Category: Legislative News

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CMS releases additional interim final rule, creating more telehealth flexibility and featuring significant regulatory changes

On April 30, 2020, the Centers for Medicare and Medicaid Services (CMS) released a second Interim Final Rule with new flexibilities and changes relevant to home-based medical care providers. The changes in this most recent Interim Final Rule are effective immediately, with many modifications retroactively effective as of 3/01/2020. These include the following:

  • CMS increased the payment for telephone Evaluation and Management (E/M) visits to be similar to payment for an office visit. This was done to accommodate providers who are caring for patients without access to two-way audio and video technology. When seeking reimbursement for telephone visits, physicians and other qualified healthcare professionals (i.e., nurse practitioners and physician assistants) may use the Telephone E/M CPT codes listed below. CMS also designated these telephone E/M services as “Medicare telehealth services,” and as such, they will require modifier 95.
    • CPT 99441Telephone E/M 5-10 minutes; Increased Non-Facility Payment $46.19; wRVU 0.48
    • CPT 99442Telephone E/M 11-20 minutes; Increased Non-Facility Payment $76.15; wRVU 0.97
    • CPT 99443Telephone E/M 21-30 minutes; Increased Non-Facility Payment $110.43; wRVU 1.50
  • In addition, the following services can also now be billed when using audio only:
    • Advance Care Planning (CPT 99497, 99498)
    • Annual Wellness Visits (HCPCS G0438, G0439)
    • Smoking Cessation Services (CPT 99406, 99407)
    • Alcohol and/or substance abuse (other than tobacco) structured assessment (e.g., AUDIT*, DAST**), and brief intervention services (HCPCS G0396, G0397)
    • Annual Alcohol Misuse Screening and Counseling (HCPCS G0442, G0443)
    • Annual Depression Screening (HCPCS G0444)
    • Chronic Care Management (CCM) Care Planning Services; please note this service is only to be used one time for new patients or patients who are not seen within a year when first enrolled in CCM (HCPCS G0506)

*Drug Abuse Screening Test
**Alcohol Use Identification Test

  • Be aware Medicare has designated additional services, e.g., psychotherapy and other therapy-related, nutrition, and education services, that allow for payment when provided via audio-only telehealth. To review the full list of Medicare audio-only telehealth services, visit the Medicare list of telehealth services.
  • The home and domiciliary E/M codes still require a two-way audio and video telecommunication method. Please review the CMS Fact Sheet and the revised FAQ that was released on 4/30/2020 for additional details.

Additional Key Updates:

