiums could be used for marketing. The proposed rule does not mention this matter, and the final rule rejects the suggestion that marketing be defined because it was not mentioned in the proposed rule (at 77396). However, a September 16, 2011 amendment to Funding Opportunity Announcement discusses what “marketing” means: “ ‘Marketing’ means activities that promote the purchase of a specific health care plan or explain a product’s benefit structure, whether targeted at new or current members. “Marketing” does not include activities related to community outreach, membership development, and membership education. Loans provided under the CO-OP program may be used to provide information to members regarding their coverage, rights, and responsibilities.”
NACHC said that it is essential that a new CO-OP be operational in 2014. The proposed rule (at 43244) agrees and says that the first loans will be made in late 2011 or early 2012.
NACHC said that a CO-OP should be considered a “related entity” to a health insurer (a) if they share any ownership or (b) control or the insurer provides more than 50% of the CO-OP’s revenue. Both the proposed rule (at 43241) and the final rule (at 42 CFR 156.505) accept the first part of NACHC’s suggestion.
NACHC said that “predecessor” should mean an entity that no longer exists but that had a common ownership or controlling interest in an entity that now exists. Both the proposed rule (at 43241) and the final rule (at 42 CFR 156.505) define “predecessor” as “any entity that participates in a merger, consolidation, purchase or acquisition of property or stock, corporate separation, or other similar business transaction that results in the formation of the new entity.”
NACHC said that a CO-OP meets the governance requirements for its board by having the applicant have a history of consumer governance along with expertise in insurance, health care, finance, law, accounting, and retail. Both the proposed rule (at 43242) and the final rule (at 42 CFR 156.515(b)) require that each of the CO-OP’s directors be elected by a majority of the persons it insures in a contested election, with the first election being held one year after the CO-OP enrolls members.
NACHC said that HHS should encourage that any profits of the CO-OP be used to reduce premiums in the year profits were earned. Neither the proposed rule nor the final rule mentions this matter.
NACHC said that program to improve the quality of care should come out of the CO-OP’s regular budget and not solely from any profits. Neither the proposed rule nor the final rule mentions this matter.
By: Susan Sumrell
Happy New Year! We wanted to be sure you saw this important message from CMS about 2011 Date of Service claims. If you have any questions, please feel free to contact NACHC’s Director of Community Health Center Finance and Operations, Gervean Williams.
As the Centers for Medicare & Medicaid Services (CMS) implements calendar year 2012 changes, Medicare claims administration contractors will be holding some institutional provider claims containing 2012 services for up to the first 10 business days of January 2012 (i.e., Sunday, January 1, 2012, through Tuesday, January 17, 2012). Claims will be released as system testing is successfully completed, which we expect during that time frame.
The hold should have minimal impact on provider cash flow because, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt. However, if you follow the status of your claim during the claims processing cycle, the claim status may not reflect what you would normally see because of the claims hold.
Medicare claims for services rendered on or before Saturday, December 31, 2011, are unaffected by the 2012 claims hold and will be processed and paid under normal procedures and time frames. We appreciate your patience as we implement calendar year 2012 changes.
By: Susan Sumrell
On December 16, 2011 CMS’ Center for Consumer Information and Insurance Oversight (CCIIO) released a bulletin on the Essential Health Benefits. This bulletin outlines CCIIO’s intentions in defining Essential Health Benefits, as required by the Affordable Care Act (ACA). CCIIO is soliciting comments on this bulletin by January 31, 2012.
In the bulletin, CCIIO outlines the background and statutory authority in the ACA to establish the Essential Health Benefits (EHB) and the process for the development of the proposals. Section 1302(b)(1) of the ACA lists the 10 benefit categories that the EHB must include: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services including oral and vision care.
Additionally, the bulletin outlines CCIIO’s intended regulatory approach, which provides States with flexibility, suggesting that EHB be defined by a benchmark plan selected by the States. This approach gives States flexibility in choosing one of four benchmark plans: the largest plan by enrollment in any of the three largest small group insurance products in the State’s small group market, any of the largest three State employee health benefit plans by enrollment, any of the largest three national FEHBP plan options by enrollment or the largest insured commercial non-Medicaid Health Maintenance Organization (HMO) operating in the state. The bulletin notes that if one of the 10 benefit categories is missing from the chosen benchmark plan, it must still be covered by health plans that are required to offer EHB.
NACHC is reviewing the Bulletin and will be submitting comment to CMS. Comments are due January 31, 2012 and can be submitted to EssentialHealthBenefits@cms.hhs.gov. We hope to have a draft of our comments to share by January 21 and we encourage PCAs and health centers to review the Bulletin and submit comments as well. We also welcome any suggestions or responses you may have to our draft comments.
By: Susan Sumrell
CMS’ Center for Consumer Information & Insurance Oversight recently put out a Frequently Asked Questions document on State Exchange Implementation. This 8 page document covers a variety of questions on Exchange implementation, including cost to states, basic health program funding, exchange eligibility, and other important questions. For more information on the Exchanges, check out the CCIIO website.
