Updates
CMS Releases Fiscal Year (FY) 2021 Medicare Hospital Inpatient and Long-Term Care Hospital (LTCH) Prospective Payment Systems Proposed Rule
On May 11, 2020, CMS issued a proposed rule to update fiscal year (FY) 2021 Medicare policies and rates under the Inpatient Prospective Payment System (PPS) and the Long-Term Care Hospital (LTCH) PPS. Given the COVID-19 public health emergency, CMS is limiting the annual rulemaking to focus primarily on essential payment policies and those that reduce provider burden. In addition to its customary payment updates, CMS proposes to require hospitals to report the median payer-specific negotiated charges by MS-DRG for all of their Medicare Advantage (MA) and commercial payer contracts on their Medicare cost report for cost reporting periods ending on or after January 1, 2021.
A fact sheet on the proposed rule can be found on the CMS website here. We will be working with you and your teams to develop comments on this proposed rule, which are due to CMS by July 10, 2020.
CMS and ONC Issue Interoperability Final Rules
On March 9, 2020, the U.S. Department of Health and Human Services (HHS) finalized two rules intended to give patients additional access to their health data. The rules, issued by the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC), implement interoperability and patient access provisions of the 21st Century Cures Act as well as the Administration’s MyHealthEData initiative.
The CMS Interoperability and Patient Access Final Rule applies to all CMS-regulated payers and, among other things, requires plans to:
- Implement and maintain a secure, standardized application programming interface (API) that allows patients to access their claims and encounter information along with cost through a third-party application of their choice for plan years on or after January 1, 2021;
- Make publicly available provider directory information via a standards-based API beginning plan years on or after January 1, 2021 (except QHP issuers on the FFEs that already provide machine-readable files); and
- Exchange certain patient clinical data between payers at a patient’s request, allowing the patient to take their information with them as they move from payer to payer beginning January 1, 2022.
Of note, the final rule does not require plans to participate in Health Information Networks at this time as was proposed.
The CMS press release can be found here. A fact sheet for the CMS Final Rule can be found here.
The ONC 21st Century Cures Act Final Rule finalizes, among other things:
- The definition for “actors” subject to the information block provision;
- The definition for “electronic health information” (EHI) to mean electronic protected health information (ePHI) as the term is defined for HIPAA;
- Eight exceptions to the information blocking provision, including a new Content and Manner Exception;
- Adoption of the United States Core Data for Interoperability Standard (USCDI) Version 1 into the 2015 Edition Health IT Certification Criteria.
The ONC press release can be found here. A fact sheet comparing the proposed and final ONC rules can be found here. Additional fact sheets for the ONC Final Rule can be found here.
A summary of the final rules can be found here.
Tri-Agencies Issue Cost Calculator Proposed Rule
On November 15, 2019, the Departments of Health and Human Services, Labor, and Treasury (the Departments) issued the Transparency in Coverage proposed rule today that would require commercial health plans—including large group and individual market—to provide consumers with personalized, real-time estimates of expected out-of-pocket costs via an internet-based tool before seeking care. In addition to consumer-focused tools, the Departments also proposed that all plans publicly post all in-network negotiated rates with all providers and historical payments of allowed amounts for out-of-network care in separate machine-readable files.
The proposed rule would require that health plans offering large group and individual coverage make available a consumer’s real-time, personalized estimate of cost-sharing before services are rendered through an internet-based self-service tool, or by paper upon request. The Departments require the disclosure of information similar to what is commonly provided in an explanations of benefits (EOBs) but before services are rendered.
The Departments also propose to make publicly available in-network negotiated rates and historical payments of allowed amounts for out-of-network providers through two machine readable files, updated at least monthly.
Finally, the Departments seek input on two requests for information related to making this information available through an API, and whether quality information should be disclosed as well.
Comments must be submitted by January 14, 2020. The final rule would be effective for plan years beginning on or after 1 year after the effective date of the final rule. The CMS press release can be found here and fact sheet on the proposed rule is here.
A summary of the proposed rule can be found here.