2016 Medicare Parts A & B Premiums and Deductibles Announced

CMS NEWS

FOR IMMEDIATE RELEASE

November 10, 2015

Contact: CMS Media Relations

(202) 690-6145 | CMS Media Inquiries

2016 Medicare Parts A & B Premiums and Deductibles Announced

Today, the Centers for Medicare & Medicaid Services (CMS) announced the 2016 premiums and deductibles for the Medicare inpatient hospital (Part A) and physician and outpatient hospital services (Part B) programs.

Part B Premiums/Deductibles

As the Social Security Administration previously announced, there will no Social Security cost of living increase for 2016. As a result, by law, most people with Medicare Part B will be "held harmless" from any increase in premiums in 2016 and will pay the same monthly premium as last year, which is $104.90.

Beneficiaries not subject to the "hold harmless" provision will pay $121.80, as calculated reflecting the provisions of the Bipartisan Budget Act signed into law by President Obama last week. Medicare Part B beneficiaries not subject to the "hold-harmless" provision are those not collecting Social Security benefits, those who will enroll in Part B for the first time in 2016, dual eligible beneficiaries who have their premiums paid by Medicaid, and beneficiaries who pay an additional income-related premium. These groups account for about 30 percent of the 52 million Americans expected to be enrolled in Medicare Part B in 2016.

"Our goal is to keep Medicare Part B premiums affordable. Thanks to the leadership of Congress and President Obama, the premiums for 52 million Americans enrolled in Medicare Part B will be either flat or substantially less than they otherwise would have been," said CMS Acting Administrator Andy Slavitt. "Affordability for Medicare enrollees is a key goal of our work building a health care system that delivers better care and spends health care dollars more wisely."

Because of slow growth in medical costs and inflation, Medicare Part B premiums were unchanged for the 2013, 2014, and 2015 calendar years. The "hold harmless" provision would have required the approximately 30 percent of beneficiaries not held harmless in 2016 to pay an estimated base monthly Part B premium of $159.30 in part to make up for lost contingency reserves, according to the 2015 Trustees Report. However, the Bipartisan Budget Act of 2015 mitigated the Part B premium increase for these beneficiaries and states, which have programs that pay some or all of the premiums and cost-sharing for certain people who have Medicare and limited incomes. The CMS Office of the Actuary estimates that states will save $1.8 billion as a result of this premium mitigation.

CMS also announced that the annual deductible for all Part B beneficiaries will be $166.00 in 2016. Premiums for Medicare Advantage and Medicare Prescription Drug plans already finalized are unaffected by this announcement.

To get more information about state-by-state savings, visit the CMS website at

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-11-10.html.  

Since 2007, beneficiaries with higher incomes have paid higher Part B monthly premiums. These income-related monthly adjustment amount (IRMAA) affect fewer than 5 percent of people with Medicare. Under the Part B section of the Bipartisan Budget Act of 2015, high income beneficiaries will pay an additional amount. The IRMAA, additional amounts, and total Part B premiums for high income beneficiaries for 2016 are shown in the following table:

Beneficiaries who file an individual tax return with income:	Beneficiaries who file a joint tax return with income:	Income-related monthly adjustment amount	Total monthly premium amount
Less than or equal to $85,000	Less than or equal to $170,000	$0.00	$121.80
Greater than $85,000 and less than or equal to $107,000	Greater than $170,000 and less than or equal to $214,000	48.70	170.50
Greater than $107,000 and less than or equal to $160,000	Greater than $214,000 and less than or equal to $320,000	121.80	243.60
Greater than $160,000 and less than or equal to $214,000	Greater than $320,000 and less than or equal to $428,000	194.90	316.70
Greater than $214,000	Greater than $428,000	268.00	389.80

Premiums for beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:

Beneficiaries who are married and lived with their spouse at any time during the year, but file a separate tax return from their spouse:	Income-related monthly adjustment amount	Total monthly premium amount
Less than or equal to $85,000	$0.00	$121.80
Greater than $85,000 and less than or equal to $129,000	194.90	316.70
Greater than $129,000	268.00	389.80

Part A Premiums/Deductibles

Medicare Part A covers inpatient hospital, skilled nursing facility, and some home health care services. About 99 percent of Medicare beneficiaries do not pay a Part A premium since they have at least 40 quarters of Medicare-covered employment.