  • CMS has officially adopted the regulation allowing for nurse practitioners, physician assistants, and clinical nurse specialists to order, establish and monitor plans of care, and certify and re-certify patients for home health services as mandated under the CARES Act. This change is permanent and applies to any service provided on or after 3/01/2020. (Click here for a guide to the CARES Act.)
  • CMS finalized on an interim basis that they will not enforce the clinical indications for therapeutic glucose monitors and they’re not subject to National Coverage Determinations (NCDs) and Local Coverage Determinations (LCSs). CMS had previously finalized on an interim basis that they will not enforce the clinical indications for respiratory devices, anticoagulation management, and infusion pumps. CMS did remind clinicians that services must be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member to be paid under Medicare. Physicians, practitioners, and suppliers are required to continue documenting the medical necessity for all services.
  • CMS waived the 16-day minimum requirement to bill for Remote Patient Monitoring (RPM) services, but only for patients who have suspected or confirmed COVID-19. In such cases, CMS recognized the value of short-term monitoring (no less than two days) for acute conditions and is allowing payment for CPT codes 99453, 99454, 99091, 99457, and 99458.
  • Until now, CMS used only its rulemaking process to add new services to the list of approved Medicare telehealth services. However, CMS is changing its process during the Public Health Emergency and will add new telehealth services on a sub-regulatory basis.
  • CMS waived some restrictions on the types of healthcare professionals that can furnish Medicare telehealth services for the remainder of the Public Health Emergency. Physical therapists, occupational therapists, and speech-language pathologists are now added to the list of eligible providers, which had already included physicians, nurse practitioners, physician assistants, licensed clinical social workers, and clinical psychologists. These providers can bill for telehealth services subject to the scope of practice laws.
  • CMS will no longer require a practitioner’s written order for patients to receive a COVID-19 test or other certain testing (e.g., serology testing) to diagnose and treat COVID-19. Pharmacists can also now perform COVID-19 tests if they’re enrolled in Medicare as a laboratory. Additionally, pharmacists can work with qualified healthcare professionals who are credentialed to bill Medicare to provide assessment and specimen collection services relating to a COVID-19 diagnosis. The physician or other qualified healthcare professional can bill Medicare for the test. This allows for parking-lot test sites and more rapid testing. (This is subject to state scope of practice laws.)
  • CMS is allowing hospitals to bill as the originating site for telehealth services, even if the patient is located at home. This applies to hospital-based practitioners for Medicare patients who are registered as hospital outpatients. This may be impactful for Hospital at Home® providers.
  • CMS is adjusting the financial methodology used for COVID-19 costs incurred by Accountable Care Organizations (ACOs) so they will be treated equitably regardless of the extent to which their patient populations are affected by the pandemic. ACOs can also forgo the annual application process; if their participation is set to end this year, they have the option to extend for another year. ACOs that are required to increase their financial risk during the current agreement period will have the option to maintain their current risk level for next year, instead of advancing automatically to the next risk level. CMS also includes virtual services, including virtual check-ins, remote evaluations, and telephone E/M services, as primary care services considered for beneficiary attribution.
  • CMS announced a new Coronavirus Commission for Safety and Quality in Nursing Homes. Read the Fact Sheet here.

Disclaimer: This information is current as of 5/05/2020. COVID-19 guidelines are changing daily. Please note for the purposes of the Home-Based Primary Care (HBPC) population: The Home Centered Care Institute (HCCI) focuses its content on CMS guidelines relevant for traditional Medicare billing. It’s always recommended to check with local MACs for specific guidance for your geographic region. Medicare Advantage and commercial payor policies will vary.

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COVID-19 Update 04/24/20 – More on Medicare Telehealth Services-related Changes

As providers and practices continue to determine the best way to safely care for their patients while navigating the ever-changing regulatory requirements related to COVID-19, HCCI is committed to continuing to provide accurate, clarifying and timely information.

“Medicare telehealth services” refer to a certain list of services that would normally be provided in-person, but due to the Public Health Emergency, are temporarily being allowed by Medicare in all locations when they are furnished using two-way audio and video technology that permits real-time communication between the provider and the patient who are in different locations.

Medicare has also previously allowed these services in geographic areas that were rural or designated as a Healthcare Professional Shortage Area (HPSA), subject to distant and originating site requirements (temporarily waived).

As a result of the interim final rule published on 3/26/20, for visits conducted via telehealth, for Medicare’s purposes, providers should report the Place of Service (POS) where the patient would have been seen face-to-face (to allow for non-facility rate payment) and use modifier 95 to identify it as a telehealth service. Telehealth services no longer require POS 02.

The following are not considered Medicare telehealth services because they would not normally be provided face-to-face. Instead, providers should report the POS where the service was rendered, with no modifier required.

  • Telephone Evaluation & Management (E/M) Services: CPT code range 99441-99443 and CPT code range 98966-98968
  • Virtual Check-in (phone call): HCPCS code G2012
  • Review of recorded video and/or photo or image: HCPCS code G2010
  • E-visits (patient portal communications over a 7-day period): CPT code range 99421-99423 and HCPCS code range G2061-G2063
  • Remote Patient Monitoring: CPT codes 99453-99454, 99091, 99473-99474, 99457, 99458

Other Modifiers

  • CS Modifier: Physician and practitioner services that lead toeither an order for, or administration of, a COVID-19 lab test are not subject to a co-pay or deductible charges. The CS Modifier is added to the physician/practitioner service to define this circumstance and allow the claim to process without co-pay or deductible application.
  • CR Modifier: Catastrophe/disaster-related; required when an item or service is impacted by an emergency or disaster and Medicare payment for that item or service is conditioned on the presence of a “formal waiver.” Please note telehealth services are excluded from CR modifier use, so do not report for telehealth services. Be sure to follow the guidance provided by your local Medicare Administrator Contractors (MAC) as a recent NGS article advised to use CR for telephone E/M services.