By: Susan Sumrell
In late November, HRSA’s Office of Pharmacy Affairs relased three new Program Notices, which clarify current HRSA Policy. The program notices focus on the non-discrimination policy, penny pricing policy, and manufacturer audits. Please take a minute to review these notices to ensure you have the latest information on these policies. For more on these new notices and other 340B information, check out the HRSA Office of Pharmacy Affairs website.
By: Asha Cesar, State Affairs Intern
A new NACHC report finds that over half the states plan to decrease direct funding to community health centers bringing state funding in SFY2012 to $335 million–its lowest level in seven years. Health centers in six states will face a decline of greater than 30%. Many health care advocates are concerned that habitual state budget cuts will decrease health center capacity to meet the growing demand. As states continue to debate their fiscal priorities during the continuing budget crisis, it will be up to health center advocates to educate policymakers about the impact these cuts have on their centers and communities.
Federally qualified health centers (FQHCs) provide care to all regardless of ability to pay. With the rise of uninsured patients—largely due to the current economic downturn— health centers will endure many challenges managing their patient load and operational activities in the face of state budget cuts.
Impacts of State Budget Cuts:
The report also reveals that some health centers in states that cut funding were forced to close clinics, institute hiring freezes and even prevent clinics from applying for FQHC status. All of these will create barriers to care and have detrimental effects on the communities they serve.
In 2010, approximately 16 million visits were for patients with chronic disease – including depression and other behavioral health conditions – who depend on health centers for their care. It is a major concern that a number of states indicated their health centers had to eliminate disease management or preventative care programs in addition to reducing overall operating costs. While it is not surprising that people with chronic conditions generally require more health care services over a longer period of time, with the elimination of essential programs such as disease management, emergency room visits and hospitalizations (which cost the system more) may increase in those specific areas.
Thankfully, health care is still a priority.
It’s not all bad news. Despite hard times and the uncertainty that lies ahead for many health programs, six states will increase funding for health centers in SFY2012. Wyoming will provide $1 million to health centers for the first time!
What can health centers do?
As many states are gearing up for the 2012 legislative session, health center advocates must continue to educate policymakers about health centers and why they are a good investment in the health of your state.
By: Susan Sumrell
CMS has posted a list of all providers who have been sent a request to revalidate their Medicare enrollment information. To view the list, visit the Medicare Provider Supplier Enrollment Revalidation Page and click “Revalidation Phase 1 Listing.” Be sure to bookmark this page, because CMS will be updating this page monthly.
For more information on what’s required for the Medicare Revalidation, see our orginial blog, reposted below.
We have received several questions on the Medicare revalidation process and wanted to provide some more information on the process and impact to FQHCs. This is very important to understand, as it will directly impact your center’s Medicare billing.
Section 6401(a) of the Affordable Care Act requires all providers and suppliers (including FQHCs) that enrolled with Medicare before March 25, 2011 to revalidate their enrollment information under new enrollment screening criteria; but only after such providers or suppliers receive notification from their MAC. Once contacted by a MAC, suppliers and providers have 60 days from the date of the letter to submit complete enrollment forms. Please note that failure to submit the enrollment
forms as requested may result in the deactivation of Medicare billing
privileges. Additionally, the $505 Medicare enrollment fee that we told you
about here also applies to revalidation.
CMS has posted two important Medicare Learning Network articles on the revalidation process and the new enrollment fee here: MLN MattersNumber: SE1126 and MLN
MattersNumber: MM7350.
For more information on the revalidation process, please contact Susan Sumrell or Gervean Williams.
By: Susan Sumrell
As you’ve heard, thanks to all of the comments submitted on CMS’ proposd rule on the Medicare Shared Savings Program and Accountable Care Organizations (ACOs), health centers saw a reversal of policy in CMS’ recently released final rule on ACOs. The final rule allows health centers to form and participate in ACOs and we have done a preliminary review of this final rule to determine the impact on health centers. This is just a review, highlighting the health center specific provisions. Stay tuned fore more infomation on the impact of the final rule. To see NACHC’s comments on the proposed rule, click here.
By: Susan Sumrell
On October 31, 2011, NACHC submitted several sets of comments on several new provisions from the Affordable Care Act, related to the creation of exchanges and new eligibility processes.
The first set of comments was on the proposed rule on the Estabishment of Exchanges and Qualified Health Plans (QHPs). This proposed rule sets the framework for the new state based exchanges which will go into effect in 2014. You can read NACHC’s comments here.
The other two proposed rules we commented on were on new eligibility requirements for both Medicaid and the Exchanges. The ACA requires that these processes be streamlined in order to ensure better access to these programs, and you can read NACHC’s comments on Medicaid eligiblity here and Exchange eligibility here.
Finally, we provided comments on a Request for Information from CMS on state flexibility to establish a Basic Health Program. You can read NACHC’s comments here.
