CMS Publishes Medicaid Access Final Rule – CMS published a Final Rule in the Federal Register on November 2, 2015, that implements a process for states to determine whether Medicaid payments satisfy what is known as the Medicaid “access requirement.”  Specifically, Social Security Act Section 1902(a)(30(A) requires that states have methods and procedures to ensure that payments are “sufficient to enlist enough providers so that care and services are available under the plan at least to the same extent that such care and services are available to the general population in the geographic area.”  Notably, the Final Rule does not require states to raise payment rates.  Rather, it requires states to consider access when setting and adjusting payment methodologies and to address, through any number of steps, any problems with access that are identified. 

CMS Releases CY 2016 Home Health Final Rule – On October 29, 2015, CMS released the calendar year 2016 Final Rule governing the Home Health Prospective Payment System; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements.  Under the Final Rule, total payments to home health agencies are expected to decrease by 1.4 percent, up from the proposed rule’s estimated rate decrease of 1.8 percent.  This rule is set for publication in the Federal Register on November 5, 2015, and is available by clicking here.  The CMS Fact Sheet is available here.

CMS Releases CY 2016 ESRD Final Rule – On October 29, 2015, CMS released the calendar year 2016 End-Stage Renal Disease (ESRD) Prospective Payment System and Quality Incentive Program Final Rule.  Under the Final Rule, total payments to ESRD facilities are expected to increase by 0.2 percent, down from the proposed rule’s estimated rate increase of 0.3 percent.  This rule is set for publication in the Federal Register on November 6, 2015, and is available by clicking here.  The CMS Fact Sheet is available here.

CMS Announces $1.5 Billion Available for Value-Based Purchasing Program Incentive Payments in FY 2016 – CMS recently released the actual Value-Based Purchasing Program (VBPP) hospital adjustment factors for FY 2016.  In the data released, CMS estimates that approximately $1.5 billion will be available to hospitals in the form of VBPP payments in FY 2016.  The VBPP adjusts payments, both positively and negatively, to hospitals according to each hospital’s adjustment factor, which is based upon the quality of care provided by each hospital.  The VBPP is funded through DRG payment reductions, which is 1.75 percent for FY 2016, that are redistributed.  The CMS Fact Sheet is available here.

CMS Proposes Sweeping Changes to Medicare Reimbursement for Clinical Diagnostic Laboratory Tests – On October 1, 2015, CMS published a Proposed Rule outlining extensive revisions to Medicare reimbursement for clinical diagnostic laboratory tests (CDLTs) that are paid based on the Medicare Clinical Laboratory Fee Schedule (CLFS).  The Proposed Rule implements a portion of the Protecting Access to Medicare Act of 2014 (PAMA), which requires that CMS set CLFS payment rates based on the weighted median of private payor rates for CDLTs as reported by clinical laboratories to CMS.  In order to set CLFS payment rates effective on January 1, 2017 using this new methodology, CMS proposes that clinical laboratories collect private payor payment data for the period from July 1, 2015 through December 31, 2015, and report this data to CMS by March 31, 2016.  Thus, clinical laboratories must immediately take steps to interpret the provisions of the Proposed Rule, assess their CDLT revenues, and prepare to implement applicable data collection and reporting processes, without the benefit of final regulations to establish the parameters of these requirements.  King & Spalding’s Reimbursement and Government Pricing Teams have published a client alert analyzing the Proposed Rule (see below).