Additional Key Updates

Previous HCCI Home-Based Primary Care-Specific Updates

Disclaimer: This information is current as of 4/24/2020. COVID-19 guidelines are changing daily. Please note for the purposes of the Home-Based Primary Care (HBPC) population: The Home Centered Care Institute (HCCI) focuses our content on CMS guidelines relevant for traditional Medicare billing. It’s always recommended to check with local MACs for specific guidance for your geographic region.

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COVID-19 Update 04/08/20 – Additional Key Information and Flexibilities in the CMS Interim Final Rule

In addition to changes in the Centers for Medicare & Medicaid Services (CMS) Interim Final Rule discussed in our previous update, Providers and practices should be aware of the following additional information and waiver flexibilities in the rule:

  • Home Health Agencies can now provide additional services to patients via telehealth if it’s part of the patient’s plan of care and does not replace the needed in-person care as ordered in the plan of care.
  • Hospice Organizations can provide services to Medicare patients via telehealth if feasible and appropriate to do so.
  • Clinicians now have maximum flexibility in determining patient needs for respiratory-related devices and equipment and the flexibility for more patients to manage their treatments at home. The current National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) that restrict coverage of these devices and services to patients with specific clinical characteristics do not apply during the Public Health Emergency. For example, Medicare will cover non-invasive ventilators, respiratory assist devices, and continuous positive airway pressure devices based on the clinician’s assessment of the patient. So, in summary, on an interim basis, CMS will not enforce clinical indications across respiratory (including home oxygen), home anticoagulation management, and infusion pump NCDs and LCDs (including articles).

The above policies include but are not limited to the following:

  • Home Oxygen
  • Continuous Positive Airway Pressure for Obstructive Sleep Apnea
  • Respiratory Assist Devices (ventilators for home use)
  • Intrapulmonary Percussive Ventilator
  • Oxygen and Oxygen Equipment (for home use)
  • Home Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring for Anticoagulation Management
  • Infusion Pumps
  • External Infusion Pumps

For additional information:

Previous HCCI Updates related to COVID-19:

Disclaimer: This information is current as of 4/08/2020. COVID-19 guidelines are changing daily. Please note for the purposes of the Home-Based Primary Care (HBPC) population: The Home Centered Care Institute (HCCI) focuses our content on CMS guidelines relevant for traditional Medicare billing. It’s always recommended to check with local MACs for specific guidance for your geographic region.

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HCCIntelligence™ Update: COVID-19 Telehealth Billing Requirements

COVID-19 Telehealth Billing Requirements

COVID-19 Telehealth Billing Requirements

In our recent article, Providing Telephonic and Virtual Care Requirements as part of COVID-19 Precautions, available on HCCI’s COVID-19 Information Hub, we highlighted the requirements of virtual visits. We also provided an overview of the 1135 Telehealth Waiver as part of the president’s emergency declaration during the country’s current public health emergency.

We realize this is a challenging time for Home-Based Providers, and the Home Centered Care Institute (HCCI) is committed to supporting the field by providing timely information so you can make the best decisions for your practice. In response to recent questions, we’ve outlined more information below to clarify additional questions you may have.

Q: What are the current Evaluation and Management (E/M) codes that can be billed for when the services are provided via telehealth under the 1135 Waiver?

