/ en Thu, 07 Aug 2025 19:15:16 -0500 Thu, 03 Jul 25 00:00:01 -0500 /advisory/2025-07-03-key-highlights-final-one-big-beautiful-bill-act <div class="container"><div class="row"><div class="col-md-8"><p>The Senate July 1, and the House July 3, passed a budget reconciliation bill, the <a href="https://sponsors.aha.org/rs/710-ZLL-651/images/07032025-Legis-language-h1_eas.pdf" target="_blank" title="Full text of the One Big Beautiful Bill Act (OBBBA) PDF.">One Big Beautiful Bill Act (OBBBA)</a>, H.R. 1, a sweeping package that enacts many of President Trump’s legislative priorities on taxes, border security, energy and deficit reduction. The bill includes significant policy changes to Medicaid and the Health Insurance Marketplaces.</p><p>The Medicaid program provides health insurance coverage for 72 million Americans, including children, pregnant women, the elderly, the disabled and millions of working Americans. According to the <a href="https://www.cbo.gov/publication/61534" target="_blank" title="Congressional Budget Office: Estimated Budgetary Effects of an Amendment in the Nature of a Substitute to H.R. 1, the One Big Beautiful Bill Act, Relative to CBO's January 2025 Baseline">Congressional Budget Office</a> (CBO) score of a draft version of the Senate bill, the OBBBA will lead to nearly $1 trillion in Medicaid cuts and result in more than 11.8 million people losing Medicaid and health insurance marketplace coverage.</p><p>Historically, provider taxes and state-directed payments (SDPs) allow hospitals to bridge the chronic and historic underpayment by Medicaid for the care they deliver. The legislation includes limitations on the use of provider taxes and SDPs. The CBO score for the policy changes related to SDPs and provider taxes is $340 billion and will result in direct decreases in hospital payments. The AHA estimates that the provider tax changes alone will result in a loss of federal payments to hospitals of $232 billion over 10 years.</p><h2>AHA Statement</h2><p>In a <a href="/press-releases/2025-07-03-aha-statement-house-passage-one-big-beautiful-bill-act" target="_blank" title="AHA Statement on House Passage of One Big Beautiful Bill Act">statement</a> shared with the media following passage in the House July 3, AHA President and CEO Rick Pollack said, “Today is an extremely disappointing and very difficult day for health care in America. Despite months of clearly demonstrating the implications that these Medicaid proposals will have on the patients and communities we serve, especially the most vulnerable populations, Congress has enacted cuts of nearly a trillion dollars to the Medicaid program. No matter how often repeated, the magnitude of these reductions — and the number of individuals who will lose health coverage — cannot be simply dismissed as waste, fraud, and abuse. The faces of Medicaid include our children, our disabled, our seniors, our veterans, our neighbors, and friends. The real-life consequences of these reductions will negatively impact access to care for all Americans.</p><p>“The AHA remains committed to working with all stakeholders to mitigate the impact of these cuts wherever possible. Our goal is to help ensure hospitals can remain open for their communities, and people can get the care they need when they need it. Our nation’s health and economic future depend on it.”</p><h2>AHA Summary of OBBBA Provisions Impacting Hospitals and Health Systems</h2><h3>SUBTITLE B — HEALTH</h3><h3>Chapter 1 — Medicaid</h3><h3><em>Subchapter A — Reducing Fraud and Improving Enrollment Processes</em></h3><h4>Section 71101: Moratorium on Implementation of Medicaid Savings Program Eligibility and Enrollment Rule (Effective from enactment through Sept. 30, 2034)</h4><p>Prohibits the Department of Health and Human Services (HHS) Secretary from implementing, administering or enforcing the amendments made by the Medicare Savings Program (MSP) rule for 10 years. This would rollback requirements that states 1) automatically enroll certain Supplemental Security Income recipients in the qualified Medicare beneficiary eligibility group of the MSP program, 2) use data from the low-income subsidy program as an application for MSPs and align the family size definitions between the MSP and Low Income Subsidy programs, and 3) accept self-attestation for certain types of income and resources. CBO estimates that this provision will result in a $85.3 billion reduction in federal spending over 10 years.</p><h4>Section 71102: Moratorium on Implementation of Medicaid, CHIP and Basic Health Program Eligibility and Enrollment Rule (Effective from enactment through Sept. 30, 2034)</h4><p>Prohibits the HHS secretary from implementing, administering or enforcing the amendments made by the provisions of the eligibility and enrollment rule for 10 years. This would limit states’ ability to use other data sources (such as payroll or state vital statistics data) to determine an individual’s eligibility for Medicaid and limit states’ use of prepopulated renewal forms. It also would allow states to impose annual and/or lifetime limits on Children’s Health Insurance Program (CHIP) benefits and to disenroll CHIP beneficiaries for failure to pay premiums or enrollment fees. CBO estimates that this provision will result in a $81.6 billion reduction in federal spending over 10 years.</p><h4>Section 71107: Eligibility Redeterminations (Effective Jan. 1, 2027)</h4><p>Requires states to redetermine eligibility once every six months for beneficiaries enrolled through the Medicaid expansion eligibility pathway, beginning in calendar year (CY) 2027. The HHS secretary must issue guidance related to implementing the rule no later than 180 days after enactment. The bill appropriates $75 million to the Centers for Medicare & Medicaid Services (CMS) administrator for fiscal year (FY) 2026 for implementation of the provisions. CBO estimates that this provision will result in a $62.6 billion reduction in federal spending over 10 years.</p><h4>Section 77109: Alien Medicaid Eligibility (Effective Oct. 1, 2026)</h4><p>Restricts eligibility for Medicaid to the following groups: legal permanent residents, certain Cuban immigrants and Compact of Free Association migrants lawfully residing in the United States. The bill appropriates $15 million to the CMS administrator for FY 2026 for implementation of the provisions. CBO estimates that this provision will result in a $6.2 billion reduction in federal spending over 10 years.</p><h4>Section 7110: Expansion FMAP for Emergency Medicaid (Effective Oct. 1, 2026)</h4><p>Beginning Oct. 1, 2026, the bill limits the Federal Medical Assistance Percentage (FMAP) to the state’s traditional FMAP for emergency Medicaid services provided to unlawfully present aliens who, except for their immigration status, would qualify for Medicaid expansion. The bill appropriates $1 million for FY 2026 to the CMS administrator for implementation of the provision. CBO estimates that this provision will result in a $28.2 billion reduction in federal spending over 10 years.</p><h3><em>Subchapter B — Preventing Wasteful Spending</em></h3><h4>Section 71111: Moratorium on Implementation of Rule Relating to Staffing Standards for Long-term Care Facilities Under the Medicare and Medicaid Programs (Effective from enactment through Sept. 30, 2024)</h4><p>Prohibits HHS from implementing the Minimum Staffing Standards for long-term care facilities and the Medicaid Institutional Payment Transparency Reporting regulation for 10 years. CBO estimates that this provision will result in a $23.1 billion reduction in federal spending over 10 years.</p><h4>Section 71112: Reducing State Medicaid Costs (Effective Jan. 1, 2027)</h4><p>Limits the timeframe for retroactive Medicaid and CHIP eligibility to 30 days prior to the application date for expansion enrollees, and 60 days prior to the application date for traditional enrollees, as opposed to the current 90-day period. CBO estimates that this provision will result in a $4.2 billion reduction in federal spending over 10 years.</p><h4>Section 71113: Federal Payments to Prohibited Entities (Effective on enactment into 2026)</h4><p>Prohibits states from receiving federal matching funds for services rendered by providers who provide abortions (other than Hyde Amendment exceptions) and receive more than $800,000 in Medicaid payments in 2023. This applies to not-for-profit, essential community providers primarily engaged in family planning services, reproductive health and related medical care. This provision applies for one year, beginning on the date of enactment. The bill appropriates $1 million for FY 2026 to the CMS administrator for implementation of the provisions. CBO estimates that this provision will result in a $52 million increase in federal spending over 10 years.</p><h3><em>Subchapter C — Stopping Abusive Financing Practices</em></h3><h4>Section 71114: Sunsetting Increased FMAP Incentive. (Effective Jan. 1, 2026)</h4><p>Repeals the ability for states that have not yet expanded Medicaid to receive 5% enhanced FMAP funds should they later choose to expand. CBO estimates that this provision will result in a $13.6 billion reduction in federal spending over 10 years.</p><h4>Section 71115: Provider Taxes (Freeze effective upon enactment; reduction begins Oct. 1, 2027)</h4><p>Freezes existing provider taxes imposed by a state or local unit of government as of the date of enactment. Removes the ability of a state or local unit of government to impose a new provider tax after enactment by setting the “hold harmless threshold” at 0%. Beginning in FY 2028, the hold harmless threshold for <strong>expansion states</strong> with an existing tax will be reduced by 0.5% annually until the threshold reaches 3.5% in 2032. Provider taxes in non-expansion states and provider taxes imposed on nursing homes and intermediate care facilities will remain frozen at their rates as of enactment. The bill appropriates $20 million for FY 2026 to the CMS administrator for implementation of the provisions. CBO estimates that this provision will result in a $191.1 billion reduction in federal spending over 10 years.</p><h4>Section 71116: State-directed Payments (SDP cap effective on enactment; reduction effective by the rating period on or after Jan. 1, 2028)</h4><p>Caps SDPs at 100% of the total published Medicare rate in expansion states and 110% of the total published Medicare rate in non-expansion states. SDPs approved (or where there was a good faith effort to be approved) by May 1, 2025, and SDP payments for rural hospitals approved (or where there was a good faith effort to be approved) by enactment will be grandfathered in at a higher rate. Completed preprints for SDPs can be submitted until enactment and may be grandfathered in at a higher rate. Beginning with the rating period on or after Jan. 1, 2028, all grandfathered SDPs would be reduced by 10 percentage points annually until the specified Medicare payment rate limit is achieved. The total published Medicare rate is defined as provided in 438.6(a) of title 42 of the Code of Federal Regulations or any future regulation that replaces it. Rural hospitals are defined as those located in a rural area, treated as being in a rural area, or located in a rural census tract, as well as critical access hospitals, sole community hospitals, Medicare-dependent hospitals, low-volume hospitals and rural emergency hospitals. The bill appropriates $7 million for each FY between 2026 and 2033 for the implementation of the provision. CBO estimates that this provision will result in a $149.4 billion reduction in federal spending over 10 years.</p><h4>Section 71117: Requirements Regarding Waiver of Uniform Tax Requirement for Medicaid Provider Tax (Effective upon enactment)</h4><p>Modifies the requirements regarding the uniformity of provider taxes and, specifically, whether a state’s tax is considered “generally redistributive.” A tax will not be considered generally redistributive if:</p><ol type="a"><li>Lower-volume Medicaid health care entities are taxed at a lower rate than higher-volume Medicaid health care entities.</li><li>High Medicaid volume health care entities are taxed more heavily than non-Medicaid health care entities.</li><li>The tax establishes any target or exclusion related to a health care entity’s Medicaid participation status.</li></ol><p>The HHS secretary will determine an applicable transition period (up to three years) for taxes considered not generally redistributive. CBO estimates that this provision will result in a $34.6 billion reduction in federal spending over 10 years.</p><h3><em>Subchapter D — Increasing Personal Accountability</em></h3><h4>Section 71119: Requirement for States to Establish Medicaid Community Engagement Requirements for Certain Individuals (Effective Dec. 31, 2026)</h4><p>Requires certain nonpregnant, nondisabled adult Medicaid beneficiaries to meet certain community engagement requirements (work requirements) beginning Dec. 31, 2026. Individuals must work or engage in qualifying activities (e.g., community service, educational programs, job training) for no less than 80 hours per month. The legislation exempts, among other groups, parents, guardians and caretaker relatives of children aged 14 or under, or disabled individuals. States are permitted to receive temporary exemptions with HHS approval. The legislation limits the types of entities that can contract with states to help implement this provision, effectively barring Medicaid managed care plans from assisting. The bill provides $200 million in FY 2026 for state implementation and $50 million for federal administration. CBO estimates that this provision will result in a $325.8 billion reduction in federal spending over 10 years.</p><h4>Section 71120: Modifying Cost-sharing Requirements for Certain Expansion Individuals Under the Medicaid Program (Effective Oct. 1, 2028)</h4><p>Requires Medicaid expansion enrollees with incomes above 100% of the federal poverty level to pay up to $35 in cost sharing per service. Cost sharing for non-emergency services provided in a hospital emergency department may exceed $35. The provision will exclude certain services, including primary care, pregnancy-related services, mental health or substance use disorder services. Total cost sharing may not exceed 5% of family income. CBO estimates that this provision will result in a $7.5 billion reduction in federal spending over 10 years.</p><h3><em>Subchapter E — Expanding Access to Care</em></h3><h4>Section 71121: Making Certain Adjustments to Coverage of Home or Community-based Services Under Medicaid (Effective July 1, 2028)</h4><p>Provides states with the option to pursue a standalone waiver under section 1915(c) and expand access to home and community-based services. The bill appropriates $50 million for FY 2026 to the HHS secretary for implementation of the provisions. Further, the bill appropriates $100 million for FY 2027 for making payments to states delivering home or community-based services. CBO estimates that this provision will result in a $6.6 billion increase in federal spending over 10 years.</p><h3>Chapter 2 — Medicare</h3><h3><em>Subchapter A — Strengthening Eligibility Requirements</em></h3><h4>Section 71201: Limiting Medicare Coverage of Certain Individuals (Effective 18 months from enactment)</h4><p>Restricts eligibility for Medicare for non-citizens to the following groups: legal permanent residents, certain Cuban immigrants and Compact of Free Association migrants lawfully residing in the United States. CBO estimates that this provision will result in a $5.1 billion reduction in federal spending over 10 years.</p><h3><em>Subchapter B — Improving Services for Seniors</em></h3><h4>Section 71202: Temporary Payment Increase Under the Medicare Physician Fee Schedule to Account for Exceptional Circumstances (Effective Jan. 1, 2026)</h4><p>Provides a rate update to the Physician Fee Schedule of 2.5% for calendar year (CY) 2026 only. There is no adjustment for CY 2025. CBO estimates that this provision will result in a $1.9 billion increase in federal spending over 10 years.