Conference
OHA Update
March 20, 2014
Charles Cataline
VP Health Economics & Policy
charlesc@ohanet.org
Alyson DeAngelo
Director Health Economics & Policy
alysond@ohanet.org
Central Ohio Chapter HFMA
March 20, 2014
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Agenda
• Federal Update
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Medicare CY 2014 OPPS Enhanced Packaging
ICD.10
Medicare RAC Re-Bid
“Two-Midnights Rule:” What’s Next?
• State Update
• Medicaid Expansion Kicks in
• Electronic Eligibility Rollout
• Hospital- Based Presumptive Eligibility
• 2014 HCAP Formula Updated to Respond to Eligibility Expansion
• DSH Audits: FFY 2011 Report & FFY 2012 Recommendations
• OHT SIM Grant & Episodic Payments
• MyCare Ohio Rollout
• Medicaid Telemedicine Coverage
• Medicaid Modernization II
• APR-DRG Conversion: FFY 2015 = Conversion Year Two
Central Ohio Chapter HFMA
March 20, 2014
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CY 2014 Medicare OPPS
• Started Jan. 1, Regardless of Delay - Overall 1.7% increase
• Changed E&M Reimbursement in Clinics
 Just One Reimbursable “G” Code Paid at APC Level
 Does Not Affect Medicaid in CY 2014
 Good News on Medicare ED E&M (for now?)
• Big Movement Toward Additional APC Packaging & “Comprehensive
APCs” Is This the Slow Start of Real Outpatient Encounter- Based
Reimbursement?
• Packaging addl. Diagnostic & Surgical Drugs/Biologicals, Diagnostic
Tests, Add-on Codes & Device Removal
• Comprehensive APCs for “Device-Dependent” APCs
• Additional Quality Standards
• Tighter Supervision Standards at CAH’s
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ICD.10
• CMS Says Oct. 1, 2014 is Hard Deadline
• Ohio Medicaid & BWC on board, too!
• Commercial payers and trading partners ?????
• Congress would have to intervene to change date
• Medicare, Medicaid, BWC Testing Underway
• Limited Medicare Provider Bill-to-Payment Testing Scheduled
• MACs converting LCDs & opening web-based test site
• Instructions on split bills out (DOS 10/1/14); See CR 7492
• No formal word from commercials !
• Effects on 2015 DRGs, IPPS Update & Budget Neutrality?
• Initial Medicaid results are troubling!!
• Clinical documentation more important than ever!
Central Ohio Chapter HFMA
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Medicare RAC Re-Bid
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RAC Contract Rebid on Hold Until June 1 (?)
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CMS will “Pause” Medicare RAC Activity Until New Contracts
are in Place
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New Regions Drawn to Re-Weigh Claims Volume
Existing Region B Subdivided – at the Very Least Some States in
Region B Must Switch Contractors
Feb. 21 – Last Day a RAC can Issue Post-Payment ADR
Feb. 28 – Last Day a MAC can Issue ADR for RAC Pre-Pay Review Demo
June 1 – Last Day a RAC Can Send Denied Claims to MAC for Recovery
Once New RACs are in Place ADRs will be Released Retro to
Start of Program “Pause”
In the Interim, CMS will Continue to “Refine” Medicare RAC
Program, Starting with…
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March 20, 2014
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Medicare RAC Map – Old v. New
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CMS: Five Medicare RAC Improvements
Central Ohio Chapter HFMA
March 20, 2014
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Medicare “Two Midnights Rule”
• Biggest Reason for New Policy is Huge Backlog of Short-Stay
Appeals at ALJ, but “Two Midnight Rule” Still Controversial
• CMS Re-Extended Partial Enforcement Delay Through Sept. 30
• RACs and MAC Cannot (Ever) Perform Post-Pay Reviews of Short Stays
with Dates of Admission from 10/1/13 – 9/30/14
• Medical Necessity and Coding Reviews can Continue
• MAC Pre-Payment “Probe & Educate” Reviews Continue on
Claims from Same Period, With Additional CMS Guidelines
• Jan. 30 - Admission Guidelines; Feb. 24 - Review Guidelines, Updated
FAQs, and P&E Project Status Update with Common Denials
• MACs Ordered to Re-Review Earlier P&E Rejections to Ensure They
Abide by Latest Clarifications
• AHA Surveying MAC Activity, Claims Volume and Results
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March 20, 2014
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Medicaid Expansion Kicks In
• Started Jan 1. 2014
• Ohio Supreme Court : Controlling Board-Based Expansion is
Constitutional!!