A: Here are the appropriate E/M codes:

  • Office/Outpatient CPT code range 99201-99215
  • Transitional Care Management CPT codes 99495 and 99496
  • Advance Care Planning CPT codes 99497 and 99498
  • Annual Wellness Visits HCPCS codes G0438 and G0439
  • Administration of caregiver-focused health risk assessment instrument CPT code 96161
  • Telehealth consultations ED or initial inpatient visits HCPCS code range G0425-G0427
  • Follow-up inpatient telehealth consultations in hospitals or SNF’s HCPCS range G0406-G0408

For a complete list of CPT codes, please refer to Medicare’s list of telehealth services

HCCI is awaiting official guidance from CMS on whether Home-Based Practices that historically bill only for home or domiciliary visits should be concerned about a potential heightened audit risk if they use the office visit code set during this pandemic. We realize, however, that many Home-Based Practices are choosing to use the set office visit code, in the interim, to maintain their practice. Our recommendation is to review all the facts before making the best decision for your practice and consider contacting your local Medicare Administrator Contractor (MAC) for specific guidance.

Q: What Place of Service (POS) and modifiers are required to bill for telehealth services?

A: For services furnished via telehealth, report Place of Service (02) for telehealth.

Per the CMS FAQs & The Medicare Learning Network’s March 20th update, CMS does not generally require additional or different modifiers on Medicare claims for telehealth services furnished under these waivers, except in the following three instances:

  • GQ – Telehealth services are furnished via asynchronous (store and forward) technology as part of a federal telemedicine demonstration project in Alaska and Hawaii
  • GT – Telehealth services are furnished under CAH Method II (Via interactive audio and video telecommunication systems)
  • G0 – Telehealth services are furnished for the purposes of diagnosis and treatment of an acute stroke

As an example of when receiving guidance from your local MAC is beneficial, a practice in Indiana reached out to their MAC (i.e., WPS Government Health Administrators) and was advised to use modifiers for telehealth claims.

Q: How do I contact and confirm who my local MAC is?

A: CMS has a contractor directory and map on their website that allows you to search by state to confirm your MAC along with links to each contractor’s site where you can find their Provider Contact Center phone number. You will need to call your MAC directly to request clarification on proper billing for home visits under the 1135 waiver. They may refer you to a specific governance email, however, HCCI is aware that practices are generally receiving timely responses within a few days.

It’s also important to note the requirement for practices to use an interactive audio and video telecommunications system that permits real-time communication between the provider and the patient at home even under the telehealth waiver. This means you cannot bill for an E/M visit via telehealth for phone call audio-only. However, under the U.S. Department of Health and Human Services (HHS), the Office of Civil Rights (OCR) Notification of Enforcement Discretion relaxed HIPAA requirements so that providers may use platforms such as Apple FaceTime, Skype, Zoom, the WhatsApp, etc., as a form of two-way audio and video telecommunications. Doxy.me, a free HIPAA-compliant telemedicine platform that allows for two-way audio and video interaction with patients and caregivers, is another option. Consider checking with your Electronic Health Record (EHR) vendor as they may have technologies available for video visits, too.

If you are providing virtual services to patients via phone call audio-only, you must refer to the Virtual Check-in Codes (requirements detailed in previous HCCI article), or use other forms of reimbursement, such as care management services (e.g., Chronic Care Management) to bill for your time.

The E-visits codes, which capture time over a 7-day period for communicating and reviewing patient information on a digital communication platform, such as a patient portal or secure email, are listed below in an HCCI chart for easy reference:

For additional information, refer to the CMS General Provider Telehealth and Telemedicine Tool-kit, or contact a member of the HCCIntelligence™ Hotline staff at 630-283-9222 or email [email protected].

Disclaimer: This information is current as of 3/23/2020. Coding regulations are subject to change annually, and COVID-19 guidelines are changing daily. Please note for the purposes of the Home-Based Primary Care (HBPC) population: The Home Centered Care Institute (HCCI) focuses our content on CMS guidelines relevant for traditional Medicare billing.

Online Digital E/M Services_1280

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Providing Telephonic and Virtual Care Requirements as part of COVID-19 Precautions

telemedicine female physicianThe Home Centered Care Institute (HCCI) understands that many Home-Based Practices and Providers are increasing the use of virtual and telephonic care as an alternative to face-to-face care, as appropriate, due to the current COVID-19 pandemic.