</p><h4>Section 71203: Expanding and Clarifying the Exclusion for Orphan Drugs Under the Drug Price Negotiation Program (Effective Jan. 1, 2028)</h4><p>Modifies the Inflation Reduction Act to exclude orphan drugs under the Drug Price Negotiation Program. CBO estimates that this provision will result in a $4.9 billion increase in federal spending over 10 years.</p><h3>Chapter 3 — Health Tax</h3><h3><em>Subchapter A — Improving Eligibility Criteria</em></h3><h4>Section 71301: Permitting Premium Tax Credit Only for Certain Individuals (Effective Jan. 1, 2027)</h4><p>Restricts eligibility premium tax credits for marketplace coverage for non-citizens to the following groups: legal permanent residents, certain Cuban immigrants and Compact of Free Association migrants lawfully residing in the United States. CBO estimates that this provision will result in a $69.8 billion reduction in federal spending over 10 years.</p><h4>Section 71302: Disallowing Premium Tax Credits During Periods of Medicaid Ineligibility Due to Alien Status (Effective Jan. 1, 2026)</h4><p>Disallows undocumented immigrants who report income below 100% of the federal poverty level and are in their five-year Medicaid waiting period (due to immigration status) from receiving premium tax credits to purchase health insurance on the marketplaces. CBO estimates that this provision will result in a $49.5 billion reduction in federal spending over 10 years.</p><h3><em>Subchapter B — Preventing Waste, Fraud and Abuse</em></h3><h4>Section 71303: Requiring Verification of Eligibility for the Premium Tax Credit (Effective Jan. 1, 2028)</h4><p>Prohibits an individual from claiming the premium tax credit if the individual’s eligibility related to income, enrollment and other requirements is not actively verified annually. This will prohibit automatic reenrollment for enrollees receiving premium tax credits by requiring them to actively prove tax credit eligibility each year. CBO estimates that this provision will result in a $36.9 billion reduction in federal spending over 10 years.</p><h4>Section 71304: Disallowing Premium Tax Credit in Case of Certain Coverage Enrolled in During the Special Enrollment Period (Effective Jan. 1, 2026)</h4><p>Prohibits individuals from receiving premium tax credits if they enroll in health coverage on the marketplace through a special enrollment period associated with their income. CBO estimates that this provision will result in a $39.5 billion reduction in federal spending over 10 years.</p><h4>Section 71305: Eliminating Limitation on Recapture of Advance Payment of Premium Tax Credit (Effective Jan. 1, 2026)</h4><p>Removes the repayment limits and requires affected individuals to reimburse the Internal Revenue Service for the full amount of excess tax credit received. CBO estimates that this provision will result in a $17.3 billion reduction in federal spending over 10 years.</p><h3><em>Subchapter C — Enhancing Choice For Patients</em></h3><h4>Section 71306: Permanent Extension of Safe Harbor for Absence of Deductible for Telehealth Services (Effective Jan. 1, 2025)</h4><p>Provides a safe harbor to allow telehealth services to be provided pre-deductible for patients with high-deductible health plans. CBO estimates that this provision will result in a $4.3 billion reduction in federal revenue over 10 years.</p><h4>Section 71307: Allowance of Bronze and Catastrophic Plans in Connection with Health Savings Accounts (Effective Jan. 1, 2026)</h4><p>Allows bronze and catastrophic plans to contribute to health savings accounts. CBO estimates that this provision will result in a $3.6 billion reduction in federal revenue over 10 years.</p><h4>Section 71308: Treatment of Direct Primary Care Service Arrangements (Effective Jan. 1, 2026)</h4><p>Allows individuals in high-deductible health plans to enroll in direct primary care service arrangements and to use their health savings accounts for payment. CBO estimates that this provision will result in a $2.8 billion reduction in federal revenue over 10 years.</p><h3>Chapter 4 — Protecting Rural Hospitals and Providers</h3><h4>Section 71401: Rural Health Transformation Program (Effective upon enactment)</h4><p>Creates a rural stabilization fund with $50 billion, to be paid out as $10 billion annually across FYs 2026 through 2030. States will need to submit a one-time application to CMS to be eligible for an allotment of these funds during a submission period specified by CMS (with an application and decision date no later than Dec. 31, 2025). Of the $50 billion in funding, 50% of the funds for each fiscal year will be equally distributed among all the states with an approved application. Forty percent of the funds for each fiscal year will be distributed in a method determined by CMS. CMS will consider the following as its distribution method: the percentage of the state population located in rural geographies, the proportion of rural health facilities in the state relative to the nation, and any other factors deemed appropriate by CMS. Not more than 10% of the amount allocated to the states can be used for administrative expenses. Separately, the legislation appropriates $200 million to the CMS administrator for FY 2025 to implement the provision.</p><h3>SUBTITLE A — TAX</h3><h3>Chapter 4 — Investing In American Families, Communities and Small Businesses</h3><h3><em>Subchapter B — Permanent Investments in Students and Reforms to Tax-Exempt Institutions</em></h3><h4>Section 70415: Endowment Tax for Universities (Effective Jan. 1, 2026)</h4><p>Amends the excise tax rate for universities based on student endowments. The rates are as follows: 1.4% for student endowments ranging from $500,000-$750,000 , 4% for student endowments ranging from $750,000-$2 million, and 8% for all student endowments above $2 million. CBO estimates that this provision will result in a $761 million increase in federal revenue over 10 years.</p><h4>Section 70416: Executive Compensation (Effective Jan. 1, 2026)</h4><p>Limits tax-exempt organizations’ ability to deduct compensation over $1 million, including for former employees, dating back to tax year 2017. CBO estimates that this provision will result in a $3.8 billion increase in federal revenue over 10 years.</p><h3><em>Subchapter C — Permanent Investments in Community Development</em></h3><h4>Section 70426: One Percent Floor on Deduction of Charitable Contributions Made by Corporations (Effective Jan. 1, 2026)</h4><p>Allows a deduction for corporate charitable contributions only to the extent that the aggregate of corporate charitable contributions exceeds 1% of a taxpayer’s taxable income and does not exceed 10% of the taxpayer’s taxable income. CBO estimates that this provision will result in a $16.6 billion increase in federal revenue over 10 years.</p><h3>Chapter 5 — Ending Green New Deal Spending, Promoting America-First Energy and Other Reforms</h3><h3><em>Subchapter A — Termination of Green New Deal Subsidies</em></h3><h4>Section 70503: Termination of Qualified Commercial Clean Vehicles Credit (Credit terminates Sept. 30, 2025)</h4><p>Eliminates the tax credit that allowed for tax-exempt entities to receive a direct payment for the lesser of 1) 15% of the vehicle’s cost (30% for vehicles not powered by gas or diesel) or 2) the incremental cost of the vehicle relative to a comparable vehicle. CBO estimates that this provision will result in a $104.5 billion increase in federal revenue over 10 years.</p><h4>Section 70504: Termination of Alternative Fuel Vehicle Refueling Property Credit (Credit terminates June 30, 2026)</h4><p>Eliminates the tax credit that allowed for a tax-exempt owner of property to receive direct payment for the cost of installing a qualified alternative fuel vehicle refueling station on property, such as electric charging stations CBO estimates that this provision will result in a $1.96 billion increase in federal revenue over 10 years.</p><h4>Section 70507: Termination of Energy Efficient Commercial Buildings Deduction (Deduction terminates June 30, 2026)</h4><p>Eliminates a tax deduction for tax-exempt organizations for energy-saving commercial building property. The deduction will terminate for any property with construction beginning after June 30, 2026. CBO estimates that this provision will result in a $134 million increase in federal revenue over 10 years.</p><h4>Section 70513: Termination and Restrictions on Clean Electricity Investment Credit (Credit terminates Dec. 31, 2027)</h4><p>Eliminates a tax credit for investing in qualifying zero-emission electricity generation facilities or energy storage technology. Under the previous law, the credit was phased out in 2032. Specifically, this provision:</p><ul><li>Terminates eligibility for covered wind and solar facilities placed into service after Dec. 31, 2027.</li><li>Increases the domestic content requirement for projects to be eligible for the domestic content bonus. The current law requires that 40% of the manufactured products in a facility be from a domestic source. The act will increase the required threshold to 45% (or 27.5% for offshore wind) from June 16, 2025, until Dec. 31, 2025; 50% (or 35% for offshore wind) for CY 2026; and 55% after Dec. 31, 2026.</li><li>Prevents access to credits for wind and solar if the taxpayer rents or leases the property to a third party.</li><li>Prohibits credits that include any material assistance from a prohibited foreign entity.</li></ul><p>Additionally, the bill eliminates the investment tax credit for certain energy properties for qualified projects. Specifically, the provision eliminates the 2% base credit for projects not meeting prevailing wage and apprenticeship requirements, applies to construction beginning on or after June 16, 2025.CBO estimates that this provision will result in a $177.9 billion increase in federal revenue over 10 years.</p><h2>Further Questions</h2><p>If you have further questions, please contact AHA at <a href="tel:1-800-424-4301">800-424-4301</a>.</p></div><div class="col-md-4"><div class="sticky"><a href="/system/files/media/file/2025/07/Legislative-Advisory-Key-Highlights-of-the-Final-One-Big-Beautiful-Bill-Act.pdf" target="_blank" title="Click here to download the Legislative Advisory: Key Highlights of the Final One Big Beautiful Bill Act PDF."><img src="/sites/default/files/inline-images/Page-1-Legislative-Advisory-Key-Highlights-of-the-Final-One-Big-Beautiful-Bill-Act.png" data-entity-uuid="6a061d3b-a8fa-410e-baa3-17eaad87d657" data-entity-type="file" alt="Legislative Advisory: Key Highlights of the Final One Big Beautiful Bill Act page 1." width="696" height="900"></a></div></div></div></div> div.sticky { position: sticky; top: 0; } Thu, 03 Jul 2025 00:00:01 -0500 Reimbursement /advancing-health-podcast/2025-07-02-when-medicaid-disappears-how-cuts-could-devastate-behavioral-health-care-rural-america <p>Potential Medicaid cuts could have devastating impacts on rural communities, particularly for behavioral health care access. In this conversation, Jon Ulven, Ph.D., behavioral health psychologist and chair of adult psychology at Sanford Health, details the fragile behavioral health landscape in rural America and how Medicaid cuts could deepen gaps in health care access and resources. Dr. Ulven also shares powerful patient stories and a compelling call to action — reminding us what’s truly at stake when access to care disappears.</p><hr><div></div><div class="raw-html-embed"><details class="transcript"> <summary> <h2 title="Click here to open/close the transcript."> <span>View Transcript</span><br>   </h2> </summary> <p> 00:00:01:04 - 00:00:25:09<br> Tom Haederle<br> Welcome to Advancing Health. South Dakota-based Sanford Health is the largest rural health system in the United States. Yet even with its size and resources, there are many challenges to delivering the care that patients need, especially regarding behavioral health services and the threats to care posed by cutbacks to Medicaid. </p> <p> 00:00:25:12 - 00:00:51:27<br> Rebecca Chickey<br> Hello, I'm Rebecca Chickey. I'm the senior director of behavioral health at the ���������� Association. And is my great honor to be here today with Dr. Jon Ulven, who is chair of psychology of Sanford Health, which is the largest rural health system in the country and covers North Dakota, South Dakota, Minnesota, and probably parts of the country that are very small and rural surrounding those states. </p> <p> 00:00:51:29 - 00:01:20:25<br> Rebecca Chickey<br> So, Dr. Ulven, thank you so much for joining us today for this very important topic: serving and meeting the mental health needs of rural Americans. And particularly the intersection of that with patients who are covered by Medicaid. So to set the stage, I'd love to have you share a little bit about Sanford Health, what it's like to really - I say rural - but you're in frontier states for the most part. </p> <p> 00:01:20:28 - 00:01:35:05<br> Rebecca Chickey<br> So the vastness of North and South Dakota and what that does to create challenges in terms of access and, the solutions that you've had to come up with but help the listeners understand the barriers. </p> <p> 00:01:35:07 - 00:02:01:07<br> Jon Ulven, Ph.D.<br> Yeah. So first of all, just thanks for having me. And I really appreciate the attention to this really important topic. You mentioned a few states, but  I'm just going to mention a few more states that we cover, Rebecca, because we're also in Wyoming, Iowa, Wisconsin and then the Upper Peninsula of Michigan. We have a very, very large footprint for our organization, and we serve about 2 million patients in that area. </p> <p> 00:02:01:09 - 00:02:26:05<br> Jon Ulven, Ph.D.<br> We do a lot of work with very rural areas, as you were mentioning, frontier type states. And North Dakota and South Dakota, most of those counties are known as behavioral health shortage areas. I practice primarily in Moorhead, Minnesota. And in the state of Minnesota about 80% - 80 to 85% - of our counties are known as a behavioral health shortage areas. </p> <p> 00:02:26:07 - 00:02:49:24<br> Jon Ulven, Ph.D.<br> So we have, just a very unique set of challenges when it comes to the trying to provide world class health care and behavioral health care to a footprint that size. And when we look at the rurality of the folks we serve. And so things that we often encounter, we counter pretty much persistent challenges with provider shortages. </p> <p> 00:02:50:01 - 00:03:14:10<br> Jon Ulven, Ph.D.<br> It's hard to recruit to this part of the country. We're in a perpetual state of recruitment. And we also know that a couple of unique things that happen with rural areas. We have people who can travel for literally some of...I've seen patients who travel across the state of North Dakota to come to an appointment on the eastern side of the state. </p> <p> 00:03:14:15 - 00:03:31:21<br> Jon Ulven, Ph.D.<br> So there are sometimes some very legitimate transportation challenges. And then, and then also, I think one of the things that is - when you are in a small rural community, and I know because I grew up in one, I actually grew up about 25 miles from where I am right here in Moorhead. I grew up on a farm. </p> <p> 00:03:31:24 - 00:03:50:22<br> Jon Ulven, Ph.D.<br> There's some nice opportunities for connectivity in a rural setting, but there's also you lose anonymity. So you have you have challenges with people who, might need behavioral health services. But, everybody knows everybody's business. So it makes it really hard to reach out and seek care. </p> <p> 00:03:50:24 - 00:04:10:09<br> Rebecca Chickey<br> I hear you, I grew up in rural Alabama. And it took 20 minutes to get to the closest gas station, and 20 more minutes from that to get to the closest hospital. So, perhaps not quite as rural as yours, but you got the fact and everyone in the little community I grew up in knew everyone else's business. </p> <p> 00:04:10:09 - 00:04:21:00<br> Rebecca Chickey<br> And with that comes the stigma of seeking care. It's incredible. That's one of the things we've been working on. So glad you're working on it, too. What about broadband? Can you speak to that for just a minute? </p> <p> 00:04:21:02 - 00:04:45:23<br> Jon Ulven, Ph.D.