The Medicare Part A annual deductible that beneficiaries pay when admitted to the hospital will be $1,288.00 in 2016, a small increase from $1,260.00 in 2015. The Part A deductible covers beneficiaries' share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. The daily coinsurance amounts will be $322 for the 61^st through 90^th day of hospitalization in a benefit period and $644 for lifetime reserve days. For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 in a benefit period will be $161.00 in 2016 ($157.50 in 2015).  

Enrollees age 65 and over who have fewer than 40 quarters of coverage and certain persons with disabilities pay a monthly premium in order to receive coverage under Part A. Individuals with 30-39 quarters of coverage may buy into Part A at a reduced monthly premium rate, which will be $226.00 in 2016, a $2.00 increase from 2015. Those with less than 30 quarters of coverage pay the full premium, which will be $411.00 a month, a $4.00 increase from 2015.

Deductibles and Coinsurance for 2016

Part A Deductible and Coinsurance Amounts for Calendar Years 2015 and 2016 Type of Cost Sharing
	2015	2016
Inpatient hospital deductible	$1,260	$1,288
Daily coinsurance for 61st-90th Day	315	322
Daily coinsurance for lifetime reserve days	630	644
SNF coinsurance	157.50	161.00

For more information on the 2016 Medicare Parts A and B premiums and deductibles (CMS-8059-N, CMS-8060-N, and CMS-8061-N), visit: https://www.federalregister.gov/public-inspection.  

Helpful Weblinks:

Federal Register Links:

Part A CMS-8059-N (PDF)- https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-29207.pdf and on 11/16/2015 and available online at http://federalregister.gov/a/2015-29207

8060-N PDF- https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-29176.pdf and 11/16/2015 and on available online at http://federalregister.gov/a/2015-29176

Part B CMS-8061-N (PDF) https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-29181.pdf and on 11/16/2015 and available online at http://federalregister.gov/a/2015-29181

SNF Therapy Payment Model expands to consider SNF non-therapy related refinement possibilities

Phase Two

In the second phase of the project, which is now in process, the contractor is using the findings from this Base Year Final Summary Report as a guide to identify potential models suitable for further analysis.  We have considered stakeholder comments and concerns as we continue to investigate alternative therapy payment approaches and plan to solicit additional feedback on this aspect of our SNF payment research.  As noted above, we expanded the scope of this project during this phase to include ideas for revising the overall SNF PPS and plan to include additional and separate opportunities to obtain stakeholder input on non-therapy related refinement possibilities.  

As the contractor began the process of further narrowing the scope of therapy payment models in this second phase of the project, Acumen hosted a Technical Expert Panel in February 2015 to discuss questions and issues related to the therapy payment research. The following report summarizes the discussion and recommendations of the Technical Expert Panel:

Skilled Nursing Facility Therapy Payment Models Technical Expert Panel Summary Draft [PDF, 264KB] 

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/therapyresearch.html

Analysis of Medicare Part A SNF PPS Payment Model

In an effort to establish a comprehensive approach to Medicare Part A SNF payment reform, we are expanding the scope of the SNF Therapy Payment Research project.  Although we always intended to ensure that any revisions to therapy payment would consider an integrated approach with the remaining payment methodology, we now plan to examine potential improvements and refinements to the overall SNF PPS payment system. This expansion will allow for improving the ability for Medicare to pay adequately and appropriately for all services provided during a Medicare Part A SNF stay.  

Overview

Since 1998, Medicare has paid for services provided by skilled nursing facilities (SNFs) under the Medicare Part A benefit on a per diem basis through the skilled nursing facility prospective payment system (SNF PPS). Currently, therapy payments under the SNF PPS are based primarily on the amount of therapy provided to a patient, regardless of the specific patient characteristics and care needs. CMS has contracted with Acumen, LLC to identify potential alternatives to the existing methodology used to pay for services under the SNF PPS. Below, we will post information about this project as it progresses.
 