• Electronic and Expedited Application Software went Live Dec. 9 at
“benefits.ohio.gov”
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Linked to Federal Data Hub
No CPJFS Visit Required
Utilize MAGI Standards
No Documentation Required
• Presumptive Eligibility RollOut Continues - Watch for
Quality Standards
• OHA Advocating for Additional Direction on Overall Process &
Preparing “Intake” Tool Kit. Stay Tuned!!
Central Ohio Chapter HFMA
March 20, 2014
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Potential Medicaid Expansion by County
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March 20, 2014
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Medicaid On-line Eligibility System
• benefits.ohio.gov Live as of Dec. 9, 2013
• Designed to Interact with the Federal “Data Hub” to Provide a “No
Touch” Application Experience
• However, Most Cases Currently Still Need to be Completed by
Follow-up with a County JFS Case Worker
• Expansion as of February…
– 23,156 have enrolled
– 9% of estimated 275,000
– About 90,000 Medicaid applications are stuck between federal and state
systems – county JFSs are working to resolve
– State expects to enroll 500,000 in next 18 months – about 231,000 from
“woodwork
• Direct people to benefits.ohio.gov even if they tell you they’ve
completed an application through healthcare.gov
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Medicaid Presumptive Eligibility
PE Today
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Pregnant women and children only
Entered through MITS
Currently 44 hospitals are Qualified Entities
Coverage is for outpatient pregnancy related services and all
services for children
PE in the Near Future
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All Medicaid populations
PE portal through the integrated eligibility system
All hospitals can become qualified entities
We are waiting for the state to finish the PE portal
The Hospital is Responsible for Following Through with Patient
to get Full Medicaid Application Completed
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• Concerns:
2014 HCAP Distribution Formula
• (OHA) The Combination of Retroactive FFY 2014 Medicaid DSH Audits
(Myers & Stauffer) with the CY 2014 Medicaid Expansion Could Cause
big Medicaid DSH Payment Recoveries from Some Hospitals
• (ODM) CMS is increasingly Demanding Medicaid DSH Programs Follow
Uninsured & Medicaid Losses
• But… How Valid is the Expansion Projection for 2014?
• Many Hospitals Currently Reporting Lower than Projected Medicaid
Eligibility “Uptake”
• Finance Committee Recommends 2014 Compromise for HCAP
Distribution Model
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Assume 50% of Projected Medicaid Expansion Uptake for FFY 2014
Protect Existing Special Allocations (Pots)
Merge Some $$ for High DSH, UC<FPL & UC>FPL ; Link to OBRA Cap
Reexamine in 2015
Central Ohio Chapter HFMA
March 20, 2014
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DSH Audits: FFY 2011 Report
& FFY 2012 Recommendations
OHA Task Force on Medicaid DSH Audits Recommendations
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Limit New Data Elements for SFY 2014 Cost Reports / Logs
Revive Medicaid Paid Claims Report (“PS&R”)
Consider Permanent Delay to Cost Report Due Date
Report All Charges (CR & LOGS) Based on Date of Service; All
Payments Based on Date of Payment / Recovery
• Clarify Whether ODM Wants all Payments Reported in
Schedule F or Just Uncompensated Payments
• Revise Schedule F Data Review “Agreed-Upon-Procedures”
• Eliminate DA
• Revise Sample Size to Increased Hospital Revenue
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OHT SIM Grant & Episodic Payments
State Innovation Models – Episodic Payments
• State Seeking CMS Grant
• Governor’s Advisory Council on Health Care Innovation 5Year Plan
• Develop Comprehensive Primary Care Initiative
• Create Payment System for Selected Clinical Episodes
• Episodic Payments Involve the Assignment of a “Primary
Accountable Provider” to be Responsible for Managing
“Costs” in the Treatment of Selected Episodes Using a
Retrospective Risk/Gain Sharing Program.
• OHA Meeting with Medicaid & Office of Health
Transformation
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Ohio Medicaid/Medicare Dually Eligible
Integrated Delivery System Demonstration
(AKA “MyCare Ohio”)
• Target Population
o Full-Benefit Dual Eligible Enrollees Excluding:
• Those Eligible for the Medicare Savings Program
• Dual Eligibles with Intellectual and Developmental Disabilities
Served Through an IDD 1915(c) HCBS Waiver or an ICF-IDD.
– Those Not Under Waiver can Opt In
• Dual Eligibles Enrolled in PACE
• Dual Eligibles under 18
o Duals With “Severe or Persistent Mental Illness” will be Included
o Individuals with SPMI in the Demonstration do not Have to Change
Providers for Behavioral Health Services.