<br> Yeah. So to try to meet this behavioral health need, Sanford has invested a tremendous amount of infrastructure and time into a virtual care platform that we offer for this footprint, an area that I described a little bit earlier, where currently we have about 1 in 5 of our behavioral health visits are virtual at this time. </p> <p> 00:04:45:26 - 00:05:08:16<br> Jon Ulven, Ph.D.<br> So people can access this through their phones, through their computers at home. And we offer a confidential service where we are able to with the technology throughout that footprint, be able to deliver that type of care. And it's something that we are training our clinicians on a regular basis about, the effective ways to provide this modality of care. </p> <p> 00:05:08:21 - 00:05:17:06<br> Jon Ulven, Ph.D.<br> I think in all of our areas, this has just become a pretty common way of life for us to do care that we have a certain portion of it that's virtual. </p> <p> 00:05:17:08 - 00:05:20:23<br> Rebecca Chickey<br> And so you complement that with in-person visits, I assume. </p> <p> 00:05:21:00 - 00:05:46:17<br> Jon Ulven, Ph.D.<br> We do. Like I said, about 1 in 5 of our visits are virtual. I really have appreciated, some of the innovative minds that we've had here at Sanford to do some unique things. Like, for example, we have a very small community. The name of the town is Lidgerwood , North Dakota. And in Lidgerwood, North Dakota, which is like I said, I grew up around here, so I remember playing basketball in Lidgerwood, just a very, very small community. </p> <p> 00:05:46:19 - 00:06:08:06<br> Jon Ulven, Ph.D.<br> And if you head to that town, what they have is they had a clinic setting there, but it was nearly impossible to keep that staffed. So now what we've done is we have some bare bones medical staff in that area. We have some imaging capabilities and we have people to check patients in as they come in, and then they can do virtual care from there. </p> <p> 00:06:08:08 - 00:06:31:16<br> Jon Ulven, Ph.D.<br> And so they can do all different types of virtual care. They could be there for a checkup with their primary care physician. They can be there for a specialty visit for one of our other departments, and they can do behavioral health care from there as well. So we're trying to have both kind of this, this nice opportunity for people to have where they can go to a location if they need, if they have some difficulties with their technology </p> <p> 00:06:31:16 - 00:06:56:19<br> Jon Ulven, Ph.D.<br> and so they can't do the virtual care themselves, that we offer that up to people. And in this building that I'm in right here in Moorhead, we have 17 psychologists and master's level therapists. We have psychiatry here, social workers, nursing staff. And then within our building we have family medicine, internal medicine, women's health, pediatrics. We have a lab here. </p> <p> 00:06:56:19 - 00:07:20:28<br> Jon Ulven, Ph.D.<br> We have a pharmacy here. So we have this nice opportunity to provide just a really well-rounded, amount of health care. To tie back into the, connecting with what we're all here for, it's talking about the, you know, our ability to do that type of care, to think that way and to provide this platform of care. </p> <p> 00:07:21:00 - 00:07:37:26<br> Jon Ulven, Ph.D.<br> A lot of it has to do with in our country the ways that we pay for health care. And that's where we get into what has been a mainstay for health systems, and especially when we think about rural health systems is the services that are allowable by Medicaid. </p> <p> 00:07:37:28 - 00:08:04:18<br> Rebecca Chickey<br> I want to get back to that point. But before we go further about the devastating cuts that are being discussed right now, help the listeners with a couple of stories, if you can. What has been - so your ability to provide these services, your ability to provide access to care virtually or in person by being creative around that clinic that was probably on the verge of maybe closing and not being there in that community. </p> <p> 00:08:04:20 - 00:08:09:18<br> Rebecca Chickey<br> What are some of the personal stories you've seen that have impacted the lives and how? </p> <p> 00:08:09:20 - 00:08:30:08<br> Jon Ulven, Ph.D.<br> Many stories that that I could share around this. I've been here with, Sanford for 21 years. I'm a licensed psychologist, and as you were saying, I'm the department chair of our adult psychology group. So I often feel like, jack of all trades and a master of none. But what I do is I do some hospital based coverage from time to time. </p> <p> 00:08:30:08 - 00:08:56:24<br> Jon Ulven, Ph.D.<br> And so we have an inpatient psychiatric unit that I will occasionally provide care for. So a very common course that we would see would be somebody who is uninsured or underinsured. And they end up coming through our emergency department for a mental health crisis. And while they're there, the team, with our emergency department determines that the patient needs hospitalization in our inpatient psychiatric unit. </p> <p> 00:08:56:26 - 00:09:23:18<br> Jon Ulven, Ph.D.<br> Patient is admitted there. While they're there, we might uncover, for example, a first episode psychosis. So if you take someone who is a young individual in one of our communities who is having an onset that might lead to schizophrenia diagnosis, they're having a first episode of psychosis. And so we have the opportunity to assess the person there, start the person on anti-psychotic medications. </p> <p> 00:09:23:18 - 00:09:42:21<br> Jon Ulven, Ph.D.<br> And then let's say that we also uncover that this person has a substance use disorder. Well, we have had the opportunity to enroll this person in Medicaid. Perhaps this person is unemployed, underemployed, has a position where they just don't have the benefits to have, that standard type of health care that a lot of us are able to have. </p> <p> 00:09:42:23 - 00:10:07:29<br> Jon Ulven, Ph.D.<br> And so we get this person on Medicaid, and what we're able to do from our inpatient unit is set this person up with a primary care provider, a psychiatrist, a therapist, and we're able to do things like get this person started on some medication that might help with cravings for substance use. And we can we can also work with some of our community partners to try to get this person engaged in that care. </p> <p> 00:10:08:02 - 00:10:27:16<br> Jon Ulven, Ph.D.<br> What I often think about is just that if that early intervention that we know that if we can help this person out at that point on an early basis, we are really and in some ways, we're bending the trajectory for their health throughout the course of that person's life. And it is such an important time. </p> <p> 00:10:27:18 - 00:10:50:10<br> Rebecca Chickey<br> That's phenomenal. For the listeners: Statistically, by the age of 14, probably about 50% of the population if you're going to show or have a psychiatric or substance use disorder, those symptoms are showing by the age of 14. And correct me if I'm wrong here, keep me honest. But then by the time you're 21 to 24, we're up to 75%. </p> <p> 00:10:50:12 - 00:11:13:05<br> Rebecca Chickey<br> So that early identification and intervention and treatment, there's so many opportunities to improve the long term health of the individual, the ability to have a joyful life, to engage and be productive and make the most of the resources around them. It's just critically important. And you're being there, is equally so. </p> <p> 00:11:13:07 - 00:11:33:12<br> Jon Ulven, Ph.D.<br> Thank you for that. You know, as we're having this conversation that when we hear stories like this, sometimes the tendency as humans to just say, oh, that's nice. And it's important to hear about that. But we, it's a bit abstracted from us. If we don't have the ability to treat that type of individual, we see, as we see, diminishing services across the board. </p> <p> 00:11:33:14 - 00:12:02:13<br> Rebecca Chickey<br> Research shows that 50% of children and 18% of adults in rural communities are covered by Medicaid. Let that sink in, listeners. 50% of the kids in rural communities are covered by Medicaid and 18% of adults. Medicaid is also the largest payer for behavioral health. So speak a little bit more about the impact of these Medicaid cuts that are, currently being discussed in Congress and what that would mean for your community. </p> <p> 00:12:02:15 - 00:12:22:02<br> Jon Ulven, Ph.D.<br> Yeah, thank you for that. And just as you were saying that, just another I think another example just comes to mind for me, and that's the that's the example of that, something that I think a lot of people don't think about. And that's health care coverage for foster kids, for foster children. So, if you think about that for a moment, you're a family who's taking on a foster child. </p> <p> 00:12:22:05 - 00:12:46:25<br> Jon Ulven, Ph.D.<br> We  don't allow that those folks to go under the foster parents' insurance. There's a gap. There's a gap in care that is consistently filled by Medicaid. And if we think about some of the folks and even if our, you know, listeners can think about some situations where they think a foster child would come from a situation if they're obviously coming from a situation that is a distressing and challenging situation. </p> <p> 00:12:46:27 - 00:13:13:13<br> Jon Ulven, Ph.D.<br> Often there are there are lots of different health related issues, including mental health issues. Essentially, these folks would possibly be in a situation where they would have no care, no, no access to care. And we know some things about, looking at places, for example, where, Medicaid expansion has hit a certain area and we can we can take a look at some big numbers about like what's the impact of that? </p> <p> 00:13:13:13 - 00:13:39:27<br> Jon Ulven, Ph.D.<br> And we know, for example, that in one study they, looked at suicide rates, of the rate of suicide. And it was over the course of many years and found that folks who had access to Medicaid expansion that suicide rates go down. In the study that they looked at over a series of years, literally thousands of lives, they can see a reduction in completed suicides, which would suggest that there were thousands of lives saved. </p> <p> 00:13:40:04 - 00:14:08:14<br> Jon Ulven, Ph.D.<br> I'll also offer just a more pragmatic one. There was a study that was out of Montana that looked at a group of people who were participating in a tele-psychiatry practice. A large number of these folks were Medicaid recipients. And what they found was that, participating in this psychiatry practice, they had a 38% reduction in inpatient hospitalizations, 18% reduction in emergency department visits. </p> <p> 00:14:08:16 - 00:14:45:00<br> Jon Ulven, Ph.D.<br> So if you think about the higher cost elements of health care, when we can invest in ways that we know have evidence support, are effective, get the job done, we're actually preventing some of that higher cost care that that truly is. But I would much rather work on preventing something from getting worse than what ends up happening when people are at that level of distress, when they make it to our emergency department, or when I'm covering on our inpatient unit and I can see that I'm working with someone who has gone without care for a significant amount of time. </p> <p> 00:14:45:02 - 00:15:09:13<br> Rebecca Chickey<br> Again, going upstream, early intervention prevention, treatment, rather than waiting for the crisis, which might not only just impact the individual, but others as well, depending upon what the crisis is and how many people show up to the emergency room. So, as we draw this podcast to a close, is there a call to action that you would share with the listeners? </p> <p> 00:15:09:13 - 00:15:19:23<br> Rebecca Chickey<br> If there's something you would like to encourage them to do? Or, the last thing that you want to make sure that they that resonates as they click off to this podcast. </p> <p> 00:15:19:25 - 00:15:48:29<br> Jon Ulven, Ph.D.<br> My heart often goes to children. I only work with adults in my practice, but I but I mean, I'm a father myself. I think about that. Just that point you just made that earlier, we can intervene the better. And I think it's important that one study found that there children who have Medicaid coverage, they're four times more likely to have a regular visits with like, a pediatrician or get some of their health care needs met. </p> <p> 00:15:49:01 - 00:16:08:28<br> Jon Ulven, Ph.D.<br> And that that includes behavioral health and that they're 2 to 3 times more likely to receive preventative care. And then we think about when it comes to, adults who are enrolled in Medicaid, that they're five times more likely to have a regular source of health care and also receive preventative care. From the listening perspective </p> <p> 00:16:08:28 - 00:16:34:28<br> Jon Ulven, Ph.D.<br> I hope that what this has done is just increased an awareness to truly wide reaching effects that a change in Medicaid is going to it's going to have for the way that we deliver health. And I would say especially in rural health care. Rural health care systems are routinely much more impacted by non reimbursable care. And so you add to that, we're going to see some pretty significant reduction in services </p> <p> 00:16:34:28 - 00:16:51:12<br> Jon Ulven, Ph.D.<br> would be I think a reasonable guess. The thing that like call to action? I think one of the things I'm so I feel so privileged about in, in that, in North Dakota. I'm a citizen of North Dakota, I practice in Minnesota, I'm right on the border. Because we're in a small state of North Dakota, </p> <p> 00:16:51:15 - 00:17:30:05<br> Jon Ulven, Ph.D.<br> I have been able to work with our government support people and been able to testify. The last two legislative sessions, we have had laws changed in the state of North Dakota. That's been a great opportunity through connections of - here's me as a psychologist, working with our legislators. We all are responsible in a health care setting or our elected officials to improve the lives of the patients and the citizens of our states. And in a bipartisan way, when we can find some nice opportunities to get some things done that are truly meaningful for people in the states we serve, it's a win for everybody. </p> <p> 00:17:30:08 - 00:17:49:16<br> Rebecca Chickey<br> That's phenomenal. Thank you. Your passion for this work, both for the patients that you serve, for the organization that you work for and with, and for having an impact work globally. It resonates throughout this entire podcast. So thank you for that passion, for bringing it to the work that you do. And thank you for sharing it with the rest of the field. </p> <p> 00:17:49:18 - 00:17:51:13<br> Jon Ulven, Ph.D.<br> Well, thank you very much. </p> <p> 00:17:51:16 - 00:17:59:27<br> Tom Haederle<br> Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts. </p> </details></div> Tue, 01 Jul 2025 23:54:19 -0500 Reimbursement /advisory/2025-06-23-cms-finalizes-2025-marketplace-integrity-and-affordability-rule <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) June 20 finalized its <a href="https://www.cms.gov/files/document/cms-9884-f-2025-pi-rule-master-5cr-062025.pdf">2025 Marketplace Integrity and Affordability rule</a>, intended to establish new standards for the health insurance marketplaces and address improper and fraudulent enrollments. Among other changes, the rule shortens the open enrollment period for the federal marketplace, limits open enrollment periods for state-based marketplaces to a nine-week period and makes changes that will increase the maximum annual cost-sharing limitation. While most of these provisions go into effect 60 days after publication in the Federal Register, CMS sunsets many of these changes after plan year 2026, noting that the marketplaces will face less risk of improper enrollments after the enhanced premium tax credits expire.</p><h2>MAJOR PROVISIONS</h2><p><strong>Open Enrollment.