Phase One

In the first phase of the project, the contractor reviewed past research studies and policy issues related to SNF PPS therapy payment and options for improving or replacing the current system of paying for SNF therapy services. The following report summarizes the analysis and findings from this first phase of the project:

SNF Therapy Payment Models – Base Year Final Summary Report, April 2014

The contractor is continuing with further refinements of the therapy model development, based on the panel's recommendations, as well as considering potential improvements to the nursing component and overall SNF PPS payment structure, we welcome your comments and feedback. Comments on the SNF PPS payment methodology may be submitted anytime to:

SNFTherapyPayments@cms.hhs.gov

DOJ still aggressively pursuing unnecessary therapy

FOR IMMEDIATE RELEASE

Thursday, October 29, 2015

Government Intervenes in Lawsuits Alleging That Skilled Nursing Chain SavaSeniorCare Provided Medically Unnecessary Therapy

The government has intervened in three False Claims Act lawsuits and filed a consolidated complaint against SavaSeniorCare LLC and related entities (Sava) alleging that Sava knowingly and routinely submitted false claims to Medicare for rehabilitation therapy services that were not medically reasonable and necessary, the Department of Justice announced today.  Sava is one of the nation's largest healthcare providers, operating approximately 200 skilled nursing facilities (SNFs) in 23 states.

"The provision of Medicare benefits must be dictated by patient need, not by Medicare providers' efforts to maximize profits by pressuring their employees to provide medically unnecessary services," said Principal Deputy Assistant Attorney General Benjamin C. Mizer of the Justice Department's Civil Division.  "The Department of Justice will continue to aggressively pursue companies that seek to engage in this kind of fraudulent scheme."

The government's complaint alleges that Sava exerted significant pressure on its SNFs to meet unrealistic financial goals that resulted in the provision of medically unreasonable, unnecessary and unskilled services to Medicare patients.  Sava allegedly set these aggressive, prospective corporate targets for the highest Medicare reimbursement rates to significantly increase Sava's revenues without regard for its patients' actual clinical needs and then pressured its staff to meet those goals.  Sava also allegedly delayed discharging patients from its facilities, even though the patients were medically ready to be discharged, in order to increase its Medicare payments.

"Enforcing the False Claims Act and combating healthcare fraud remains a top priority of the U.S. Attorney's Office," said U.S. Attorney David Rivera of the Middle District of Tennessee.  "When healthcare providers subject patients to unnecessary treatment, we will intervene and hold them accountable."

The three consolidated lawsuits were filed under the qui tam, or whistleblower, provisions of the False Claims Act, which permit private parties to sue on behalf of the government for false claims for government funds and to receive a share of any recovery.  The False Claims Act also permits the government to intervene in such lawsuits, as it has done in these cases.  Under the Act, a defendant that is found liable is subject to damages equal to three times the government's loss plus applicable penalties. 

The government's intervention in these matters illustrates its emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by the Attorney General and the Secretary of Health and Human Services.  The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation.  One of the most powerful tools in this effort is the False Claims Act.  Since January 2009, the Justice Department has recovered a total of more than $26.2 billion through False Claims Act cases, with more than $16.4 billion of that amount recovered in cases involving fraud against federal health care programs.  Tips and complaints from all sources about potential fraud, waste, abuse and mismanagement, including the conduct described in the United States' complaint, can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477).

The lawsuits are being handled by the Civil Division's Commercial Litigation Branch and the U.S. Attorney's Office of the Middle District of Tennessee.  Investigative support is being provided by the U.S. Attorneys' Offices of the Southern District of Texas and the Western District of Texas; the Offices of Inspector General for the Department of Health and Human Services and the Office of Personnel Management and the National Association of Medicaid Fraud Control Units.

The cases are captioned United States ex rel. Hayward v. SavaSeniorCare, LLC, et al., No. 3:11-0821 (M.D. Tenn.);United States ex rel. Scott v. SavaSeniorCare Administrative Services, LLC, 3:15-0404 (M.D. Tenn.); and United States ex rel. Kukoyi v. Sava Senior Care, L.L.C., et al., No. 3:15-1102 (M.D. Tenn.).

