QM Manual V10.0 Posted now

The new QM manual V10.0 is posted here.


I am offering a public webinar on the new QMs on May 9th. See www.judywilhide.com, click on seminars/webinars and scroll down to register.

Virginia DMAS (Medicaid agency) unveils new website for the new dual-eligible program replacing CCC

Attention MLTSS Stakeholders:

We are pleased to share that the DMAS MLTSS webpage has been revised and includes several important updates, available at:  http://www.dmas.virginia.gov/Content_pgs/mltss-home.aspx.   We value your ongoing input and support!  Please continue to share any input that you have for us at VAMLTSS@dmas.virginia.gov.

Thank you!

Tammy Driscoll

Senior Programs Advisor to the Deputy of Complex Care and Services

Virginia Department of Medical Assistance Services (DMAS)

600 East Broad Street

Richmond, VA 23219

804-225-2552

Tammy.Driscoll@DMAS.Virginia.Gov 

SNF PFR for FY 17 posted

Direct link to proposed final rule  here.

FACT SHEET

FOR IMMEDIATE RELEASE

April 21, 2016

Contact: CMS Media Relations

(202) 690-6145 | CMS Media Inquiries

Proposed fiscal year 2017 payment and policy changes for Medicare Skilled Nursing

Overview

On April 21, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule [CMS-1645-P] outlining proposed Fiscal Year (FY) 2017 Medicare payment rates and quality programs for skilled nursing facilities (SNFs). The FY 2017 proposals and other issues discussed in the proposed rule are summarized below.

The proposed policies in the proposed rule continue to shift Medicare payments from volume to value. The Administration has set measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they provide to their patients. The Administration met the goal of tying 30 percent of Medicare payments to care provided in alternative payment models ahead of schedule and is continuing this momentum to reach the goal of tying 50 percent of payments to care provided in alternative payment models by the end of 2018. This proposed rule includes policies that advance that vision and support building a health care system that delivers better care, spends health care dollars more wisely, and results in healthier people. CMS encourages comments, questions, or thoughts on this proposed rule by June 20, 2016.

Changes to Payment Rates under the SNF Prospective Payment System (PPS)

Based on proposed changes contained within this proposed rule, CMS projects that aggregate payments to SNFs will increase in FY 2017 by $800 million, or 2.1 percent, from payments in FY 2016. This estimated increase is attributable to a 2.6 percent market basket increase reduced by 0.5 percentage points, in accordance with the multifactor productivity adjustment required by law.

SNF Quality Reporting Program (QRP)

The Improving Medicare Post-Acute Care Transformation Act of 2014 (P.L. 113-185) (IMPACT Act), enacted on October 6, 2014, requires the implementation of a quality reporting program for SNFs beginning with FY 2018. SNFs that do not submit required quality data to CMS under the SNF Quality Reporting Program (QRP) will be subject to a 2.0 percentage point reduction to their annual updates.

The IMPACT Act requires the continued specification of quality measures for the SNF QRP, as well as resource use and other measures. In order to satisfy the requirements of the IMPACT Act, CMS is proposing one new assessment-based quality measure, and three claims-based measures for inclusion in the SNF QRP. These measures align with the measures proposed for inclusion in the Long Term Care Hospitals (LTCH) QRP and the Inpatient Rehabilitation (IRF) QRP.

Assessment-based measure for the FY 2020 payment determination and subsequent years:

Drug Regimen Review Conducted with Follow-Up for Identified Issues.

Claims-based measures for the FY 2018 payment determination and subsequent years:

1.       Discharge to Community – Post Acute Care (PAC) SNF QRP;

2.      Medicare Spending Per Beneficiary (MSPB) – PAC SNF QRP; and

3.       Potentially Preventable 30 Day Post-Discharge Readmission Measure for SNFs.

The proposed rule further defines the SNF QRP requirements. CMS proposes to use a Calendar Year (CY) schedule for measure and data submission requirements that includes a period for provider review and correction, with quarterly deadlines following each quarter of data submission beginning with data reporting for the FY 2019 payment determinations.  