</strong> CMS changes the open enrollment parameters for individual market coverage both on and off the marketplaces, including those for marketplaces operated by individual states. Beginning in 2026 for the 2027 plan year, all open enrollment periods must begin by Nov. 1, end by Dec. 31 and not exceed nine calendar weeks. In addition, all plans purchased during open enrollment must begin on Jan. 1. For on- and off-marketplace plans sold in states operating on the federal platform, the 2027 plan year open enrollment will be Nov. 1-Dec. 15. </p><p>Previously, open enrollment periods for marketplaces on the federal platform ran from Nov. 1-Jan. 15; state-based marketplaces had flexibility to extend open enrollment beyond that window. </p><p><strong>Low-income Monthly Special Enrollment Period (SEP). </strong>CMS temporarily ends the monthly SEP for those with projected household incomes at or below 150% of the federal poverty level (FPL), effective 60 days after enactment of the final rule through the 2026 plan year. </p><p><strong>Agent, Broker and Web-broker Termination.</strong> CMS finalized its proposal to improve transparency of agent, broker and web-broker compliance reviews by adopting a “preponderance of the evidence” standard. CMS expects this will reduce noncompliant behavior, including improper and unauthorized enrollment.</p><p><strong>Premium Adjustment Percentage Methodology.</strong> CMS re-adopts the premium adjustment percentage methodology finalized in the 2020 Notice of Benefit and Payment Parameters, which uses private health insurance premiums to estimate future premium growth. This calculation is used to determine cost-sharing parameters, such as the maximum annual limitation on cost sharing.</p><p>Based on the finalized methodology, CMS sets a maximum annual limitation on cost sharing for the 2026 plan year of $10,600 for self-only coverage and $21,200 for family coverage. These amounts are roughly 15 percent higher than the 2025 plan year cost-sharing limits.</p><p><strong>Eligibility Verification for SEP. </strong>CMS reestablishes pre-enrollment eligibility verification for all types of SEPs on the federal marketplace. Since the 2023 Notice of Benefit and Payment Parameters, pre-enrollment verification was limited to the loss of minimum essential coverage SEP. In addition, all federally facilitated marketplaces must conduct pre-enrollment eligibility verification for at least 75% of all new enrollees. CMS did not finalize these changes for state-based marketplaces. These changes sunset at the end of the 2026 plan year.    </p><p><strong>De Minimis Thresholds.</strong> CMS finalizes its proposal to widen the “de minimis range” for most individual and small group market plans subject to the actuarial value requirements to +2/-4 percentage points. For expanded bronze plans, the new de minimis range will be +5/-4 percentage points. CMS also removed the de minimis range requirements of +2/0 percentage points for individual market silver plans and changed the de minimis range for silver cost-sharing reduction plans to +1/-1 percentage point. </p><p><strong>Deferred Action for Childhood Arrivals (DACA) Recipients.</strong> CMS changes the definition of “lawfully present” such that DACA recipients are no longer eligible to enroll in marketplace or basic health plans or receive premium tax credits or cost-sharing reductions. DACA recipients gained eligibility through the 2024 DACA Rule.</p><p><strong>Essential Health Benefits.</strong> CMS prohibits classifying gender-affirming care as an essential health benefit beginning in plan year 2026. Plans can still cover gender-affirming care if they choose to.</p><p><strong>Program Integrity. </strong>CMS finalizes several policies intended to ensure that individuals are only enrolling in plans and receiving premium tax credits that they are eligible for, including:</p><ul><li>Temporarily requiring all enrollees who attest to projected household income between 100-400% FPL but whose income verification results in a household income below 100% FPL to answer additional verification questions and provide supporting documentation. This policy is intended to ensure only eligible individuals above 100% FPL receive premium tax credits. This policy was finalized in the 2019 Notice of Benefit and Payment Parameters but was vacated by the courts. This policy sunsets after the 2026 plan year.</li><li>Temporarily reinstating a policy deeming an individual ineligible for future premium tax credits if they fail to file their federal income tax return and reconcile premium tax credits for one year. This policy was changed to two consecutive tax years in the 2024 Notice of Benefit and Payment Parameters. This policy sunsets after the 2026 plan year.</li><li>Temporarily requiring marketplaces to verify income with other trusted data sources if IRS data is not available, including requiring additional supporting documentation or other actions by enrollees. Previously, marketplaces accepted enrollees’ self-attestation of projected household income if IRS income verification was not possible. This policy sunsets after the 2026 plan year.</li><li>Removing the 60-day extension of the statutorily required 90-day window during which enrollees must resolve income inconsistencies.</li></ul><p><strong>Additional Policies</strong>. CMS finalizes several additional policies, including:</p><ul><li>Allowing issuers to require enrollees to pay past-due premiums before enrolling in new coverage.</li><li>Temporarily eliminating the fixed-dollar and gross percentage-based premium thresholds finalized in the 2026 Notice of Benefit and Payment Parameters and requiring issuers to adopt a net percentage-based threshold, which will require enrollees to pay more of their premium to maintain coverage. This policy sunsets after the 2026 plan year.</li><li>Temporarily changing the eligibility redetermination process for the 2026 plan year for enrollees in zero-dollar premium plans. These enrollees are required to affirm or update their eligibility information or face $5 premiums upon re-enrollment. The premiums will be eliminated once the enrollee confirms eligibility.</li><li>Removing the re-enrollment hierarchy that allows marketplaces to re-enroll low-income bronze plan enrollees into a silver plan if the silver plan is the same product, has the same provider network and has an equal or lower premium.</li></ul><p><strong>Coverage Impacts.</strong> CMS estimates that between 725,000 and 1.8 million individuals will lose marketplace coverage in 2026 as a result of the policies finalized in this rule.</p><h2>FURTHER QUESTIONS</h2><p>For more information, contact Ariel Levin, AHA’s director of coverage policy, at <a href="mailto:alevin@aha.org">alevin@aha.org</a>.</p><p> </p></div><div class="col-md-4> <a href=" org system files media file target="_blank" title="Click here to download the Regulatory Advisory: CMS Finalizes 2025 Marketplace Integrity and Affordability Rule PDF."><img src="/sites/default/files/2025-06/cover-from%20cms-finalizes-2025-marketplace-integrity-and-affordability-rule-advisory-6-23-2025.png" data-entity-uuid data-entity-type="file" alt="Regulatory Advisory: CMS Finalizes 2025 Marketplace Integrity and Affordability Rule" width="NaN" height="NaN"></div></div></div> Mon, 23 Jun 2025 15:45:13 -0500 Reimbursement /news/headline/2025-04-29-supreme-court-sides-hhs-case-undercounting-ssi-eligible-recipients-dsh-formula <p>The Supreme Court April 29 <a href="https://www.supremecourt.gov/opinions/24pdf/23-715_5426.pdf" title="Supco ruling">ruled</a> 7-2 in favor of the Department of Health and Human Services in a case that challenged how HHS applied Congress’ formula for calculating Medicare Disproportionate Share Hospital payments. The formula includes a fraction that counts supplemental security income-eligible Medicare beneficiaries in the numerator and the total Medicare-eligible population in the denominator. The court upheld HHS’s longstanding position that if a patient is ineligible for a monthly cash benefit under SSI, a hospital cannot count that person towards the SSI portion of its DSH fraction.  <br> <br>The AHA last year filed an <a href="/amicus-brief/2024-08-14-aha-amicus-brief-supreme-court-urging-correction-hhs-undercounting-ssi-eligible-recipients-dsh-formula" title="amicus">amicus brief</a> in the case, arguing that HHS was undercounting the number of SSI-eligible Medicare beneficiaries by claiming patients are “entitled to” SSI benefits only if they actually receive SSI benefits, which lowers the numerator in the formula and results in smaller payments.  </p> Tue, 29 Apr 2025 14:48:12 -0500 Reimbursement /member-knowledge-exchange/2024-12-06/optimize-your-hospitals-revenue-cycle-efficient-patient-centered-operations <div> </div>header.jumbotron {display:none} <div> /* center_body */ .center_body { /*margin-top:50px;*/ /* margin-bottom: 50px;*/ } .center_body h3 {} .center_body p { font-size: 16px } p.center_Intro { color: #002855; line-height: 1.2em; font-size: 30px; margin: 10px 0 25px 0; font-weight: 700; font-size: 2em; } @media (max-width:768px) { p.center_Intro { line-height: 1.2em; font-size: 23px; font-size: 1.45em; } } .center_body .center_Lead { color: #63666A; font-weight: 300; line-height: 1.4; font-size: 21px; } /* center_body // */ /* Banner_Title_Overlay_Bar */ .Banner_Title_Overlay_Bar { position: relative; display: block; overflow: hidden; max-width: 1170px; margin: 0px auto 25px auto; } .Banner_Title_Overlay_Bar h1 { position: absolute; bottom: 40px; color: #003087; background-color: rgba(255, 255, 255, .8); width: 100%; padding: 20px 40px; font-size: 3em; box-shadow: 0 3px 8px -5px rgba(0, 0, 0, .6); } @media (max-width:991px) { .Banner_Title_Overlay_Bar h1 { bottom: 0px; margin: 0px; font-size: 2.5em; } } @media (max-width:767px) { .Banner_Title_Overlay_Bar h1 { font-size: 2em; text-align: center; text-indent: 0px; padding: 10px 20px; } } @media (max-width:530px) { .Banner_Title_Overlay_Bar h1 { position: relative; background-color: #63666A22; } } /* Banner_Title_Overlay_Bar // */ <header class="Banner_Title_Overlay_Bar"><img src="/sites/default/files/2024-12/VED_RI_RevenueCycle_banner_1170x250.png" alt="Banner Image" width="1170" height="250"><div><h1>Optimize Your Hospital’s Revenue Cycle for Efficient, Patient-Centered Operations</h1></div></header>/* CntMenuSub */ .CntMenuSub{ margin:20px 0px; padding-bottom: 5px; color: #afb1b1; letter-spacing: 1.5px; font-weight: 400; font-size: .7em; } .CntMenuSub .CntMenuBar{ border-bottom: 1px solid lightblue; } .CntMenuSub .CntMenuBar a:after{ content: "|"; padding: 0 3px 0 6px; color: #555; } .CntMenuSub .CntMenuBar a:last-child:after{ content: ""; } .CntMenuSub .CntMenuSubHome, .CntMenuSub .CntMenuSubParent{ text-transform: uppercase; color: #555; opacity: .9; } .CntMenuSub .CntMenuSubParent{ } .CntMenuSub .CntMenuSubChild{ } .CntMenuSub .CntMenuSubCurrent{ opacity: .7; } .CntMenuSub .CntMenuSubHome:hover, .CntMenuSub .CntMenuSubParent:hover{ text-transform: uppercase; color: #d50032; } /* CntMenuSub // */ <div class="container CntMenuSub"><div class="col-md-1"> </div><div class="col-md-10 row CntMenuBar"><a class="CntMenuSubHome" href="/education-events/aha-virtual-executive-dialogues">AHA Knowledge Exchange</a> <span class="CntMenuSubChild" id="CntMenuSubChild">Optimize Your Hospital’s Revenue Cycle for Efficient, Patient-Centered Operations</span></div><div class="col-md-1"> </div></div><div class="row spacer"><div class="col-sm-3"><div><a href="#DownloadFile" target="_blank"><img src="/sites/default/files/2024-12/KnowEx_RI_RevenueCycle_cover_910x1220_rev1.jpg" alt="AHA Knowledge Exchange | Optimize Your Hospital’s Revenue Cycle for Efficient, Patient-Centered Operations" width="100%" height="100%"></a></div></div><div class="col-sm-9 center_body">.sponsortype { color: #9d2235; font-size: 1.5em; margin: 0px; font-weight: 700; } <p class="sponsortype">AHA Knowledge Exchange</p> xxxxxx </p> --> Intro.............. </p> --><h2>Enhance critical KPIs via intelligent innovations using AI and automation</h2><p>As hospitals and health systems prepare for 2025, reinforcing financial stability and cash flow in the face of rising costs, declining reimbursements and workforce challenges is top of mind. Health care leaders need full visibility into key performance indicators (KPIs) and the drivers of performance in revenue cycle management (RCM) outcomes to make informed decisions.</p><p>By reducing redundant tasks, artificial intelligence (AI) streamlines documentation and processes, which in turn can help lower denial rates and boost patient satisfaction. This Knowledge Exchange e-book examines KPIs vital for revenue-cycle outcomes and focuses on how AI and other advanced technologies may drive RCM improvements and the delivery of high-quality patient care.</p><div class="row">@media (min-width:768px){ .EDsponsorFloat{ float:right; } } @media (max-width:767px){ .EDLinkFloat{ position:relative; left:27%; } .EDsponsorFloat { text-align:center } } <div class="col-sm-6"><a class="btn btn-wide btn-primary EDLinkFloat" href="#DownloadFile" title="AHA Knowledge Exchange | Optimize Your Hospital’s Revenue Cycle for Efficient, Patient-Centered Operations" data-view-context="top-level-view">Download the Report</a></div><div class="col-sm-6"><div class="EDsponsorFloat">Sponsored by: <a href="https://www.r1rcm.com/" target="_blank" rel="noopener nofollow"><img src="/sites/default/files/2024-03/Logo_R1_834x313.jpg" alt="R1 Logo" width="100%" height="100%"></a></div></div></div></div></div>.sp_CTA5_holder { margin-top:0px; border-bottom: solid 1px #555; padding-bottom: 50px; } .sp_CTA5_holder_last { border-bottom: solid 0px #555; } .sp_CTA5_holder >div{ overflow: auto; } .sp_CTA5_holder ul { list-style: none; /* Remove default bullets */ padding-left: 0px; /*width: calc(100% - 15%);*/ /*margin: 50px auto 0;*/ margin:auto 50px; } .sp_CTA5_holder ul li{ margin-bottom:7px; line-height: 1.5em; font-size:16px; } .sp_CTA5_holder ul li::before { content: " "; font-size: 1em; margin-right: 10px; display: inline-block; height: 12px; background-color: #9d2235; width: 12px; position: relative; top: 0px; -webkit-transform: rotate(45deg); -moz-transform: rotate(45deg); -o-transform: rotate(45deg); } .sp_CTA5_holder ul li{ padding-left:23px; text-indent:-23px; } .body ol>li, .body ul>li{ font-size:16px: } .sp_CTA5_holder h2 { color: #002855; /*! line-height: 2em; */ font-size: 2.15em; margin: 0 0 15px 0; /*! font-size: 30px; */ } .sp_CTA5_holder h3 { /*color: #002855;*/ line-height: 1em; /*font-size: 1.5em;*/ margin-bottom: 25px; margin-top:5px; font-size: 28px; } .sp_CTA5_section{ margin-top: 25px } .sp_CTA5_ImgShadow { /*background-color:green;*/ /* just a visual */ text-align: center } .sp_CTA5_ImgShadow { padding-bottom:75px; /* must match the padding on the img*/ margin: 0px; } .sp_CTA5_ImgShadow img{ width: calc(100% - 35px - 15px); -webkit-box-shadow: 50px -75px 0px 0px rgba(185, 217, 235, 1); -moz-box-shadow: 50px -75px 0px 0px rgba(185, 217, 235, 1); box-shadow: 50px -75px 0px 0px rgba(185, 217, 235, 1); position: relative; top: 75px; max-width: 490px; } @media (max-width:990px){ .sp_CTA5_ImgShadow img{ max-width: 350px;} } @media (max-width:990px){ .sp_CTA5_ImgShadow { padding-bottom:75px; /* must match the padding on the img*/ margin: 0px; margin-right: 40px } } <div class="row spacer sp_CTA5_holder sp_CTA5_holder_last"><div class="col-md-12"><h3>9 ways health leaders are leveraging automation and AI to improve financial performance and service quality</h3><div class="sp_CTA5_section"><ul><li><strong>Establish a team to analyze denial patterns</strong>. Consider utilizing robotic process automation (RPA) to keep up with changing payer and plan policies that may result in denials.</li><li><strong>Reduce days in accounts receivable by using predictive modeling</strong> based on historical data from payer denials and scoring of accounts to assign work to teams.</li><li><strong>Reduce denials by using automation in the electronic health record (EHR)</strong> to identify appropriate coding for particular services, which can be shared with specialist providers.</li><li><strong>Use RPA to automate eligibility verification and registration processes</strong> in order to optimize workflows and operations.</li><li><strong>Consider AI functionality to efficiently create clinical documentation improvement alerts</strong>, which will help staff identify accounts and claims in need of additional clinical information.