The claims asserted in the government's complaint against Sava are allegations only and there has been no determination of liability.

From http://www.justice.gov/opa/pr/government-intervenes-lawsuits-alleging-skilled-nursing-chain-savaseniorcare-provided

CMS Extends Deadline to submit ADR packets

SUBJECT: Pub. 100-08 Chapter 3 Updates: Section 3.2.3.2 Timeframes for Submission and Section 3.2.3.8 - No response to Additional Documentation Requests 

SUMMARY OF CHANGES: The purpose of this change request (CR) is to extend the due date for submitted documentation from providers, requested by the Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT) and Recovery Auditors in chapter 3 of Pub. 100-08, sections 3.2.3.2-Timeframes for Submission and 3.2.3.8 - No response to Additional Documentation Requests. 

EFFECTIVE DATE: November 17, 2015 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: November 17, 2015

Requirements:

·         When requesting documentation for post payment review, the MAC, CERT and Recovery Auditors shall notify providers that the requested documents are to be submitted within 45 calendar days of the request

·         MACs and CERT, shall grant at least one extension to providers who need more time to comply with the request.

More information:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R620PI.pdf

AMDA makes it's newsletter available for free to anyone. Link to sign up in this blog post

Caring for the Ages Editor-in-Chief Karl Steinberg, MD, CMD, takes great pride in the publication. "There is something for everyone in it. Every month, we make sure it is chock full of practical ideas and information, nuts and bolts of policy issues and regulatory news, research and drug news, and turnkey type tips and protocols that you can take and put in your arsenal of tools," he says.

"We're thrilled to make Caring available online to a broader audience. I encourage all AMDA members to recommend this opportunity to their colleagues, including physicians, administrators, front-line staff, nurses, and others," he says.

This is a scroll box. Click it and scroll down to get the link to sign up for the free newsletter  in the last line of this scroll box.

“We’re thrilled to make Caring available online to a broader audience. I encourage all AMDA members to recommend this opportunity to their colleagues, including physicians, administrators, front-line staff, nurses, and others,” he says. “We will not share their email addresses or contact information with anyone—it will be completely private; and they can un-subscribe at any time.”

Dr. Steinberg takes great pride in Caring. “There is something for everyone in it. Every month, we make sure it is chock full of practical ideas and information, nuts and bolts of policy issues and regulatory news, research and drug news, and turnkey type tips and protocols that you can take and put in your arsenal of tools.” The Caring for Consumers column, he further notes, is a great tool to share with family members and residents; and it is the perfect way to start conversations on a wide variety of issues.

For Caring readers and others, Dr. Steinberg is a familiar face and welcome presence. In addition to being an active medical director and attending physician in California and Editor-in-Chief of Caring, Dr. Steinberg is on the AMDA Board of Directors and chairs AMDA's Public Policy Committee, and he chairs the Coalition for Compassionate Care of California. His smiling face—as well as those of his dogs—can be seen in the pages of the annual AMDA Foundation Caring Canines calendar; in fact, in his facilities, his dogs are as well-known as he is (or more so, he says).

Dr. Steinberg isn’t just Editor of Caring. He also is a devoted reader. “I review every article that goes in and some that don’t. I really get a broad overview of what is happening, and I keep a finger on the pulse of new developments, trends, and studies. I also learn about the great things my colleagues are doing across the country.” 

Click here to sign up for your free Caring e-table of contents.