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MyCare Ohio Dually Eligible Integrated Delivery Demo
• Model Design
o At Least Two Competing Health Plans in each of Seven Regions
Chosen for the Demonstration (Most Rural Areas Exempt)
o Enrollees can Choose Between the Health Plans in Their Region
• All Regions Have at Least 3 Medicare Advantage Plans Currently
Serving Medicare Beneficiaries
o The Demonstration will Auto-Enroll the Eligible Population With an
Option to Opt in for Medicare-Covered Benefits
• If They Don’t Opt in for Medicare They Will Still be Enrolled in
Medicaid Managed Care
• Enrollees Will Have the Option of Switching Plans and can Opt
into / out of Medicare at any Time
o Utilizes a “Payment Structure That Blends Medicare and Medicaid
Funding”
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MyCare Ohio Dually Eligible Integrated Delivery Demo
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Approx. 196,000 Medicare-Medicaid Enrollees in Ohio Are Currently
Receiving Benefits Primarily Through FFS
Approx. 115,000 Included in the Demonstration Program
Medicaid Enrollment Starts May1 and is Phased in Through June & July
Individuals have up to Eight Months to Decide Medicare Status
Starting Jan. 2015, Individual who Have not Chosen a Medicare Plan will
be Enrolled in a MyCare Ohio Plan, but they still have the Option to
Return to Medicare FFS or Medicare Advantage if they Choose
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MyCare Ohio Dually Eligible Integrated Delivery Demo
• Draft Payment System
o Medicare and Medicaid will Contribute to the Blended Payments in a
Manner that Expected Aggregate Savings are Proportionately Shared
Between the two Programs
o The Blended Capitation Payment Structure is Expected to Provide
Plans the Flexibility to Utilize the Most Appropriate Cost Effective
Service for the Enrollee, Eliminating Incentives to Shift Costs Between
Medicare and Medicaid
o Reimbursement will Include Pay-for-Performance Incentives
• OHA’s Concerns
o Can MCPs Really Integrate and Manage this Array of Providers,
Agencies and Services?
o How Would This Affect Existing UPL Programs
o Is it Right to Limit Enrollees Freedom of Choice?
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Medicaid TeleHealth Coverage
• Proposed Rule Out (OAC 5160-1-18)
• “Originating” v. “Distant” Sites Defined
• Sites Must be at Least Five Miles Apart, Unless Emergency or
when Travel Poses “Undue” Patient Hardship
• Coverage Limited to:
• Originating = Dr. Office, Hospital, FQHC, Nursing Facility
• Distant = Consulting Practitioner
• Payment = Lesser of Billed Charge or Fee Schedule
Amount
• Originating =
• E&M (Only if Service is Separately Billable)
• Telehealth “Originating” Fee
• Distant = Normal Professional Claim for Service
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Medicaid Modernization II
• Additional $67M Cut Over SFY 2014/2015 Biennium
• 2009 5% Payment Increase Reversed for Non-Childrens Hosp’s.
• Inpatient Now, Outpatient Still Unclear
• Cost-Based Hospitals’ Payments Reduced to 90% (7/1/14?)
• Capital Expenditures Reduced to 85% Cost (No Settlement!)
• Cuts to Outpatient Hospital Payments – Effective 1/1/14
 Unknown (99-Level) CPT Codes Moved to Fee Schedule
o Small Exception for Dental That will not Benefit Many
 “Paragraph L” Services Reduced to 60% of Cost
 Secondary Procedure Payment Reduction to 50%
 Lab Fee Schedule Reworked to Match Medicare
• Add’l Attention to Medicaid Re-Admissions off the Table for Now
• Will ODM Recoup APR-DRG “Excess Payments?”
• Medicaid Interest on Overpayments Reduced (Eff. 1/1/14)
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APR-DRG Conversion: FFY 2015 = Conversion
Year Two
SFY 2014 Policy Shifts
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CMS Grouper 15 to 3M APR-DRG
Outliers Policy Changed to Mirror Medicare
New Peer Group Base Rates
Newly Calibrated Relative Weights
Stop Loss/Stop Gain Applications Within Peer Groups
Med-ed Payments Held Harmless
What’s Next for 2015 ?
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New APR-DRG Starts Each Year with Discharges 10/1 and After
Stop Loss/Gain Transition Moves to Year Two
Accuracy of Payments & Projections – Rebalance to Come?
Additional Discussion Expected About:
– Peer Groups, Next Scheduled DRG Re-base & Re-Calibration, Medical
Education Payments, HAC, Other?
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