</li><li><strong>Implement computer-assisted coding to drive down “Discharged Not Final Billed” accounts</strong> and consider autonomous where feasible to alleviate coding staff shortages and allow coders to focus on more complex cases.</li><li><strong>Utilize AI and RPA to assist with drafting appeal letters</strong> in order to streamline steps and reduce administrative burden on staff and clinicians.</li><li><strong>Employ a payer scorecard</strong> with denial analytics and predictive modeling to assist in Joint Operating Committee (JOC) meetings with payers.</li><li><strong>Craft a patient-centric financial experience</strong> using AI to create a transparent and flexible billing experience.</li></ul></div></div></div><h2>Participants</h2>/* people */ .people { margin-top: 50px; } .people img:nth-child(1) { border-radius: 200px; -moz-border-radius: 200px; -webkit-border-radius: 200px; margin-bottom: 10px; max-width:200px; /* for Transformation Talks */ display:block; /* for Transformation Talks */ margin:auto; /* for Transformation Talks */ } .people img:nth-child(1):hover { opacity: .7 } @media 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content:""; border-bottom: solid 1px #55555522; display: block; clear: both; width: 85%; margin: 5PX auto 10px; } <div class="people"><div class="row rowEqual_768"><div class="col-md-4 col-sm-6 ci_profile"><img src="/sites/default/files/2024-11/Ackroyd_Elizabeth_300x300.png" alt="Elizabeth Ackroyd" width="300" height="300"><p class="ci_profile_name">Elizabeth Ackroyd, MBA, CPC</p><p class="ci_profile_title">Senior Manager of Revenue Integrity</p><p class="ci_profile_company">Sarasota Memorial Health Care System</p> profile_combined </p> <p class="ci_profile_award"> profile_award </p> <div class="ci_profile_social"> profile_social </div> --></div><div class="col-md-4 col-sm-6 ci_profile"><img src="/sites/default/files/2024-11/Blakely_Marley_300x300.png" alt="Marley Blakeley" width="300" height="300"><p class="ci_profile_name">Marley Blakeley</p><p class="ci_profile_title">Vice President, Revenue Cycle Operations</p><p class="ci_profile_company">R1</p> profile_combined </p> <p class="ci_profile_award"> profile_award </p> <div class="ci_profile_social"> profile_social </div> --></div><div class="col-md-4 col-sm-6 ci_profile"><img src="/sites/default/files/2024-11/Cook_Jessica_300x300.png" alt="Jessica Cook" width="300" height="300"><p class="ci_profile_name">Jessica Cook</p><p class="ci_profile_title">Patient Access Supervisor</p><p class="ci_profile_company">Children’s Healthcare of Atlanta</p> profile_combined </p> <p class="ci_profile_award"> profile_award </p> <div class="ci_profile_social"> profile_social </div> --></div><div class="col-md-4 col-sm-6 ci_profile"><img src="/sites/default/files/2024-11/Hauser_Ruth_300x300.png" alt="Jackie Rouse" width="300" height="300"><p class="ci_profile_name">Ruth Hauser, RHIA, CDIP, CHPC</p><p class="ci_profile_title">Director, Health Information Management and Clinical Documentation Improvement</p><p class="ci_profile_company">Children’s Hospital Los Angeles</p><div class="ci_profile_social"> </div></div><div class="col-md-4 col-sm-6 ci_profile"><img src="/sites/default/files/2024-11/Johnston_Valerie_300x300.png" alt="Valarie Johnston" width="300" height="300"><p class="ci_profile_name">Valarie Johnston, BSHA, CPC, CRCR</p><p class="ci_profile_title">Director, Patient Financial Services</p><p class="ci_profile_company">Bryan Medical Center</p><div class="ci_profile_social"> </div></div><div class="col-md-4 col-sm-6 ci_profile"><img src="/sites/default/files/2024-11/Kirkland_Kathie_300x300.png" alt="Kathie Kirkland" width="300" height="300"><p class="ci_profile_name">Kathie Kirkland, MBA</p><p class="ci_profile_title">Director, Patient Financial Services</p><p class="ci_profile_company">Henry Mayo Newhall Hospital</p><div class="ci_profile_social"> </div></div><div class="col-md-4 col-sm-6 ci_profile"><img src="/sites/default/files/2024-11/Marqueira_Lisa_300x300.png" alt="Lisa Maqueira" width="300" height="300"><p class="ci_profile_name">Lisa Maqueira</p><p class="ci_profile_title">Vice President of Finance and Chief Revenue Cycle Officer</p><p class="ci_profile_company">Cedars-Sinai</p><div class="ci_profile_social"> </div></div><div class="col-md-4 col-sm-6 ci_profile"><img src="/sites/default/files/2024-04/Hoppszallern_Suzanna_300x300%20%281%29.png" alt="Suzanna Hoppszallern" width="300" height="300"><p class="ci_profile_name">Moderator:</p><p class="ci_profile_name">Suzanna Hoppszallern</p><p class="ci_profile_title">Senior Editor, Center for Health Innovation</p><p class="ci_profile_company">���������� Association</p></div></div></div><div class="raw-html-embed"> .SponsorMarketoForm { background-color: ; padding: 5px 25px; border: solid 2px #307FE2; margin: 50px 15px 0px !important; display: inline-block; width: -webkit-fill-available; margin-bottom: 25px; } .SponsorMarketoForm h3 { margin: 10x 0 0 0; color: #eaaa00; font-size: .7em; text-transform: uppercase; font-weight: 400; letter-spacing: 3px; max-width: 200px; /* Custom for the copy length */ 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alt="KnowEx_RI_RevenueCycle_620x381_rev1" /> </a> </div> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-12-05T14:26:53-06:00">Dec 5, 2024</time> </span> </div><div class="views-field views-field-title"> <span class="field-content"><a href="/member-knowledge-exchange/2024-12-06/optimize-your-hospitals-revenue-cycle-efficient-patient-centered-operations" hreflang="en">Optimize Your Hospital’s Revenue Cycle for Efficient, Patient-Centered Operations</a></span> </div><div class="views-field views-field-body"> <div class="field-content">Optimizing hospital’s revenue cycle for efficient, patient-centered operations and enhancing critical KPIs using AI and robotic process automation.</div> </div></div> <div class="article views-row"> <div class="views-field views-field-field-page-title-background"> <div class="field-content sed-thumb"> <a href="/2024-11-14/empowering-patient-engagement-and-behavior-change-improve-health-and-reduce-disparities" hreflang="en"><img loading="lazy" src="/sites/default/files/styles/small_200x200/public/2024-11/VED_PatientPoint_Engagement_620x381.jpg?itok=dHKIfRK6" width="200" height="123" alt="PatientPoint_Engagement_620x381" /> </a> </div> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-11-13T15:51:45-06:00">Nov 13, 2024</time> </span> </div><div class="views-field views-field-title"> <span class="field-content"><a href="/2024-11-14/empowering-patient-engagement-and-behavior-change-improve-health-and-reduce-disparities" hreflang="en">Empowering Patient Engagement and Behavior Change to Improve Health and Reduce Disparities</a></span> </div><div class="views-field views-field-body"> <div class="field-content">Empowering patient engagement and leveraging customized communication and education via digital technologies to improve health and reduce disparities.</div> </div></div> </div> </div> <div class="more-link"><a href="/aha-knowledge-exchange-archive">View All: AHA Knowledge Exchange</a></div> </section> </div> </div></div> Thu, 05 Dec 2024 14:26:53 -0600 Reimbursement /special-bulletin/2024-11-27-special-bulletin-cmmi-issues-increasing-organ-transplant-access-iota-model-final-rule <div class="container"><div class="row"><div class="col-md-8"><p>The Center for Medicare and Medicaid Innovation (CMMI) Nov. 26 <a href="https://www.federalregister.gov/public-inspection/2024-27841/medicare-program-alternative-payment-model-updates-and-the-increasing-organ-transplant-access-model" target="_blank">finalized</a> a new mandatory payment model that will begin on July 1, 2025 and test whether hospital performance-based incentive payments or penalties will increase access to kidney transplants while preserving or enhancing the quality of care and reducing Medicare expenditures. The rule also includes standard provisions that will apply to all CMMI models whose first performance period begins on or after Jan. 1, 2025.</p><div class="panel module-typeC"><div class="panel-heading"><h2>Key Highlights</h2><p>CMMI’s IOTA model will:</p><ul><li>Require participation from 103 eligible kidney transplant hospitals. Eligible hospitals include non-pediatric transplant hospitals in select markets performing 11 or more kidney transplants across all payers in a three-year baseline period. </li><li>Run for six years, from July 1, 2025, through June 30, 2031. </li><li>Assess performance across three domains: achievement (60% of score), efficiency (20% of score) and quality (20% of score). </li><li>Provide incentive payments or penalties based on hospitals’ aggregate performance scores. Hospitals will be eligible for incentive payments of up to $15,000 per case or penalties of up to $2,000 per case. </li><li>Provide a one-year glidepath to downside risk.</li></ul></div></div><h2>AHA TAKE </h2><p>We applaud CMMI for making adjustments to certain model design elements, as we <a href="/lettercomment/2024-07-16-aha-letter-cms-increasing-organ-transplant-access-iota-model" target="_blank">recommended</a>. For example, the agency increased the maximum incentive payment from $8,000 to $15,000 per case; withdrew certain burdensome transparency requirements; and removed three problematic quality measures from the performance scoring methodology. </p><p>However, we still have deep concerns about the IOTA model. Specifically, we believe the model may have unintended consequences by focusing so heavily on volume (possibly incentivizing subpar matches). Furthermore, a model based solely on three quality measures is not robust enough for either patients or hospitals. Additionally, we are concerned the model requires mandatory participation, thus negating organizations’ ability to assess whether a model is appropriate to best serve their patients’ and communities’ needs. Finally, while the agency did delay the start date to July 1, 2025, we are concerned that this still will not provide sufficient lead time to implement such a complex model, especially in light of the transformation already occurring in the organ transplant space. We look forward to continuing to work with the agency to address our members’ concerns. </p><p>Additional details are below:</p><h3>MODEL PERFORMANCE PERIODS </h3><p>CMMI finalizes its proposal that IOTA will include a six-year model performance period. However, the agency delayed the start date from Jan. 1, 2025, to July 1, 2025, with the model now ending June 30, 2031. </p><h3>PARTICIPATION AND MARKET SELECTION </h3><p><strong>Participant Eligibility. </strong>CMMI finalizes its proposal that eligible participants will include non-pediatric kidney transplant hospitals that perform 11 or more transplants annually across all payers across baseline years. </p><p><strong>Mandatory Participation.</strong> Despite AHA’s concerns, all kidney transplant hospitals meeting eligibility criteria in selected geographic areas will be required to participate in the IOTA model. The agency asserts that mandatory participation is necessary to ensure enough hospitals participate in the model, and that its low-volume thresholds will exclude smaller transplant hospitals that may not have financial resources to support the model. </p><p><strong>Geographic Selection.</strong> To determine which hospitals are required to participate, CMMI selected half of all donation service areas (DSAs) nationally using a stratified sampling method – all eligible hospitals in these DSAs will be required to participate. The agency posted a list of these 103 hospitals on their website (<a href="https://nam11.safelinks.protection.outlook.com/?url=https%3A%2F%2Flinks-2.govdelivery.com%2FCL0%2Fhttps%3A%252F%252Fwww.cms.gov%252Fpriorities%252Finnovation%252Ffiles%252Fiota-participant-dsa-list.xlsx%2F1%2F010101936a6edbbe-60e75cf8-c8f4-433c-9e59-3b1a241c42cd-000000%2Fa1bU4h7YjRScXjfuAdaUJfMIBgcKdRd6Xa1ahDWMK_o%3D381&data=05%7C02%7Cjholloman%40aha.org%7Cad23849b107e458f4e4108dd0e6936d7%7Cb9119340beb74e5e84b23cc18f7b36a6%7C0%7C0%7C638682567240761794%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=RK40EoIflD6B4sv3pcFnTPYiU1DLJaJi7ey7AFR6SN8%3D&reserved=0" target="_blank">list of hospitals selected to participate</a>). </p><h3>ATTRIBUTION </h3><p>CMMI finalizes its attribution methodology as proposed. Specifically, patients will be attributed to IOTA model participants based on their registration for waitlists, regardless of payer type or waitlist status, or based on completed transplant procedures. If a patient is on multiple waitlists, they could be attributed to multiple IOTA participants. Patients will be attributed through an initial attribution process and then quarterly. At the end of each performance year (PY), CMMI will create a final list of attributed and deattributed patients. </p><h3>IOTA PERFORMANCE ASSESSMENT </h3><p>CMMI finalizes its proposals to assess performance across three domains — achievement, efficiency, and quality. The agency also finalizes weights for each of the domains, with a final maximum possible score of 100 points. It did modify measures in the quality domain by removing three measures that were included in the proposed rule. Table 1 below summarizes the measures and points assigned to each domain.</p><p class="text-align-center"><strong>Table 1: IOTA Model Performance Score Domains, Points, and Measures</strong></p><table><tbody><tr><td>Domain</td><td>Points</td><td>Measures</td></tr><tr><td>Achievement  </td><td>60 </td><td>Number adult kidney transplants compared to a historical target. </td></tr><tr><td>Efficiency </td><td>20 </td><td>Organ offer acceptance rate ratio.</td></tr><tr><td>Quality </td><td>20 </td><td>Post-transplant composite graft survival rate.</td></tr></tbody></table><p> </p><p><strong>Achievement Domain. </strong>CMMI finalizes its proposal to include only one measure in the achievement domain — the number of kidney transplants performed on adults 18 years and older compared to a historical target. The agency did not finalize the health equity adjustment it had proposed. The Centers for Medicare & Medicaid Services (CMS) will use all-payer Organ Procurement and Transplantation Network (OPTN) and Medicare claims data to calculate the number of kidney transplants performed by the IOTA participant during a PY. Performance will be calculated inclusive of all payers. </p><p><u>Historical Target.</u> CMMI modifies the methodology for calculating the historical target for the achievement domain. Instead of using as the target the highest number of deceased and living donor kidney transplants per year during a rolling baseline period, the agency will use an average of annual deceased and living donor kidney transplants across baseline years. This number will then be projected forward using a national growth rate that CMS will calculate for all IOTA participants. Each baseline year will reflect 12 months and run from July 1 to June 30. </p><p>The national growth rate will be defined as the percentage increase or decrease in kidney transplants performed over 12 months by all kidney transplant hospitals (excluding pediatric kidney transplant hospitals). The agency modified one aspect of the methodology for calculating the national growth rate in that it will not exclude transplant hospitals falling below CMS’ low-volume threshold. </p><p><u>Scoring Approach. </u>CMMI made adjustments to the proposed scoring approach by reducing the threshold for a maximum score in the achievement domain. Specifically, instead of requiring hospitals to increase volume by 150% or more as compared to their target, the agency will require hospitals to increase volume by 125%. The agency also modified the rest of the scoring to create a more graduated scale as depicted in table 2.