The IMPACT Act requires that procedures for public reporting of quality and resource use and other measures include a process consistent with the Hospital Inpatient Quality Reporting (IQR) review and correction processes. CMS proposes the following for public display of quality measure data for the SNF QRP, including review and correction periods, and the pre- and public reporting preview period:

·         Align the SNF QRP quarterly reporting timeframes and quarterly review and correction periods for assessment-based measures with the approach followed in the IQR;

·         Align processes related to the review and correction of claims based measures with the approach followed in the IQR; and

·         Apply a 30-day preview period prior to publishing SNF quality data during which corrections to data cannot be made, but SNFs may ask for a correction to their measure calculations.

SNF Value-Based Purchasing Program (VBP)

Section 215 of the Protecting Access to Medicare Act of 2014 (PAMA) added new subsections (g) and (h) to section 1888 of the Social Security Act. The new section 1888(h) of the Social Security Act authorizes the establishment of a Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program beginning with FY 2019 under which value-based incentive payments are made to SNFs based on performance.

Measures

This rule proposes to specify the SNF 30-Day Potentially Preventable Readmission Measure, (SNFPPR), as the all-cause, all-condition risk-adjusted potentially preventable hospital readmission measure to meet the requirements of section 1888(g)(2) of the Social Security Act. The SNFPPR assesses the facility-level risk-standardized rate of unplanned, potentially preventable hospital readmissions for SNF patients within 30 days of discharge from a prior admission to a hospital paid under the Inpatient Prospective Payment System, a critical access hospital, or a psychiatric hospital.

Other Policy Proposals

In this proposed rule, CMS is seeking public comments on additional proposals related to the SNF VBP requirements including:

·         Establishing performance standards;

·         Establishing baseline and performance periods;

·         Adopting a performance scoring methodology; and

·         Developing confidential feedback reports.

For More Information

The proposed rule went on display on April 21, 2016, at the Federal Register's Public Inspection Desk and will be available under "Special Filings," at www.federalregister.gov/articles/2016/04/25/2016-09399/.... Public comments on the proposed rule will be accepted until June 20, 2016.

For further information, please see:

·         SNF PPS: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/...

·         SNF QRP: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html and https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html

·         SNF VBP: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP.html

CJR, the first mandatory bundle: Important information about how your star rating will determine if a resident can readmit (or admit) to you for a SNF stay

From an email thread between me and the CJR folks at CMS.  My basic question was:

If a resident who qualifies for the CJR bundle wants to return to his or her home SNF after hospitalization and it doesn't have three stars, do they have to pay for the SNF Stay?

There is a SNF waiver that will begin in year 2 of the final rule. In the final rule, as described further in section III.C.11., CMS will waive the 3-day rule for episodes being tested in the CJR model for performance years 2 through 5 only if the SNF is qualified as one that has an overall rating of three stars or better in the Five-Star-Quality Rating System for SNFs on the Nursing Home Compare website for at least 7 through 12 preceding months. CMS will be providing a list of SNFs that meet this requirement to hospitals participating in the CJR model prior to the waiver becoming available for CJR hospitals.  In addition, in section III.F. of the final rule, we finalized policies that maintain a beneficiary’s right to choose any provider or supplier. In the final rule, as described in the regulation texts § 510.405, the hospital is required to notify the beneficiary if the hospital is discharging a beneficiary to a SNF prior to the occurrence of a 3 day hospital stay, and the beneficiary is being transferred to or is considering a SNF that would not qualify under the SNF 3-day waiver in § 510.610, that the beneficiary will be responsible for costs associated with that stay except those which would be covered by Medicare Part B during a non-covered inpatient SNF stay.