Virginia DMAS Emergency Preparations: From VHCA & DMAS

October 1, 2015

Dear Judy,

The Department of Medical Assistance Services (DMAS) asked VHCA to pass along the following information to members.   Due to the upcoming potential for inclement weather, DMAS has instituted the following emergency procedures:   1.  All pre-admission screening requirements are currently being waived for emergency admissions to the nursing facilities due to the potential for inclement weather.  The time frame covered for this waiver Friday, October 2, 2015 to Tuesday, October 6, 2015.  Any admission to nursing facilities during this time frame will be approved by DMAS provided documentation is given to support the emergency admission.  All documentation related to the emergency admission should be directed to Melissa Fritzman via fax at (804) 612-0040.  The documentation should include the completed PIRS form and information regarding the nature of the emergency admission.   2.  All emergency transportation needed to facilitate movement of individuals from their homes to a nursing facility and/or hospital will be reimbursed by DMAS.  Our transportation coordinator, LogistiCare, has been notified of DMAS' intent to honor all emergency transportation issues related to the facilitation of movement of these individuals to nursing facilities and/or hospital during the period of Friday, October 2, 2015 to Tuesday, October 6, 2015.  All transportation claims related to the movement of individuals to nursing facilities/hospitals in an emergency basis because of the inclement weather should be sent directly to Melissa Fritzman at the following address and should include clear documentation that of the nature of the transportation related to an emergency placement.     3.  Please contact LogistiCare at 1-866-679-6330 during the period of Friday, October 2, 2015 to Tuesday, October 6, 2015 for emergency placements ONLY.  This number will only be active during the time frame outlined above specifically for emergency placements ONLY.  The approvals will cover round trip transportation.     Send claims to:    Melissa Fritzman, Supervisor  Long-Term Care Division  Department of Medical Assistance Services  600 East Broad Street, Suite 1300  Richmond, Virginia 23219 If we receive any additional information or updates related to the forecasted severe weather, we will forward it to you.   Sincerely,   Keith Hare President and CEO VHCA / VCAL

Payroll Based Journal: Action Items from CMS - PBJ Voluntary sign up now, mandatory July 2016

Important PBJ Provider Action Items Step 1: Registration opened August 4th: Registration Training: - PBJ Training Modules for an introduction to the PBJ system and step by step registration instruction are available on QTSO e-University, select the PBJ option. (https://www.qtso.com/webex/qiesclasses.php) Registration: -Obtain a CMSNet User ID for PBJ Individual, Corporate and Third Party users, if you don't already have one for other QIES applications. (https://www.qtso.com/cmsnet.html) -Obtain a PBJ QIES Provider ID for CASPER Reporting and PBJ system access. You will need to be logged into your CMSNet account to access this page (https://mds.qiesnet.org/mds_home.html) -PBJ Corporate and Third-Parties must use the current form based process to register for a QIES ID. Registration forms are available under the Access Request Information / Forms section on the right side of the page. (https://www.qtso.com/) Step 2: Voluntary Data Submission will start October 1st: Data Submission Training: -PBJ Training Modules for the CASPER Reporting and PBJ systems will be available on September 25, 2015, on QTSO e-University, select the PBJ option. (https://www.qtso.com/webex/qiesclasses.php) -The CASPER Reporting and PBJ systems will be available on October 1, 2015. A user will be able to submit XML files or manually enter staffing and census data for work performed on or after October 1, 2015. (https://mds.qiesnet.org/mds_home.html) Other Resources: -Staffing Data Submission - PBJ Website: (http://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html) -We will communicate information about PBJ through the Skilled Nursing Facilities/Long-Term Care Open Door Forum. More information can be found at https://www.cms.gov/Outreach-and- Education/Outreach/OpenDoorForums/ODF_SNFLTC.html. MAXIMUM NUMBER OF QIES USER IDs ALLOWED Nursing home individual providers are allowed a maximum of two (2) users with Access Type = PBJ An existing MDS user may request PBJ access be added to their existing QIES (MDS) ID if they will be responsible for submitting PBJ data or A new user may register for a QIES (PBJ) ID that allows access to only the PBJ application Exceptions to these limitations may be requested and granted, if approved. If the maximum number of individual QIES user IDs is already associated with your provider, an error message will display “The max number of users has been reached for the provider”. Providers requiring more than the prescribed maximum number of active individual QIES user IDs must complete and submit an “Individual User Account Request” form to request additional IDs. This form is available at https://www.qtso.com/accesspbj.html Please Note: PBJ Corporate and PBJ Third Party Service Bureaus do not have a limit on the number of active users with Access Type = PBJ. PBJ Corporate and PBJ Third Party Service Bureaus will register/update their QIES User ID using the current form based process. These forms are located at https://www.qtso.com/accesspbj.html A list of important action items for PBJ Providers is available for download. Important PBJ Provider Action Items [PDF 31 KB] From https://www.qtso.com/providernh.html