</p><p class="text-align-center"><strong>Table 2: Scoring Approach for Achievement Domain</strong></p><table><tbody><tr><td><strong>Performance Relative to Target Number</strong> </td><td><strong>Points</strong></td></tr><tr><td>Less than 75%  </td><td>0</td></tr><tr><td>75% to less than 85% </td><td>10 </td></tr><tr><td>85% to less than 95% </td><td>20 </td></tr><tr><td>95% to less than 105%  </td><td>30</td></tr><tr><td>105% to less than 115% </td><td>40 </td></tr><tr><td>115% to less than 120%  </td><td>50</td></tr><tr><td>120% to less than 125% </td><td>55 </td></tr><tr><td>Greater than 125% </td><td>60</td></tr></tbody></table><p> </p><p><u>Health Equity Performance Adjustment</u>. Due to stakeholder feedback and potential unintended consequences, the agency is not finalizing the proposed health equity performance adjustment at this time. The agency stated that it will monitor impacts to low-income individuals’ access and will consider new or updated policies in future rulemaking. </p><p><strong>Efficiency Domain. </strong>CMMI will use OPTN’s organ offer acceptance rate ratio as the sole measure in the efficiency domain. This measure is calculated by dividing the number of kidney transplant organs accepted by each IOTA participant by the riskadjusted number of expected organ acceptances. The measure uses logistic regression with risk adjustment for several characteristics, including donor quality and recipient characteristics; donor-candidate interactions, such as size and age differences; number of previous offers; and distance of potential recipient from the donor. Additional details on the measure are available on the e Health Resources and Services Administration (HRSA) <a href="https://optn.transplant.hrsa.gov/media/qfuj3osi/mpsc-enhance-transplant-program-performance-monitoring-system_srtr-metrics.pdf" target="_blank" title="Health Resources and Services Administration (HRSA)">website</a>, and risk adjustment models are available on the Scientific Registry of Transplant Recipients (SRTR) <a href="https://www.srtr.org/tools/offer-acceptance/" target="_blank" title="Scientific Registry of Transplant Recipients (SRTR) website.">website</a>. </p><p>To translate measure performance into a score, CMMI finalizes its proposal to calculate two separate scores for each IOTA participant: an "achievement score" reflecting its current level of performance and an "improvement score” reflecting changes in its performance over time. Participants would receive points equal to the higher of the two scores, up to a maximum of 20 points. </p><p>For achievement scores, CMMI will award points based on an IOTA participant’s national quintile of performance. CMMI will rank IOTA hospitals against national performance inclusive of all eligible kidney transplant hospitals regardless of whether they are included in the IOTA model.</p><p>For improvement scores, CMMI modifies its proposal for maximum points, although the scoring methodology comparing performance to a benchmark score remains the same. Specifically, a participant can receive up to 15 points for improvement scores (not 12 points). CMMI will calculate an “improvement benchmark rate,” which it defines as 120% of the IOTA participant’s performance on the organ offer acceptance rate measure during the third baseline year of each PY. CMMI will then compare the PY performance to the benchmark or performance during the third baseline year to determine eligibility for improvement points using the approach in table 3 below:</p><p class="text-align-center"><strong>Table 3: Improvement Scoring for IOTA Efficiency Domain</strong></p><table><tbody><tr><td>Performance </td><td>Points</td></tr><tr><td>At or above improvement benchmark rate </td><td><p class="text-align-center">15 </p></td></tr><tr><td>At or below measure rate for third baseline year </td><td><p class="text-align-center">0 </p></td></tr><tr><td>Greater than third baseline year but less than improvement benchmark </td><td><p class="text-align-center">Up to 15 points based on following formula: 15 x (Rate in Performance Year-Third Baseline Year Rate) (Improvement Benchmark Rate-Third Baseline Year Rate)</p></td></tr></tbody></table><p> </p><p><strong>Quality Domain.</strong> CMMI removed three of the four proposed measures from the quality domain measure set. </p><p><u>Composite Graft Survival Rates.</u> CMMI finalizes its proposal to include in the model the composite graft survival rates measure. This measure will be defined as the cumulative number of functioning grafts divided by the cumulative number of all kidney transplants performed by the IOTA participant. For the first model year, CMS will calculate the rate using only data from PY 1. However, the graft survival rate will be cumulative for the remainder of the IOTA model. </p><p>CMS will rank IOTA hospitals against national performance inclusive of all eligible kidney transplant hospitals regardless of whether they are included in the IOTA model. CMMI did receive concerns from stakeholders about the lack of risk adjustment in this measure. However, it asserts that since PY 1 is upside only, it will evaluate risk adjustment for future rulemaking. </p><p>In light of the fact that three measures were removed from the quality domain, as described below, the composite graft survival rates measure will account for all 20 points in the quality domain. Points will be awarded based on the national quintiles for performance as depicted in table 4.</p><p class="text-align-center"><strong>Table 4: Scoring Approach for Quality Domain</strong></p><table><tbody><tr><td><strong>Performance Relative to Target </strong></td><td><strong>Points</strong></td></tr><tr><td>Greater than 80th percentile </td><td>20</td></tr><tr><td> 60th to 80th percentile </td><td>18</td></tr><tr><td>40th to 60th percentile  </td><td>16</td></tr><tr><td>20th to 40th percentile  </td><td>14</td></tr><tr><td>10th to 20th percentile  </td><td>12</td></tr><tr><td>Less than 10th percentile </td><td>10</td></tr></tbody></table><p> </p><p><u>Other Quality Measures.</u> CMMI did not finalize its other proposed quality measures for the quality domain. Specifically, the agency will not include the CollaboRATE shared decision-making measure, colorectal cancer screening rate measure, or Three-item Care Transition Measure (CTM-3) in the IOTA quality domain. </p><p>The agency indicates that it will assess processes to add, remove or replace quality measures in future rulemaking. </p><h3>HEALTH EQUITY REQUIREMENTS </h3><p><strong>Health Equity Plan.</strong> CMMI modified provisions pertaining to the health equity plans. Specifically, submission of health equity plans will be voluntary across all PYs. </p><p><strong>Demographic and Health-related Social Need (HRSN) Data Reporting.</strong> CMMI did not finalize requirements for demographic and HRSN data reporting. The agency stated that it will continue to review feedback for future rulemaking. </p><h3>PAYMENT </h3><p>CMMI finalizes its proposal that IOTA will include both upside and downside risk for Medicare fee-for-service (FFS) payments for kidney transplants. </p><p><strong>Alternative Payment Model Design for Kidney Transplants. </strong>CMMI finalizes that payments to participants will be limited to Medicare FFS cases. Specifically, while aggregate performance for participants is based on attributed patients regardless of payer, the payment portion of IOTA will include kidney transplants furnished to attributed patients whose primary or secondary insurance is Medicare FFS (since payment is made on a per-case basis). </p><p><strong>Performance-Based Payment.</strong> Participants will be assigned to payment categories based on their performance score. As shown below in Table 5, incentive payments will be made to participants with a performance score of 60 or more. For PY 1, hospitals below this threshold will not receive a payment or be required to make a repayment. Starting in PY 2, hospitals with a score of 40 or lower will be required to pay CMS.</p><p class="text-align-center"><strong>Table 5: Performance Scores and Payment Methodology by PY</strong></p><table><tbody><tr><td><strong>Final Score</strong></td><td><strong> PY 1 </strong></td><td><strong>PY 2-PY 6</strong></td></tr><tr><td>60-100 </td><td>Payment to hospital </td><td>Payment to hospital</td></tr><tr><td>41-59 </td><td>Neutral Zone (no payment adjustment) </td><td>Neutral Zone (no payment adjustment) </td></tr><tr><td>0-40 </td><td>Neutral Zone (no payment adjustment) </td><td>Repayment to CMS</td></tr></tbody></table><p> </p><p><u>Payments to Hospitals.</u> CMMI increased the potential upside payments to participants in the final rule. Hospitals will be eligible for up to $15,000 per case based on their aggregate performance score (compared to the $8,000 per case that was proposed). Payment will be calculated based on the following formula: </p><p class="text-align-center">Payment = $15,000*((Final Performance Score-60)/40)*Medicare Kidney Transplants </p><p><u>Repayment.</u> As was proposed, CMMI finalizes that hospitals in the repayment category will be required to repay CMS up to $2,000 per case based on their aggregate performance score. This is estimated to be 8% of the average kidney transplant MSDRG cost. Repayment to CMMI will be calculated based on the following formula: Repayment = $2,000*((40-Final Performance Score)/40)*Medicare Kidney Transplants </p><p><u>Neutral Zone.</u> Hospitals scoring below 60 in PY 1 or from 41 through 59 in PYs 2-6 will be in the neutral zone and, as such, will neither receive payments nor be subject to repayment.</p><h3>TRANSPARENCY REQUIREMENTS </h3><p><strong>Publication of Patient Selection Criteria for Kidney Transplant Evaluation. </strong>The agency finalizes its proposal to require IOTA participants to publicly post by the end of PY 1, on a website, their selection criteria for evaluating patients for addition to their kidney transplant waitlist. </p><p><strong>Transparency into Kidney Transplant Organ Offers. </strong>The agency did not finalize its proposals that would require an IOTA participant to inform IOTA Medicare waitlist patients of the number of times an organ is declined on their behalf and the reason(s) for the decline on a monthly basis. </p><p>However, the agency did modify requirements for reviewing organ offer acceptance criteria (rather than acceptance criteria and organ offer filters) with IOTA Medicare waitlist patients at least once every six months. </p><p>The agency will consider additional requirements to increase transparency in future rulemaking.</p><h3>FRAUD AND ABUSE WAIVER AND OIG SAFE HARBOR AUTHORITY </h3><p>The Health and Human Services (HHS) Secretary has the authority per Section 1115A of the Social Security Act to waive specified fraud and abuse laws to test payment models. However, no fraud and abuse waivers are issued in the final rule. Therefore, as it stands, any arrangement or agreement under the model that implicates these laws would not be protected unless it falls under an existing exception or safe harbor. </p><p>The final rule notes that any fraud and abuse waivers would be promulgated separately. The AHA will work to ensure that CMS and the HHS Office of Inspector General (OIG) provide necessary waivers so that participating hospitals can pursue the program’s goals without running afoul of fraud and abuse laws. These legal protections are critical to hospitals’ ability to coordinate care among all caregivers. </p><p>CMMI stated that it expects that all financial relationships established between IOTA participants and providers or suppliers for purposes of IOTA would only be those permitted under applicable laws and regulations, including the applicable fraud and abuse laws and all applicable payment and coverage requirements. </p><p>CMS did make a determination that a federal anti-kickback statute safe harbor for CMSsponsored model arrangements and CMS-sponsored model patient incentives is available to protect remuneration exchanged pursuant to certain financial arrangements and patient incentives that may be permitted under the final rule. Specifically, the agency determined that the CMS-sponsored models safe harbor would be available to protect the following financial arrangements and incentives: the IOTA Model Sharing Arrangement’s gainsharing payments and alignment payments, the Distribution Arrangement’s distribution payments, the Part B and Part D immunosuppressive drug cost sharing support policy and attributed patient engagement incentives.</p><h3>GENERAL PROVISIONS FOR ALL INNOVATION CENTER MODELS </h3><p>CMS finalizes standard provisions that will apply more broadly to all CMMI models that begin on or after Jan. 1, 2025. Specifically, it finalizes sections pertaining to beneficiary protections, cooperation in model evaluation and monitoring, audits and record retention, rights in data and intellectual property, monitoring and compliance, remedial action, model termination by CMS, limitations on review and bankruptcy, reconsideration review processes and other notifications be applied across models. </p><h3>FURTHER QUESTIONS </h3><p>If you have further questions regarding IOTA, please contact Jennifer Holloman, AHA’s senior associate director of policy, at <a href="mailto:jholloman@aha.org" title="jholloman@aha.org">jholloman@aha.org</a>.</p></div><div class="col-md-4"><p><a href="/system/files/media/file/2024/11/2024-11-27_SB_IOTA-f.pdf" target="_blank" title="Click here to download the Special Bulletin: CMMI Issues Increasing Organ Transplant Access (IOTA) Model Final Rule PDF."><img src="/sites/default/files/2024-11/CMMI-Issues-Increasing-Organ-Transplant-Access-p1.png" data-entity-uuid data-entity-type="file" alt="Special Bulletin: CMMI Issues Increasing Organ Transplant Access (IOTA) Model Final Rule cover." width="600" height="779"></a></p></div></div></div> Wed, 27 Nov 2024 11:49:52 -0600 Reimbursement /action-alert/2024-11-13-aha-asks-congressional-leadership-fund-hospitals-protect-health-care-workers <div class="container"><div class="row"><div class="col-md-8"><p>Following the elections, lawmakers are returning to Washington, D.C., to tackle key funding issues, including Medicaid disproportionate share hospital (DSH) payment reductions and support for rural programs. They also will consider site-neutral payment proposals, oversight of health plans, continuation of telehealth and hospital-at-home waivers, and the prevention of violence against health care workers.</p><p>Before the lame-duck session ends and the 118th Congress adjourns, it is essential that federal lawmakers understand the challenges hospitals and health systems face and what is at stake for the patients and communities they represent. With several programs facing expiration at the end of this year, quick action is needed to preserve necessary funding and support for the nation’s health care organizations.</p><p>Here are the issues AHA leaders are <a href="/2024-11-12-aha-urges-congress-act-key-priorities-lame-duck-session" target="_blank" title="Issues AHA Leaders are calling on Congress to reinforce">calling on congressional leaders</a> to reinforce. Following is an overview of the issues and what you can do to assist these advocacy efforts.</p><h2>SUPPORT MEDICAID DSH DEAR COLLEAGUE LETTER</h2><p>At the beginning of the year, billions of dollars will be cut from the Medicaid DSH program, severely jeopardizing hospitals’ finances and threatening communities’ access to care. Contact your representative(s) and ask them to sign on to the bipartisan <a href="/system/files/media/file/2024/11/congress-dear-colleague-letter-to-stop-medicaid-disproportionate-share-hospital-dsh-payment-cuts-11-13-2024.pdf" target="_blank" title="House Dear Colleague Letter">House Dear Colleague letter</a> being circulated by Reps. Dan Crenshaw, R-Texas, Yvette Clarke, D-N.Y., Gus Bilirakis, R-Fla., and Diana DeGette, D-Colo., calling for Medicaid DSH cuts to be addressed. <a href="https://www.votervoice.net/AHA/Campaigns/118959/Respond">Click here</a> to send a message to your representatives.</p><h2><strong>LEGISLATIVE ACTION NEEDED</strong></h2><p><strong>Address the Medicaid</strong> <strong>DSH Payment Reductions. </strong>The <a href="/fact-sheets/2023-03-28-fact-sheet-medicaid-dsh-program" target="_blank" title="Medicare DSH Program Information">Medicaid DSH program</a> provides essential financial assistance to hospitals that care for our nation’s most vulnerable populations — children, impoverished, disabled and elderly. The fiscal year 2025 Medicaid DSH payment reductions are scheduled to be implemented on Jan. 1, 2025, when $8 billion in reductions take effect. The AHA calls on Congress to continue to provide relief from the Medicaid DSH cuts.