In the case you refer to the SNF waiver would not apply if the beneficiary wants to go to a SNF that is rated 2 stars or below.  In section III.F of the CJR Final rule, it specifically states that the participant hospitals will notify beneficiaries of their liability should they be discharged upon a less-than-3- day stay to a SNF that does not qualify for the waiver that we are finalizing for this model, and to notify the beneficiary of possible beneficiary liability if the hospital recommends or refers the beneficiary to any other services, which it knows or should have known to be non-covered services under Medicare. This notice is in addition to any ABN or other hospital notice of non-coverage that may be required under existing regulations. Please review the final rule for further details concerning the requirements set forth in the CJR final rule. Please refer requirements laid out in the regulation text 510.405 for Discharge planning.

Note: As stated in the CJR Final rule under the regulation text 510.405, the CJR model does not restrict Medicare beneficiaries’ ability to choose any Medicare enrolled provider or supplier, or any physician or practitioner who has opted out of Medicare.

From Judy:  For your residents to be be able to come back to you after hospitalization (without paying for the SNF stay themselves), if you do not have three stars or better,  they need to be able to say they do not want to participate in this bundle and/or they do not want the three day stay waived. There is a hospital I am aware of that is "educating" the feeder SNFs and the slides say this:  "If resident wants to discharge to a SNF with less than 3 stars, they have to pay for it themselves."  This hospital fails to mention that the beneficiary can opt out entirely of the bundle and the hospital can opt out of the waiver of the three day stay for that resident.  

And for the record.  We all can't be three stars or better.  It's a skewed bell curve.  When the bottom 25% of SNFs go out of business (as predicted by some),  the ones left will fill the bell curve..........AND,  the bell curve is INTERSTATE, not national, but this is a national bundled payment model.  The worst in one state may be  three stars in another state  (I have actual examples).   Please,  don't let your eyes glaze over with the technical details.  Get to your stakeholder organization and advocate.  Meanwhile,  we have to fight unjust level 2 deficiencies on survey as hard as we traditionally fight level 3 or higher.  Five '4 point' Ds equal one G in the points system for assigning survey stars.  

The full text of the CJR model final rule is available here:  http://federalregister.gov/a/2015-29438.  The CJR model website, found at http://innovation.cms.gov/initiatives/cjr/, also contains information about the proposed and final rules.

Should you have further questions on this matter, please feel free to communicate with us through this email account.

Best,

Maria Agresta Workman, RN
for Comprehensive Care for Joint Replacement

cjr@cms.hhs.gov

https://innovation.cms.gov/initiatives/cjr

CMS Announcement: New QMs to be posted no later than the end of April

At the AANAC conference yesterday, CMS announced they do not have an exact date for posting the new QMs, but it would be by the end of April.  They have posted the data specs for the new claims based measures here.  Previously,  CMS announced the new measures would be up on NH Compare on April 7th.

Of note, these new data specs are the vendor report.  We are awaiting an update to the Quality Measures manual or some other CMS document.  The two new MDS measures are not in this document.

D-Level Deficiencies on MDS Focus Surveys Result in CMPs

From Virginia Healthcare Association

VHCA has recently learned of instances when two nursing facilities that underwent Minimum Data Set (MDS) focus surveys were cited for D-level deficiencies and were issued notices for civil monetary penalties (CMP) by the Centers for Medicare and Medicaid Services (CMS).

Upon learning about these CMPs, which have not previously been issued for D-level deficiencies, VHCA reached out to the Office of Licensure and Certification (OLC) for clarification on whether CMPs would be routinely levied for D-level deficiencies for MDS focus surveys or other types of surveys (standard, complaint, etc.).

Kathaleen Creegan-Tedeschi, Director of the Division of Long Term Care with OLC informed us that these cases of CMPs being issued for D-level deficiencies were related only to the MDS focus surveys.  She indicated that CMPs were not going to be applied to other types of surveys, barring any future CMS guidance to the contrary.  Please contact Matt Mansell at VHCA-VCAL by email or by phone at 804.212.1697 if you have any future survey-related questions or concerns.