Though a telehealth waiver is mentioned under recent legislation (H.R.6074 – Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020), CMS initially responded to the bill advising providers to use Communication-Technology Based Services (CTBS) and interprofessional consults.

In the CMS FAQ published on 3/5/2020, Medicare directs providers to use the current CTBS services as a means of telehealth for traditional Medicare purposes. There are, however, exceptions for Medicare Advantage (MA) patients whose MA Plan offers telemedicine as one of their supplemental benefits.

On 3/17/2020, a new Medicare Fact Sheet and FAQ’s (links below) were then published, indicating authority for the expansion of telehealth under the 1135 waiver to pay for Evaluation & Management (E/M) Office visits, Hospital visits, and other specified visits in the patient’s place of residence valid 3/6/2020.

Before billing for E/M Home Visits (CPT Code Range 99347-99350) or Domiciliary Visits, e.g., assisted living and group homes (CPT Code Range 99334-99337), however, please be advised these services are not included on the list of Medicare Telehealth Services. So, in summary, E/M Office visits (CPT Code Ranges 99201-99205 and 99211-99215) can be paid under telehealth, but E/M Home and E/M Domiciliary visits cannot at this time.

Below are the limited services included on Medicare’s list of telehealth services, which Home-Based Providers typically provide and can potentially bill for − if furnished via telehealth using Place of Service (POS) code 02 for telehealth:

  • CPT codes 99495 and 99496 for Transitional Care Management
  • CPT codes 99497 and 99498 for Advance Care Planning
  • Annual Wellness Visits CPT codes G0438 and G0439
  • CPT code 96161 − Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring, and documentation, per standardized instrument.

CTBS Services and E-Visits (CPT Code Range 99421-99423) can be provided and billed for now and prior to the telehealth waiver without Medicare telehealth restrictions.  We’ve detailed the requirements to bill for these services below (currently, and per the 2019 Medicare Physician Fee Schedule Final Rule, there is no frequency limitation for G2012 and G2010):

G2012: Brief Communication Technology-Based Virtual Check-in

  • Includes a minimum of a 5-10-minute medical discussion by a physician or other qualified healthcare professional (e.g., Advanced Practice Providers) with the patient/caregiver; this cannot include clinical staff time
  • Communication may be audio-only (e.g., telephone) or two-way video
  • Can only be used for established patients
  • Intended to assess the patient’s condition to determine if a face-to-face (F2F) visit is needed
  • Cannot be related to an E/M F2F visit within the previous 7 days and cannot result in an E/M visit within the next 24 hours or the next available appointment
  • Requires a patient-initiated question or call
  • Verbal patient consent is required, however, please note that, as a result of the Medicare 2020 Physician Fee Schedule Final Rule, only a once-per-year annual consent is required for CTBS services as long as the patient is made aware of possible cost-sharing
  • CMS National Payment Amount: $14.80

G2010: Remote Evaluation of Recorded Video and/or images

  • Pre-recorded image and/or video of sufficient quality provided by the patient or caregiver
  • Requires documentation of consent at least once per year (may be verbal, written, or electronic)
  • Requires interpretation and follow-up to the patient and/or caregiver within 24 business hours (follow-up may be via a patient portal communication, telephone, secure text/email or two-way video)
  • Can only be used for established patients
  • CMS National Payment Amount: $12.27

Please note: In the CMS FAQ published on 3/17/20, CMS clarifies that, while these interactions must be patient-initiated, CMS does condone providers making their patients aware of these services and billing for them, as appropriate. Please keep in mind medical necessity is always a requirement of payment, and documentation needs to support the necessity and decision-making of the care provided.

  • Supporting excerpt from CMS FAQ: “We expect that these virtual services will be initiated by the patient, however, practitioners may need to educate beneficiaries on the availability of the service prior to patient initiation.”

CMS has explicitly stated that they do not consider Remote Patient Monitoring (RPM) Services and CTBS to be part of their definition of telehealth services. Therefore, you can bill for the above and below additional services without the regulatory restrictions of Medicare telehealth requirements (e.g., originating and distant site, geographic restrictions do not apply).