</p><p><strong>Protect Rural Communities’ Access to Care.</strong> The AHA urges Congress to continue the <a href="/advocacy/advocacy-issues/2024-10-31-advocacy-issue-rural-mdh-and-lva-programs" target="_blank" title="Medicare-dependent Hospitals and Low-volume Adjustment programs">Medicare-dependent Hospitals and Low-volume Adjustment programs</a>. These programs provide rural, geographically isolated and low-volume hospitals additional financial support to ensure rural residents have access to care. These programs expire on Dec. 31, 2024. Congress should also enact a technical correction to remove barriers for Rural Emergency Hospitals to receive hospital-level reimbursement for outpatient services under Medicaid<strong>.</strong> </p><p><strong>Reject Site-neutral Payment Proposals.</strong> The AHA strongly opposes efforts to expand <a href="/advocacy/advocacy-issues/2023-09-11-advocacy-issue-site-neutral-payment-proposals" target="_blank" title="Site-neutral payment cuts information">site-neutral payment cuts</a> to include essential drug administration services furnished in off-campus hospital outpatient departments (HOPDs). Current Medicare payment rates appropriately recognize that there are fundamental differences between patient care delivered in HOPDs compared to other settings. HOPDs have higher patient safety and quality standards, and, unlike other sites of care, hospitals take important additional steps to ensure drugs are prepared and administered safely for both patients and providers. </p><p>The AHA also calls on Congress to reject legislative efforts requiring each off-campus HOPD to be assigned a separate unique health identifier from its provider as a condition of payment under Medicare or group health plans. Hospitals are already required to be transparent about the location of care delivery. This requirement would be duplicative and impose unnecessary and onerous administrative burdens and costs by needlessly requiring the overhaul of current billing practices and systems.</p><p><strong>Hold Commercial Health Plans Accountable.</strong> Certain health plan practices, such as inappropriate care denials and delayed payments, threaten patient access to care. These practices also contribute to clinician burnout and add excessive administrative costs and burdens to the health care system. The AHA urges Congress to pass the<a href="/lettercomment/2024-06-12-aha-support-house-improving-seniors-timely-access-care-act" target="_blank" title="Improving seniors timely access to care"> Improving Seniors Timely Access to Care Act</a> (H.R. 8702/ S. 4532), bipartisan legislation supported by more than half of the members of the House and Senate. The bill would streamline the prior authorization process in the Medicare Advantage program by eliminating complexity and promoting uniformity to reduce the wide variation in prior authorization methods that frustrate both patients and providers.</p><p><strong>Extend </strong><a href="/system/files/media/file/2024/05/fact-sheet-2024-telehealth-advocacy-agenda.pdf" target="_blank" title="Telehealth information"><strong>Telehealth</strong></a><strong> and </strong><a href="/system/files/media/file/2024/07/Fact-Sheet-Extending-the-Hospital-at-Home-Program-20240719.pdf" target="_blank" title="Hospitals-at-home information"><strong>Hospital-at-home</strong></a><strong> Waivers.</strong> During the COVID-19 public health emergency, Congress established a series of waivers expanding access for millions of Americans and increasing convenience in caring for patients. Telehealth provides a tremendous ability to leverage geographically dispersed provider capacity to support patient demand. The AHA calls on Congress to permanently adopt telehealth waivers and expand the telehealth workforce. </p><p>The AHA also urges Congress to pass the <a href="/lettercomment/2024-05-23-aha-support-house-bill-hospital-inpatient-services-modernization-act-2024" target="_blank" title="Hospitals Inpatient Services Modernization Act">Hospital Inpatient Services Modernization Act</a> (H.R. 8260/S. 4350), extending the hospital-at-home waiver for five years through 2029. Congressional action will reassure hospitals and health systems that are interested in developing such programs for their communities. </p><p><strong>Prevent Reimbursement Cuts for Physicians. </strong>Congress should take action to mitigate the scheduled physician reimbursement cuts for 2025 and to continue its work on broader reform for sustainable physician payment. Physicians have dealt with over two decades of conversion factor decrements, as well as significant staffing shortages and rising inflation in recent years. The scheduled 2.8% payment reduction in the 2025 Physician Fee Schedule would result in a significant risk to patients’ access to care.</p><p><strong>Protect America’s Health Care Workers.</strong> The AHA calls on Congress to enact the <a href="/system/files/media/file/2022/09/Fact-Sheet-Workplace-Violence-and-Intimidation-and-the-Need-for-a-Federal-Legislative-Response.pdf" target="_blank" title="SAVE Act information">Safety from Violence for Healthcare Employees (SAVE) Act</a> (H.R. 2584/S. 2768). This bipartisan bill would provide federal protections from workplace violence for hospital workers, similar to the protections in current law for airport and airline workers.</p><h2>FURTHER QUESTIONS</h2><p>Visit the <a href="/advocacy/action-center" target="_blank" title="AHA Action Center">AHA Action Center</a> for more resources on these issues and other priorities important to hospitals and health systems.</p><p>If you have further questions, please contact AHA at 800-424-4301.<br> </p></div><div class="col-md-4"><a href="/system/files/media/file/2024/11/aha-asks-congressional-leadership-to-fund-hospitals-protect-health-care-workers-alert-11-13-2024.pdf"><img src="/sites/default/files/inline-images/cover-aha-asks-congressional-leadership-to-fund-hospitals-protect-health-care-workers-alert-11-13-2024.png" data-entity-uuid="40f68d4b-dfe5-4e56-af78-6f8af97f13ca" data-entity-type="file" alt="Action Alert Cover Image" width="640" height="834"></a></div></div><p> </p></div> Wed, 13 Nov 2024 14:05:33 -0600 Reimbursement /2024-11-12-aha-urges-congress-act-key-priorities-lame-duck-session <p>November 12, 2024</p><table><tbody><tr><td>The Honorable Mike Johnson<br>Speaker<br>U.S. House of Representatives<br>Washington, DC 20515</td><td>The Honorable Hakeem Jeffries<br>Democratic Leader<br>U.S. House of Representatives<br>Washington, D.C. 20515</td></tr><tr><td>The Honorable Charles E. Schumer<br>Majority Leader<br>United States Senate<br>Washington, DC 20510</td><td>The Honorable Mitch McConnell<br>Republican Leader<br>United States Senate<br>Washington, DC 20510</td></tr></tbody></table><p><br>Dear Speaker Johnson, Leader Schumer, Leader Jeffries, and Leader McConnell:</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) writes regarding the forthcoming government funding deadline.</p><p>Hospitals and health systems are experiencing significant financial pressures that challenge their ability to provide 24/7 care for the patients and communities they serve.  Increased expenses for drugs and supplies, inflation and the mounting burden due to certain commercial health insurer denial and delay practices continue to strain hospitals and health systems. At the same time, underpayments in reimbursements from Medicare and Medicaid do not keep pace with these mounting costs and exacerbate the problems hospitals are having.</p><p>As Congress begins to focus on its end-of-the-year work, America’s hospitals and health systems respectfully request that you consider the following priorities.</p><p><strong>Address the Medicaid</strong> <strong>Disproportionate Share Hospital (DSH) Payment Reductions. </strong>The Medicaid DSH program provides essential financial assistance to hospitals that care for our nation’s most vulnerable populations — children, impoverished, disabled and elderly. The fiscal year 2025 Medicaid DSH payment reductions are scheduled to be implemented on Jan. 1, 2025, when $8 billion in reductions take effect. Congress should continue to provide relief from the Medicaid DSH cuts.</p><p><strong>Protect Rural Communities’ Access to Care.</strong> We urge Congress to continue the Medicare-dependent Hospitals and Low-volume Adjustment programs. These programs provide rural, geographically isolated and low-volume hospitals additional financial support to ensure rural residents have access to care. These programs expire on Dec. 31, 2024. Congress should also enact a technical correction to remove barriers for Rural Emergency Hospitals to receive hospital level reimbursement for outpatient services under Medicaid<strong>.</strong></p><p><strong>Reject Site-neutral Payment Proposals.</strong> We strongly oppose efforts to expand site-neutral payment cuts to include essential drug administration services furnished in off-campus hospital outpatient departments (HOPDs). Current Medicare payment rates appropriately recognize that there are fundamental differences between patient care delivered in HOPDs compared to other settings. HOPDs have higher patient safety and quality standards, and, unlike other sites of care, hospitals take important additional steps to ensure drugs are prepared and administered in a safe manner for both patients and providers.</p><p>HOPDs provide care for Medicare patients who are more likely to be sicker and more medically complex than those treated at physicians’ offices. This is especially true in rural and other medically underserved communities. Additional cuts will directly impact the level of care and services available to vulnerable patients in these communities.</p><p>We also call on Congress to reject legislative efforts requiring each off-campus HOPD to be assigned a separate unique health identifier from its provider as a condition of payment under Medicare or group health plans. Hospitals are already required to be transparent about the location of care delivery. This requirement would be duplicative and impose unnecessary and onerous administrative burdens and costs by needlessly requiring the overhaul of current billing practices and systems.</p><p><strong>Hold Commercial Health Plans Accountable.</strong> Certain health plan practices, such as inappropriate care denials and delayed payments, threaten patient access to care. These practices also contribute to clinician burnout and add excessive administrative costs and burdens to the health care system. We urge Congress to pass the Improving Seniors Timely Access to Care Act (H.R. 8702/ S. 4532), bipartisan legislation supported by more than half of the members of the House and Senate. The bill would streamline the prior authorization process in the Medicare Advantage program by eliminating complexity and promoting uniformity to reduce the wide variation in prior authorization methods that frustrate both patients and providers.</p><p><strong>Extend Telehealth and Hospital-at-home Waivers.</strong> During the public health emergency, Congress established a series of waivers expanding access for millions of Americans and increasing convenience in caring for patients. Telehealth provides a tremendous ability to leverage geographically dispersed provider capacity to support patient demand. Congress should permanently adopt telehealth waivers and expand the telehealth workforce.</p><p>Hospital-at-home programs are a safe, innovative way to care for patients in the comfort of their homes. With over 300 hospitals with hospital-at-home programs, many other hospitals and health systems indicate they are interested in developing programs for their communities but are reluctant to do so without congressional action. We urge Congress to pass the Hospital Inpatient Services Modernization Act (H.R. 8260/S. 4350), extending the hospital-at-home waiver for five years through 2029.</p><p><strong>Prevent Reimbursement Cuts for Physicians. </strong>Congress should take action to mitigate the scheduled physician reimbursement cuts for 2025 and to continue its work on broader reform for sustainable physician payment. Physicians have dealt with over two decades of conversion factor decrements, as well as significant staffing shortages and rising inflation in recent years. The scheduled 2.8% payment reduction in the 2025 Physician Fee Schedule would result in a significant risk to patients’ access to care.</p><p><strong>Protect America’s Health Care Workers.</strong> Congress should enact the Safety from Violence for Healthcare Employees (SAVE) Act (H.R. 2584/S. 2768). This bipartisan bill would provide federal protections from workplace violence for hospital workers, similar to the protections in current law for airport and airline workers.</p><p>We appreciate your leadership and look forward to working together to ensure patients continue to have access to quality care in their communities.</p><p>Sincerely,</p><p>/s/</p><p>Richard J. Pollack<br>President & Chief Executive Officer</p> Tue, 12 Nov 2024 14:38:12 -0600 Reimbursement /news/headline/2024-08-13-aha-comments-medpac-2024-2025-cycle <p>The AHA Aug. 13 <a href="/2024-08-12-aha-comments-340b-drug-pricing-program-irf-payments-physician-fee-schedule-and-telehealth">commented</a> to the Medicare Payment Advisory Commission in anticipation of the commission’s 2024-2025 cycle. The AHA urged MedPAC to carefully consider the negative consequences for beneficiaries, providers and communities if Medicare payments to 340B hospitals are cut; reconsider its pursuit of inpatient rehabilitation facility-skilled nursing facility site-neutral payment policy; support updates to physician reimbursement that more adequately account for inflation; and recommend repealing in-person visit requirements for tele-behavioral health services.</p> Tue, 13 Aug 2024 14:16:15 -0500 Reimbursement /testimony/2024-05-16-aha-statement-senate-finance-committee-hearing-rural-health-care <p class="text-align-center"><strong>Statement of the</strong><br><strong>���������� Association</strong><br><strong>for the</strong><br><strong>Committee on Finance</strong><br><strong>of the</strong><br><strong>U.S. Senate</strong><br><strong>“Rural Health Care: Supporting Lives and Improving Communities”</strong></p><p class="text-align-center"><strong>May 16, 2024</strong></p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations; our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers; and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) welcomes the opportunity to comment on policies to ensure rural patients continue to receive access to high-quality care.</p><p>Hospitals and health systems are the lifeblood of their communities and committed to ensuring local access to health care. At the same time, many hospitals, including those in rural areas, continue to experience unprecedented challenges that jeopardize access and services. These include workforce shortages, high costs of prescription drugs, and continued severe underpayment by Medicare and Medicaid.</p><p>Rural hospitals make up about 35% of all hospitals in the U.S. Nearly half of rural hospitals have 25 or fewer beds, with just 16% having more than 100 beds. Given that rural hospitals tend to be much smaller, patients with higher acuity often travel or are referred to larger hospitals nearby. As a result, in rural hospitals, the acute care occupancy rate (37%) is less than two thirds of their urban counterparts (62%).</p><p>Below are a series of proposals and suggestions for the Finance Committee to consider as it seeks to ensure financial stability of providers, maintain critical flexibility to protect access and services, build the workforce of tomorrow and improve infant and maternal care in rural communities. </p><h2>FLEXIBLE PAYMENT OPTIONS </h2><p>To improve health care in rural communities, sustainable financing for rural hospitals and health systems is imperative. As a result, rural hospitals require flexible payment options to address barriers and invest in new resources in rural communities.