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Improving the lives of 10 million older adults by 2020
Understanding Relevant
Medicare Billing, MACRA and
Other Changes on the Horizon
May 25, 2017
Tim McNeill, Independent Health Care Consultant
Sharon Williams, Consultant, NCOA
Howard Bedlin, Vice President, Public Policy and Advocacy, NCOA
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Crash Course:
Medicare and
MACRA
Timothy P. McNeill, RN, MPH
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Shift Toward Value-Based Purchasing
• The current system is changing from Fee-For-Service to
payment for outcomes.
• A Value-Based Purchasing system provides financial
incentives for outcomes (Value)
• MACRA legislation provides direct incentives to
Physicians and Hospitals to move towards a system that
pays for outcomes
• In the past, there were real financial incentives to
providers, when complications occur
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Value-Based Purchasing Opportunities
4
• Disease self-management programs that can address the cost
of care, reduce readmissions, and improve outcomes address
key issues facing the healthcare system
– Improve Physician Value-based purchasing
– Reduce Readmissions Penalties
– Improve Hospital Value-based purchasing
– Health Systems and industry will create programs to address
this problem if good options are not presented
• ROI must be clearly defined and measured
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Which Population has the most chronic
disease?
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• Most chronic conditions were more prevalent for dual-eligible
beneficiaries
– 72% of dual-eligible beneficiaries had two or more conditions
– Dual eligible beneficiaries were 1.7 times as likely to have 6 or
more chronic conditions
– 1.7 times more likely to have COPD
– 1.6 times more likely to have heart failure
– 1.4 times more likely to have diabetes
• 98% of readmissions, in 2010, were for Medicare beneficiaries
with two or more chronic conditions– CMS Chronic Conditions Among Medicare Beneficiaries, Chartbook – 2012 Edition. Available
Online: https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-
reports/chronic-conditions/downloads/2012chartbook.pdf
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What Does Medicare Cover?
• Part A: Medicare Part A covers inpatient hospital care,
skilled nursing facility care, home health services, and
hospice.
• Part B: Medicare Part B covers physician services,
office visits, screenings, therapies, preventive services,
outpatient services, emergency care, ambulance
services, medical supplies and durable medical
equipment.
• Part C: Medicare Part C is the private health insurance
option for Medicare beneficiaries. Medicare Part C is
often referred to as Medicare Advantage.
• Part D: Medicare Part D is the prescription drug benefit
option.
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Medicare Part B
• Part B: Medicare Part B covers physician services,
office visits, screenings, therapies, preventive services,
outpatient services, emergency care, ambulance
services, medical supplies and durable medical
equipment.
• Co-Insurance: Part B covers 80% of charges and the
beneficiary is responsible for the co-insurance amount
(20%)
• Medigap policies cover the 20% co-insurance
• Dual-Eligible beneficiaries have Medicare + Medicaid
– Medicaid is the Medigap policy
– Person on Waiver with Medicare is a Dual
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Medigap Market
• Medicare Part B beneficiaries can purchase a
Medigap or supplemental policy to cover the
20% coinsurance requirements
• A Medigap policy defined
• Health insurance sold by private insurance
companies to fill gaps in Original Medicare coverage
• Coinsurance, copayments, deductibles
• If a beneficiary elects Medicare Advantage, they
cannot be sold or use a Medigap policy
• Beneficiaries with Medicaid (Duals) generally
cannot buy a Medigap policy
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When Medicare Isn’t Enough….Supplement
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MEDICARE ACCESS AND CHIP
REAUTHORIZATION ACT
MACRA
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MIPS Reporting Requirements - eCQMs or
eMeasures
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• 2017 is the MIPS transition year
– All Physicians accepting Medicare must report
– Baseline established for future payment adjustments
• electronic Clinical Quality Measures – eCQMs
• Specific clinical quality measures that must be reported by
physicians, providers, and hospitals that are eligible for
incentive payments
• MACRA regulations begin to link provider performance on
eCQMs to payment
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eCQMs or eMeasures
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• electronic Clinical Quality Measures – eCQMs
• Specific clinical quality measures that must be reported by
physicians, providers, and hospitals that are eligible for
incentive payments
• MACRA regulations begin to link provider performance on
eCQMs to payment
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Provider Merit Incentive Payment System
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Provider MIPS Categories applicable to
CBOs
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• Quality
– Diabetes outcomes
– Depression screening
– Fall risk
• Advancing Care Information
– Referrals to community programs
– Send a summary of care
• Improvement Activities
– Care transitions documentation
– Engagement of community for health status improvement
– Evidence-based interventions to promote self-management
– Chronic care and preventive care management
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Potential Role of CBO in supporting MIPS
Quality Measures
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• Identify which measures provider is going to report
• Align CBO programs with the planned reporting measures
• Examples:
– Fall Risk – Matter of Balance, Stepping On, Etc.