  • 99451, 99452, 99446-99449 (Interprofessional Telephone/Internet/Electronic Health Record Consultation Services)
  • 99453, 99454, 99457, 99458 (Remote Physiologic Monitoring)
  • 99091 (Review and analysis of physiologic data)
  • 99421, 99422, 99423 (Online Digital E/M by a qualified provider); Please note this service is bundled with Chronic Care Management (CCM); Refer to our 2/19/20 HCCIntelligence™ Webinar “What You Should Know About 2020 Coding Updates!” for further details regarding online E/M services
  • G2061, G2062, G2063 (Online Digital E/M by a nonphysician healthcare professional); Please note this service is bundled with CCM

Other Key Considerations:

  • CMS will not enforce an existing provider-patient relationship to furnish telehealth services. The Department of Health & Human Services (HHS) advised: “HHS will not conduct audits to ensure an existing provider relationship during this public health emergency.”
  • Effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers who serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency. For more information: https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf
  • HCCI encourages all Home-Based Providers and Practices to contact their local Medicare Administrator Contractor (MAC) to inquire if they will pay for E/M Home Visits furnished via telehealth under the current telehealth waiver.

For additional information on COVID-19 regulations and legislation, please visit the CMS current emergencies page or contact a member of the HCCIntelligence™ Hotline staff at 630-283-9222 or email [email protected]..

You can also visit the HCCI COVID-19 Information Hub for additional information and resources.

Disclaimer: This information is current as of 3/17/2020. Coding regulations are subject to change annually, and COVID-19 guidelines are changing daily. Please note for the purposes of the Home-Based Primary Care (HBPC) population; the Home Centered Care Institute focuses our content on CMS guidelines. All G codes are used for Medicare purposes, and commercial payors utilize a corresponding set of CPT codes.

 

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HHS and CMS Announce Brad Smith as CMMI Director, Senior Advisor for Value-Based Transformation

January 6, 2020
Press Release from U.S. Department of Health & Human Services

Today, the Department of Health and Human Services and the Centers for Medicare & Medicaid Services announced that Brad Smith will serve as Director of the Center for Medicare & Medicaid Innovation at CMS and Senior Advisor to Secretary Azar for Value-Based Transformation.

Smith most recently served as the Chief Operating Officer of Anthem’s Diversified Business Group and was previously co-founder and CEO of Aspire Health, a healthcare company focused on providing home-based palliative care services to patients facing serious illnesses.

“Brad will help HHS and CMS continue and accelerate the value-based transformation work that we have begun under President Trump,” said Secretary Azar. “Delivering better value in healthcare is a key piece of how we’re executing on President Trump’s healthcare vision. Paying for outcomes rather than procedures through CMMI models is an important tool for the value-based transformation of healthcare that President Trump has prioritized. Brad has impressive experience with innovative care delivery and paying for value, and he will help expand Administrator Verma’s and CMS’s efforts to ensure Medicare and Medicaid beneficiaries are getting better care, and better health, at a lower cost.”

“Brad’s experience thinking outside-the-box to improve healthcare as a successful entrepreneur, along with his stellar academic and policy background, have prepared him well to lead CMMI and bring innovative solutions to our healthcare system’s most pressing challenges,” said CMS Administrator Seema Verma. “I am excited that we have selected Brad to join the ranks of CMS and help us build on the important work the Trump Administration has undertaken to transform our healthcare system to deliver better value to patients.”

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CMS Announces Request for Applications for Primary Care First Model Options

CMS Request For Applications

CMS Request For Applications

CMS Announces Request for Applications for Primary Care First Model Options

(Highlights for Consideration included below)

CMS released the Request for Applications (RFA) for the Primary Care First (PCF) and Seriously Ill Population (SIP) models last Thursday, October 24. The practice application period also started that day while the deadline to apply via the live portal is January 22, 2020.