</p><p>Providing certainty and stability in rural Medicare hospital payments is essential. Low reimbursement, low patient volume, sicker patients and challenging payer mix, common at many rural hospitals, puts added financial pressure on those facilities. <strong>The AHA supports policies that promote flexible payment options and address financial challenges faced by the full spectrum of rural hospitals, which will allow them to continue providing high-quality care for their patients.</strong></p><ul><li><strong>Making Permanent the Medicare-dependent Hospital (MDH) and Low- volume Adjustment (LVA). </strong>MDHs are small, rural hospitals where at least 60% of admissions or patient days are from Medicare patients. MDHs receive the inpatient prospective payment system (IPPS) rate plus 75% of the difference between the IPPS rate and their inflation-adjusted costs from one of three base years. AHA supportsmaking the MDH program permanent and adding an additional base year that hospitals may choose for calculating payments. The LVA provides increased payments to isolated, rural hospitals with a low number of discharges. AHA also supports making the LVA permanent. The MDH designation and LVA protect the financial viability of these hospitals to ensure they can continue providing access to care and AHA supports the <strong>Rural Hospital Support Act (S. 1110) </strong>and the<strong> Assistance for Rural Community Hospitals Act (H.R. 6430) </strong>to extend those important designations.</li><li><strong>Extend Telehealth Flexibilities.</strong> The expansion of telehealth services has transformed care delivery, expanded access for millions of Americans and increased convenience in caring for patients, especially those with transportation or mobility limitations. Given current health care challenges, including major clinician shortages nationwide, telehealth holds tremendous potential to leverage geographically dispersed provider capacity to support patient demand. AHA supports  the <strong>CONNECT for Health Act (S. 2016 / H.R. 4189)</strong> to make permanent coverage of certain telehealth services made possible during the pandemic, including lifting geographic and originating site restrictions, allowing Rural Health Clinics and Federally Qualified Health Centers to serve as distant sites, expanding practitioners who can provide telehealth, and allowing the continuation of audio-only telehealth services, among others.</li><li><strong>Reopen the Necessary Provider Designation for Critical Access Hospitals (CAHs). </strong>The CAH designation allows small rural hospitals to receive cost-based Medicare reimbursement, which can help sustain services in the community. Hospitals must meet several criteria, including a mileage requirement, to be eligible. A hospital can be exempt from the mileage requirement if the state certified the hospital as a necessary provider, but only hospitals designated before Jan. 1, 2006, are eligible. <strong>AHA urges Congress to reopen the necessary provider CAH program to further support local access to care in rural areas</strong>. </li><li><strong>Strengthen the Rural Emergency Hospital (REH) Model. </strong>REHs are a new Medicare provider type to which small rural and critical access hospitals can convert to provide emergency and outpatient services without needing to provide inpatient care. <strong>AHA supports strengthening and refining the REH model to ensure sustainable care delivery and financing.</strong> </li><li><strong>Rebase Sole Community Hospitals (SCHs). </strong>SCHs must show they are the sole source of inpatient hospital services reasonably available in a certain geographic area to be eligible. <strong>AHA supports the Rural Hospital Support Act (S. 1110) to add an additional base year that SCHs may choose for calculating their payments</strong>. </li><li><strong>Improve Access to Capital. </strong>Access to capital is important to stabilize a vulnerable hospital or advance innovations in others<strong>. AHA supports expanding the USDA Community Facilities Direct Loan & Grant Program and creating a new Hill-Burton like program to update rural hospitals to ensure continued access in rural communities. </strong></li></ul><h2>FINANCIAL STABILTY – FAIR, TIMELY AND ADEQUATE REIMBURSEMENT<strong> </strong></h2><p>Medicare and Medicaid each pay less than 90 cents for every dollar spent caring for patients — with Medicare hitting a historic low of 82 cents for every dollar — according to the latest AHA data. Given the unique financial challenges of providing care in rural areas, reimbursement rates across payers need to be updated to cover the cost of care.</p><p><strong>AHA supports the following policies to ensure fair, timely and adequate reimbursement. </strong></p><ul><li><strong>Medicare Advantage Payment Parity for CAHs. </strong>The Medicare Advantage (MA) program has grown significantly in the past decade. MA enrollment, which traditionally has grown slower in rural areas, is now surpassing the growth rate in urban areas. For example, MA enrollment quadrupled between 2010 to 2023 in rural counties, compared to metropolitan areas which doubled in enrollment during the same period. Yet, MA plans are not required to pay CAHs at the same cost basis as fee-for-service Medicare; and they are increasingly paying below costs, straining the financial viability of many rural providers. Further, MA plans have the additional burden of prior authorization and other health plan requirements with which rural providers must increasingly contend  requirements that do not exist to nearly the same extent in fee-for-service Medicare and add additional costs for rural providers to comply. <strong>We support legislation to ensure CAHs receive cost-based reimbursement for MA patients</strong>. </li><li><strong>Prompt Pay</strong>. Ensuring prompt payment from insurers for medically necessary, covered health care services is important for ensuring financial stability of rural hospitals and health systems. Delayed payments are particularly problematic for rural hospitals given their low patient volume and often challenging financial position. <strong>We support policies to increase oversight and accountability of health plans including establishing more stringent standards for timely payment to address certain commercial insurer tactics to delay and deny payment to health care providers.</strong> </li><li><strong>Make the Ambulance Add-on Payments Permanent. </strong>Rural ambulance service providers ensure timely access to emergency medical care but face higher costs than other areas due to lower patient volume. We support<strong>, </strong>permanently extending the existing rural, “super-rural” and urban ambulance add-on payments to protect access to these essential services<strong>. AHA asks Congress to pass the Protecting Access to Ground Ambulance Medical Services Act of 2023 (S. 1673 / H.R. 1666) to maintain those enhanced ambulance payments</strong>. </li><li><strong>Commercial Insurer Accountability. </strong>Systematic and inappropriate delays of prior authorization decisions and payment denials by commercial insurers for medically necessary care are putting patient access to care at risk. <strong>We support regulations and legislative solutions that streamline and improve prior authorization processes, including the Improving Seniors’ Timely Access to Care Act, which would codify many of the reforms in the Interoperability and Prior Authorization Final Rule. In addition, we support policies that ensure patients can rely on their coverage by disallowing health plans from inappropriately delaying and denying care, including by making unilateral mid-year coverage changes. </strong></li><li><strong>Wage Index Floor. AHA supports the Save Rural Hospitals Act (S. 803) to place a floor on the area wage index, effectively raising the area wage index with new money for hospitals below that threshold</strong>. </li><li><strong>Behavioral Health. </strong>Implementing policies to better integrate and coordinate behavioral health services will improve care in rural communities. We urge Congress to:<ul><li>Fully fund authorized programs to treat substance use disorders, including expanding access to medication assisted treatment.</li><li>Implement policies to better integrate and coordinate behavioral health services with physical health services.</li><li>Enact measures to ensure vigorous enforcement of mental health and substance use disorder parity laws.</li><li>Permanently extend flexibilities under scope of practice and telehealth services granted during the COVID-19 public health emergency.</li><li>Increase access to care in underserved communities by investing in supports for virtual care and specialized workforce.</li></ul></li></ul><h2>BOLSTERING THE WORKFORCE </h2><p>Recruitment and retention of health care professionals is an ongoing challenge and expense for many hospitals. Nearly 70% of the primary health professional shortage areas are in rural or partially rural areas. Hospitals and health systems need a robust and highly qualified staff to handle medical care in emergency situations. To achieve this goal, targeted programs that help address workforce shortages in rural communities should be supported and expanded. Workforce policies and programs also should encourage nurses and other allied professionals to practice at the top of their licenses. Below are listed a variety of different proposals and pieces of legislation Congress should consider enacting to tackle the workforce shortage crisis. </p><ul><li><strong>Graduate Medical Education. </strong>We urge Congress to pass the <strong>Resident Physician Shortage Reduction Act of 2023 (S. 1302 / H.R. 2389)</strong>, legislation to increase the number of Medicare-funded residency slots, which would expand training opportunities in all areas including rural settings to help address health professional shortages. </li><li><strong>Conrad State 30 Program. </strong>We urge Congress to pass the <strong>Conrad State 30 and Physician Access Reauthorization Act (S. 665 / H.R. 4942) </strong>to extend and expand the Conrad State 30 J-1 visa waiver program, which waives the requirement to return home for a period if physicians holding J-1 visas agree to stay in the U.S. for three years to practice in federally-designated underserved areas. </li><li><strong>International Workforce.</strong> The AHA urges Congress to pass the <strong>Healthcare Workforce Resilience Act (S. 3211 / H.R. 6205)</strong>, bipartisan legislation that would recapture 25,000 unused employment-based visas for foreign-born nurses and 15,000 for foreign-born physicians to help address staffing shortages. </li><li><strong>Loan Repayment Programs. </strong>We urge Congress to pass the <strong>Restoring America’s Health Care Workforce and Readiness Act (S. 862) </strong>to significantly expand National Health Service Corps funding to provide incentives for clinicians to practice in underserved areas, including rural communities. AHA also supports the <strong>Rural America Health Corps Act (S. 940 / H.R. 1711) </strong>to directly target rural workforce shortages by establishing a Rural America Health Corps to provide loan repayment programs focused on underserved rural communities. </li><li><strong>Boost Nursing Education. </strong>We urge Congress to invest significant resources to support nursing education and provide resources to boost student, faculty and preceptor populations, modernize infrastructure and support partnerships and research at schools of nursing. AHA also supports expanding the National Nurse Corps.</li><li><strong>Health Care Workers Protection. </strong>We urge Congress to enact the <strong>Safety from Violence for Healthcare Employees Act (S. 2768 / H.R. 2584) </strong>to provide federal protections for health care workers against violence and intimidation. </li></ul><h2>IMPROVING MATERNAL HEALTH IN RURAL COMMUNITIES </h2><p>The AHA and its hospitals and health systems are dedicated to eliminating maternal mortality and reducing maternal morbidity to provide mothers and babies with the opportunity to lead healthy and productive lives. Last year, we <a href="/system/files/media/file/2023/09/Federal-Public-Policy-Legislative-Solutions-Improving-Maternal%20Health_August%202023_Final.pdf">released </a>a comprehensive set of federal public policy and legislative solutions for improving maternal health. In addition, the AHA has <a href="/advocacy/maternal-and-child-health">shared </a>tools and resources and promoted the fields’ efforts through case studies, webinars and podcasts. </p><p>Over the last decade, more than 200 rural hospitals have closed obstetric (OB) units. The decision to close an OB unit is not made lightly. Hospitals and health systems consider various factors, including patient care, staffing challenges, declining patient volume and inadequate reimbursement, in addition to the important role they play in their communities and the lives of their patients. A recent Government Accountability Office study<a href="#_ftn1" title=""><sup>[1]</sup></a> estimated that half of all rural counties lack access to this essential care. </p><p>As Congress examines this issue more closely, we would encourage legislative approaches that focus on: </p><ul><li><strong>Increasing reimbursement for obstetric services.</strong> For example, some states have implemented add-on payments for labor and delivery - paid directly to the hospital - by their state Medicaid programs; a federal match could be helpful in maintaining and expanding the use of these payments. </li><li><strong>Reducing regulatory barriers to encourage partnerships and innovative approaches to delivering care</strong>. Partnerships between smaller rural hospitals and larger health systems can allow systems to share staff, connect patients with complex health needs to specialists, and in some cases, transfer high-risk pregnant women to other facilities. </li><li><strong>Encouraging state Medicaid graduate medical education (GME) programs to support expanding capacity of existing workforce.</strong> States have broad authority to create Medicaid GME programs that meet the needs of their state, including through fee-for-service and Medicaid managed care programs. In some states, primary care or family practitioners have received training in labor and delivery, including performing cesarean sections, to offer care as part of a broader clinical team that includes obstetricians and gynecologists. CMS could assist with guidance and encourage state Medicaid agencies to develop Medicaid GME programs focused on rural hospitals that provide maternity care.</li><li><strong>Requiring state Medicaid programs to cover telemedicine for maternal care.</strong> Telehealth can provide support throughout the perinatal period as well to allow for consultations with specialists and access to care for rural areas that do not have obstetric providers.<a href="#_ftn1" title=""><sup>[1]</sup></a> A study by the CDC examined work done by 13 state maternal mortality review committees to identify contributing factors and strategies to prevent future pregnancy-related deaths, which included addressing personnel issues at hospitals by providing telemedicine for facilities with no obstetric provider on-site.<a href="#_ftn2" title=""><sup>[2]</sup></a> In addition, the use of remote patient monitoring, such as with blood pressure cuffs weekly glucose review, both lowered pregnancy-related stress and improved patient satisfaction with their treatment. While the use of telemedicine for obstetric services has increased over the last few years, not all states may be requiring Medicaid to reimburse for these services. </li></ul><h2>CONCLUSION </h2><p>We thank you for the opportunity to comment on ways to improve rural health care and strengthen the communities that rely on the services provided by their local hospitals and health systems. We look forward to continuing to work with you on this important issue. </p><p>__________</p><p><small class="sm"><sup>1</sup> </small><a href="https://www.gao.gov/products/gao-23-105515" target="_blank"><small class="sm">htps://www.gao.gov/products/gao-23-105515</small></a></p> Wed, 15 May 2024 23:19:03 -0500 Reimbursement