DMAS Announcement today about replacement for CCC in Virginia

From DMAS Director April 4, 2016

DMAS Stakeholders:

This notice is to provide stakeholders with important updates on the Department of Medical Assistance Services' (DMAS) managed care program initiatives. These changes are consistent with General Assembly directives to add more populations and services into managed care and to strengthen the managed care programs.

The lessons learned from our Commonwealth Coordinated Care (CCC) program and the development of the Medicaid Managed Long Term Services and Supports (MLTSS) program has provided DMAS with the unique opportunity to reevaluate our managed care programs and design them in a manner that best serves Medicaid and FAMIS populations. For this reason, Medallion 3.0 and FAMIS will be restructured to serve pregnant women, families and children, and MLTSS will serve aged, blind, and disabled (ABD) populations. (The Program of All Inclusive Care for the Elderly, or PACE. will continue to be an integrated managed long-term care option for qualifying individuals.)

This strategy will allow for improved continuity of care and help to mitigate serve gaps, especially during transitions into complex community or institutional long-term care settings. DMAS will work with members, providers, health plans, and other interested stakeholders to provide outreach and education about these managed care initiatives. High level information by program is provided below. DMAS will provide additional details as available on the DMAS website.

Medallion 3.0 Procurement

DMAS will restructure and re-procure the Medallion 3.0 program, which currently serves more than 700,000 individuals.  Medallion 3.0 will serve adults and children in the low income families with children (LIFC), FAMIS, FAMIS MOMS and pregnant women covered groups. Individuals receiving LTSS who are enrolled in Medallion 3.0 for their acute and primary care services (known as the HAP population) and Medallion 3.0 ABD individuals will transition to MLTSS. The HAP population will transition to MLTSS during the MLTSS regional launch with the fee-for-service LTSS populations. The Medallion 3.0 ABDs without LTSS will transition to MLTSS in January 2018. Following the transition of HAP and ABD members to MLTSS, Medallion 3.0 will continue to serve over 665,000 Medicaid and 56,000 FAMIS members. The

Medallion 3.0 request for proposals (RFP) will be developed over the next several months and be released  later this calendar year  with an anticipated  implementation  date of Januaryl ,  2018.

Additional' information will be made available on the DMAS Medallion 3.0 webpage at: http://www.dmas.virginia.gov/Content     pgs/mc-home.aspx .

Managed  Long-Term  Services  and Supports Procurement

DMAS will revise the MLTSS design to include all aged, blind, and disabled (ABD) populations,  including  duals and LTSS populations.

•    PACE will continue to remain an integrated managed care option for all qualifying individuals.

•    The MLTSS RFP is scheduled to be released in April 2016. MLTSS will launch in the Spring of 2017, in regional phases, with full implementation  by January  1, 2018. The   HAP population  will transition  from Medallion  3.0 to MLTSS  during the MLTSS regional launch with the fee-for-service LTSS populations. The ABD population without LTSS currently  served under Medallion  3.0 will transition to MLTSS  in January of   2018.

•    The CCC population will transition into MLTSS at the end of the CCC demonstration (12/31/2017) in January, 2018. Additional information is available on the DMAS MLTSS webpage  at:   http://www.dmas.virginia.gov/Content    pgs/mltss-home.aspx .

DMAS  appreciates  your ongoing  support and cooperation  and we continue to look to each of  you, as our trusted stakeholders and partners, as we endeavor to design, develop, and implement initiatives and programs to better serve the citizens of the Commonwealth. We will continue to provide additional details on these initiatives to keep you fully informed and engaged. Questions related  to the MLTSS  program  may  be  sent to VAMLTSS@dmas.virginia.gov  .  Questions related  to Medallion  3.0 may  be  sent to ManagedCareHelp@dmas.virginia.gov .