The model will now begin in January 2021 (a delay of one year from the originally anticipated start date). CMS will select practices and payers during Winter/Spring 2020 and will onboard participating practices and payer partners to the model from July to December 2020.

Following are important highlights of the new program for practices to consider:

Fees and Measurements

  • Under PCF General, the primary care flat visit fee will be reduced to $40.82.
  • HCC Risk Group 4 will be the highest-level risk group with a payment of $175 Per Beneficiary Per Month (PBPM).
  • Practice risk groups 3 and 4 will not use the acute hospitalization performance measure; instead, performance for these groups will be measured on the Advance Care Plan and Total Per Capita Cost (TPCC).

SIP

  • SIP practices are expected to have an 8-month management and transition period for stabilization of their patients and then to transition them back to another primary care setting or practice.
    • This is known as the average length of attribution (LOA).
    • If the 8-month term is exceeded, a $50 PBPM reduction will apply to the monthly SIP payment through a quality adjustment.
  • SIP patients will require a face-to-face visit once every 60 days for them to remain attributed to the practice.
  • SIP payment redesign now states that after a practice conducts its initial face-to-face visit with the SIP patient, CMS will make a one-time payment of $325. With PCF, beginning the month following the initial visit, the practice will receive a $275 PBPM minus a $50 quality withhold that can be earned back with a potential quality bonus at the end of the first performance year.
  • SIP practices must describe the service area(s) in which they are interested in participating using zip codes and must define the maximum number of SIP patients the practice has the capacity and capability to manage.

Participation and Eligibility

  • Practices participating in the Independence at Home (IAH) Demonstration are eligible to participate even if it is not offered in the region(s) of the IAH practice.
  • Practices participating in the Comprehensive Primary Care Plus (CPC+) model cannot participate in 2021, however, they can participate in 2022.
  • Concierge practices, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) are not eligible to participate.
  • Eligible practitioners are those practicing in internal medicine, general medicine, geriatric medicine, family medicine and/or hospice and palliative medicine.

Home Centered Care Institute Support

If you have questions about these changes or other home-based primary care questions, you can contact our HCCIntelligence™ Resource Center Hotline at 630-283-9222, 9:00am to 5:00pm (Central Time) Monday through Friday – or email us at [email protected]. The hotline and additional offerings in the Resource Center, including monthly webinars, virtual office hours, and tools and tips sheets are available at no charge due in part to a grant from The John A. Hartford Foundation.

 

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AAHCM and HCCI present a webinar on new CMS Primary Cares Payment Models

Woman watching a webinar

Woman watching a webinar

The American Academy of Home Care Medicine (AAHCM) in collaboration with the Home Centered Care Institute (HCCI) will host a webinar Tues. July 30 at 4 pm (ET) on the new CMS Primary Cares Initiative payment models relevant to home care medicine. The three different payment models will be discussed in detail; Primary Care First (PCF), Seriously Ill Population (SIP), and Direct Contracting (DC).

Register

CMS Primary Cares Initiative

In April, the Center for Medicare and Medicaid Innovation (CMMI) announced a CMS Primary Cares Initiative which includes new payment demonstrations meant to promote value-based care, with a shift of up to 25 percent of primary care Medicare fee-for-service patients to these new models. Primary Care First (PCF), Seriously Ill Population (SIP), and Direct Contracting (DC) will offer enhanced payment for home care medicine and other providers to provide primary care for people with advanced illness.

Primary Care First (PCF) & Seriously Ill Population (SIP)

The Primary Care First (PCF) and Seriously Ill Population (SIP) models will be offered in 22 states and 4 regions for a January 2020 start date:   STATEWIDE in Alaska, Arkansas, California, Colorado, Delaware, Florida, Hawaii, Louisiana, Maine, Massachusetts, Michigan, Montana, Nebraska, New Hampshire, New Jersey, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, Tennessee, and Virginia. In Local Regions of Greater Buffalo, NY, Kansas City (Kansas and Missouri), Greater Philadelphia (Pennsylvania), North Hudson-Capital Area, NY, and Northern Kentucky.