– Diabetes Management – DSMT
– Depression Screening/Mgmt – PEARLS
– Readmissions – Care Transitions and chronic care mgmt
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Chronic Care Management
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What is Chronic Care Management
• An extensive range of services intended to support a
person to improve clinical outcomes and reduce
exacerbation of disease
– Managing Transitions
– Care Management Services
– Coordinating community and social support services
– Coordinating with external agencies supporting the consumer
– Disease self-management support
– Health Education
– Symptom management
– Medication management
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Chronic Care Management Opportunity
• Chronic Care Management CCM
– Benefit established in 2015 targeting Medicare
– CPT Code: 99490
• 20 min of clinical staff time
• Complex Chronic Care Management
– Expanded Benefit beginning January 1, 2017
– CPT Code: 99487
• 60 min of clinical staff time
– CPT Code: 99489
• Ea. Additional 30 min of clinical staff time
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Eligibility
• Chronic Care Management services can be provided to
any Medicare FFS beneficiary that meets the following
criteria:
– Must have Medicare Part B benefits
– Co-Insurance requirements apply
– Must have two or more chronic conditions that are expected to last at
least 12 months
– Chronic conditions could lead to worse health outcomes or death is not
properly managed
• Eligibility for CCM and Complex CCM are the same
– Intensity of services defines which code to use
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Chronic Care Management Opportunity
• Medicare Providers can deliver this service or contract
with a third-party care management company to provide
the service
• Services can be provided by “General Supervision”
– Incident To rules have been changed to include Transitional
Care Management and Chronic Care Management Services as
services that can be rendered under General Supervision
• Requires development of a Person-Centered Care
Management Plan
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Behavioral Health Integration
• New set of billing codes to provide expanded care
management and support services to persons with a
behavioral health diagnosis
– Established January 1, 2017
– Supports having an embedded social worker to facilitate
enrollment, person-centered planning, and evaluation
– Self-management supports for depression
– Billed on a calendar month basis
– Can be billed along with Chronic Care Management
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Creating a Care Plan
• Services that can be included as part of the Chronic Care
Management Person-Centered Plan
– Education and outreach
– Disease Self-Management Support Services
– Care Coordination
– Communication with all providers
– Support to address Psycho-Social Barriers impacting health
– Medication Reconciliation
– Health Coaching services
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Questions
• Questions can be submitted in this open forum or by e-
mail:
• [email protected]
Timothy P. McNeill, RN, MPH
Consultant
Direct: (202) 344-5465
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Improving the lives of 10 million older adults by 2020
Managed Long Term Services
And Supports:
Lights, Camera, Action!!
May 25, 2017
Sharon R. Williams
CEO Williams Jaxon Consulting, LLC
Consultant, NCOA
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Improving the lives of 10 million older adults by 2020 | © 2017 National Council on Aging 25
Healthcare Reform: The Script
Unknowns > Knowns
• Regulatory/legislative resolution by new federal fiscal
year?
• Healthcare industry reaction
• State markets response
• Implications for aging, disability, and other HCBS
providers
• Medicare/Medicaid integrated care initiatives
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Improving the lives of 10 million older adults by 2020 | © 2017 National Council on Aging 26
These Previous Blockbusters are Good Bets…
Accountable Care Organizations
MLTSS
Growth in Medicare Advantage enrollment
Value Based Payment Reform
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Improving the lives of 10 million older adults by 2020 | © 2017 National Council on Aging 27
A Star Is Born!
Managed Long Term Services and Supports
(MLTSS) refers to the delivery of long term services
and supports through capitated Medicaid managed
care programs. Increasing numbers of states are
using MLTSS as a strategy for expanding home- and
community-based services, promoting community
inclusion, ensuring quality and increasing efficiency.
-CMS
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Improving the lives of 10 million older adults by 2020 | © 2017 National Council on Aging 28
Coming Attraction:
Managed Long Term Services and Supports
Introduced in the ACA
Creates Opportunities to reduce barriers to
services/payments for Medicare/Medicaid
Dually Eligible Consumers
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Improving the lives of 10 million older adults by 2020 | © 2017 National Council on Aging 29
The Cast
Over 10 million Americans covered by both Medicare & Medicaid
In 2014, Federal/states governments spent $496.6 billion on Medicaid, 25% was
for LTSS
Between 2004 and 2013, the number of individuals receiving LTSS through
managed care programs increased from 105,000 to 550,000
MLTSS options include subcontracting with healthcare organizations on a
capitated, risk basis to:
• Enhance the consumers’ experience with healthcare system
• Foster integration of clinical/HCBS services
• Enhance person centered care planning
• Increase access to comprehensive care
• Improve quality outcomes and contain healthcare spending
Most MLTSS waivers involve 3-way contract with CMS/State Medicaid and
healthcare contractor
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Improving the lives of 10 million older adults by 2020 | © 2017 National Council on Aging 30
The Remake
As of 2012,16 States operate MLTSS programs
States split on type of enrollment (auto or voluntary)
Three primary contractors: private, not for profit,
Public or quasi-public
• Private for profit have largest share of enrollment, nationally
About half of states restrict to people needing institutional
LOC
Almost all contractors at risk for cost of institutional
services
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Improving the lives of 10 million older adults by 2020 | © 2017 National Council on Aging 31
You’re The Ideal Co Star!
Experience
Expertise/Infrastructure
Member Engagement/Education
Advocacy
Increase in healthcare industry’s
recognition of the value of Social
Determinants of Health (SDOH)
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Improving the lives of 10 million older adults by 2020 | © 2017 National Council on Aging 32
How Do You Secure a Starring Role?
Stay out in front of MLTSS transformation:
• Advocate for Evidence Based Program inclusion in MTSS
waivers at local/federal levels
• Confer with Medicaid Agency experts
• Connect with local healthcare providers
• Participate in Waiver public hearings and submit public
comments
• Review the solicitation proposal (generally a Request for
Proposals (RFP))
• Confer with potential RFP bidders
• Tell compelling stories about your capacity to contribute to
MLTSS goals - backed up with solid data!
• Identify/fortify with stakeholders
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Improving the lives of 10 million older adults by 2020 | © 2017 National Council on Aging 33
ACCESS
www.access.org
CMS
www.cms.gov/MLTSS
Kaiser Family Foundation
www.kff.org
Bibliography
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Improving the lives of 10 million older adults by 2020 | © 2017 National Council on Aging 34
Sharon R. Williams
[email protected]
MLTSS