PCF/SIP Timeline:   A letter of intent (LOI) is not required for PCF or SIP.   A request for application (RFA) will be released in the coming weeks and is required for participation.  Both models are scheduled to begin January 2020.

Direct Contracting

The Direct Contracting (DC) path will engage practices or groups of providers who can reach 5,000 beneficiaries by Year 3 (with potential exceptions for smaller practices), as well as Health systems, Accountable Care Organizations, Medicare Advantage plans, and Medicaid Managed Care Organizations.  DC builds upon the Next Generation ACO model and has no geographic limitations on who may apply.   The DC path will include three models: Professional PBP, Global PBP, Geographic PBP (Proposed).

Timeline:  A Letter of Intent (LOI) is required to apply for participation in the DC Models and is due on Friday, August 2. The LOI is non-binding. CMS will then release the request for application (RFA), which will be required for participation. All models are scheduled to begin January 2020 except the DC Geographic Option, which will begin at a later date.

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CMS details new primary care payment model with range of risk options

Risk - Reward Model Graphic

Risk - Reward Model Graphic

Author Shannon Muchmore  |  April 23, 2019  |  healthcaredive.com

  • CMS on Monday announced a new voluntary Medicare payment model for primary care providers. The two-pronged program has paths for small practices and large organizations and a range of options from partial shared risk to full downside risk.
  • The agency projects as many as a quarter of traditional Medicare fee-for-service beneficiaries will be incorporated into the five-year program, called Primary Cares Initiative. It is slated to roll out in January, with a call for applications expected in about a month.
  • CMS is also asking for input on an additional model in the program that would give one organization responsibility for the total cost of care for an entire Medicare population in a geographic area. That model would begin in January 2021.

Center for Medicare and Medicaid Innovation Director Adam Boehler noted in a press conference unveiling the model that primary care makes up only a small fraction of the country’s total healthcare spend (and of Medicare spending), but emphasized its potential to have great affect on downstream costs and quality outcomes.

“A strong primary care foundation is essential to an effective healthcare system broadly,” Boehler said.

HHS Secretary Alex Azar said the Primary Cares Initiative represented a pivotal moment for the agency as it pushes providers toward value-based care arrangements, and he hoped the Medicare program would have ripple effects. “This initiative is specifically designed to encourage state Medicaid programs and commercial payers to adopt similar approaches,” he said at the press conference. Read the full article

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New CMMI Models Announced to Support Primary Care for People with Complex Chronic Illness

Secretary of Health and Human Services Alex M. Azar CMS Primary Cares Press Conference

Secretary of Health and Human Services Alex M. Azar CMS Primary Cares Press Conference

4/24/19  |  aahcm.org

The American Academy of Home Care Medicine (AAHCM) is pleased to share initial details on two new Alternative Payment Models (APMs) that promote primary care of Medicare beneficiaries with complex, advanced illness. The high-level outlines of these new APMs were announced on April 22 by the Center for Medicare and Medicaid Innovation (CMMI). The Academy’s media statement is available here. These APMs are part of a new CMS Primary Cares Initiative and will offer a choice of two new payment paths. The new payment demonstrations are meant to promote value-based care, with a voluntary shift of up to 25 percent of primary care Medicare fee-for-service patients to these new models. This e-alert summarizes the information CMS has released to date about the models.  Several important details, such as exact payment amounts and patient eligibility criteria, remain to be announced. We will issue additional alerts to Academy members as soon as information is made available in the coming weeks.

Overview

The two new options, Primary Care First (PCF) and Direct Contracting (DC), will offer enhanced payment for home care medicine and other providers to provide primary care for people with advanced illness. The Academy, along with others, has worked closely with CMMI to develop this new payment model, with a focus on relevant quality measures for people with advanced illness and use of outcome-based payment methods.  Many core principles of the successful Independence at Home (IAH) Demonstration are included in Primary Care First. Home care medicine providers and policymakers have learned much from IAH, thanks to the foresight of our champions on Capitol Hill and the CMS leadership.  Read the full article