Vice President for Government Relations
Virginia Commonwealth University

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CMS Regulations Archives

November 28, 2011. The Office of Management and Budget (OMB) recently announced that the Administration has cut wasteful improper payments by $17.6 billion dollars in 2011 as part of the Obama Administration’s Campaign to Cut Waste — fueled by decreases in payment errors in Medicare, Medicaid, Pell Grants, and Food Stamps. 

Combined with curbing improper payments in 2010, agencies have avoided making over $20 billion in improper payments in the two years since President Obama issued an Executive Order initiating an aggressive campaign against the wasteful payment errors. To help cut improper payments, the Centers for Medicare & Medicaid Services (CMS) has announced it will launch demonstration programs beginning in January 2012 targeting some of the most common factors that lead to improper payments. The demonstration programs will help strengthen Medicare by aiming at eliminating fraud, waste, and abuse.

To see the OMB press release, please visit HERE and to learn more about CMS efforts to cut improper payments, please visit HERE .

November 7, 2011. The Centers for Medicare & Medicaid Services (CMS) has issued a final rule with comment period that updates payment policies and rates for physicians and non-physician practitioners (NPPs) for services paid under the Medicare Physician Fee Schedule (MPFS) in calendar year (CY) 2012.

More than 1 million providers of vital health services to Medicare beneficiaries — including physicians, limited license practitioners such as podiatrists, and NPPs such as nurse practitioners and physical therapists — are paid under the MPFS. CMS projects that total payments under the MPFS in CY 2012 will be approximately $80 billion.

CMS is required to issue a final rule that reflects current law. Under current law, providers will face steep across-the-board reductions in payment rates, based on a formula — the Sustainable Growth Rate (SGR) — that was adopted in the Balanced Budget Act of 1997. Without a change in the law from Congress, Medicare payment rates to providers paid under the MPFS will be reduced by 27.4 percent for services in CY 2012 — less than the 29.5 percent reduction that CMS had estimated in March of this year because Medicare cost growth has been lower than expected. 

The final rule with comment period will appear in the Federal Register on November 28.  CMS will accept comments on those provisions that are subject to comment until January 31, 2012, and will respond in the MPFS for CY 2013.

For more information, visit HERE.

October 10, 2011. According to the Centers for Medicare & Medicaid Services (CMS), nearly 20.5 million people with Medicare reviewed their health status at a free Annual Wellness Visit or received other preventive services with no deductible or cost sharing this year. In addition, nearly 1.8 million people with Medicare have received discounts on brand-name drugs in the Medicare Part D coverage gap, also known as the "donut hole," between January and August of this year. The total value of discounts to people with Medicare in the donut hole is nearly $1 billion through August of this year, with an average savings of $530 per beneficiary.

Some of the free preventive services available to people with Medicare include:

  • Mammograms and cervical cancer screenings;

  • Annual Wellness Visit;

  • Cholesterol and other cardiovascular screenings; and

  • Colorectal and prostate cancer screenings.

The rising number of people who are taking advantage of preventive benefits and prescription drug discounts comes as people with Medicare are beginning to review their plan options for next year. The popular web-based Medicare Plan Finder is now available to help beneficiaries, their families, other caregivers, and senior program advocates look at all local drug and health plan options that are available for the 2012 benefit year. 

The annual enrollment period begins earlier this year than last year, on October 15, and runs through December 7. People with Medicare will have seven weeks to review Medicare Advantage and Part D prescription drug coverage benefits and plan options, and choose the option that best meets their unique needs or keep the plan they have today. The earlier open enrollment period also ensures that Medicare has enough time to process plan choices so that coverage can begin without interruption on January 1, 2012. 

To access the Medicare Plan Finder, visit HERE

For more information about how the Affordable Care Act closes the donut hole over time, visit HERE

For state-by-state information on the number of people who are benefiting from discounts in the donut hole in 2011, visit HERE.

For state-by-state information on utilization of free preventive services and the Annual Wellness Visit, visit HERE.

For more information on Medicare’s prevention benefits, go to the Share the News. Share the Health! Website, visit HERE.

September 12, 2011. The Department of Health and Human Services (HHS) has announced new guidance to support enforcement of rules that protect hospital patients’ right to choose their own visitors during a hospital stay, including a visitor who is a same-sex domestic partner.

These rules, finalized by the Centers for Medicare & Medicaid Services (CMS) last year, apply to all hospitals that participate in Medicare and Medicaid. The guidance also supports enforcement of the right of patients to designate the person of their choice; including a same-sex partner, to make medical decisions on their behalf should they become incapacitated.

The rules updated the Conditions of Participation (CoPs), which are the health and safety standards all Medicare and Medicaid participating hospitals and critical access hospitals must meet, and apply to all patients of those hospitals even if they are not on Medicare or Medicaid. Among other things, the CoPs require hospitals to explain to all patients their right to choose who may visit them during their inpatient stay, regardless of whether the visitor is a family member, a spouse, a domestic partner (including a same-sex domestic partner), or another type of visitor, as well as their right to withdraw such consent to visitation at any time.

CMS has sent a letter to State Survey Agencies (SSA), which conduct on-site inspections of hospitals on behalf of CMS. The letter highlights the equal visitation and representation rights requirements and directs SSAs to be aware of the guidance when evaluating hospitals' compliance with CoPs.

For more information on the CMS rules issued, visit HERE and to view a copy of the letter sent to State Survey Agencies, please visit HERE.

August 8, 2011. The Centers for Medicare & Medicaid Services (CMS) has announced changes to existing tools and the development of a new tool for patients and caregivers to empower consumers to make informed choices about their health care, and to help improve the quality of care in America’s hospitals, nursing homes, physician offices, and other health care settings. CMS has developed the following:

  • A Quality Care Finder to provide consumers with one online destination to access all of Medicare’s Compare tools -- comparison information on hospitals, nursing homes and plans;

  • An updated Hospital Compare website, which now includes data about how well hospitals protect outpatients from surgical infections and whether hospitals care for outpatients who are treated for suspected heart attacks with proven therapies that reduce death; and 

  • An enhanced Quality Improvement Organization (QIO) program under which QIOs provide technical assistance and resources to health care providers across the country to assist them in changing how care is delivered in hospitals, nursing homes, physician offices, and across care settings.

The QIOs will integrate and coordinate care across settings within communities, improve community health by promoting preventive services, and make health care costs sustainable in the long term by supporting care that keeps patients safe from costly and dangerous complications and harm. The work supports the administration’s National Quality Strategy and its Partnership for Patients, designed to build collaborative models to improve health care quality, reduce hospital-acquired conditions and lower hospital readmissions.

For more information about the QIO Program, visit the CMS website HERE, and for more information about Hospital Compare, visit HERE.

July 26, 2011. Last week, the Centers for Medicare & Medicaid Services (CMS) took steps to encourage the creation of Consumer Operated and Oriented Plans (CO-OPs), new private non-profit, consumer-governed health insurance plans that will help increase competition and give consumers and small businesses additional affordable health insurance choices. CMS is proposing standards for CO-OPs, and for qualifying for $3.8 billion in repayable loans to help start-up and capitalize these new health plans. All CO-OP loans must be repaid with interest and loans will only be made to private, nonprofit entities that demonstrate a high probability of becoming financially viable.

CO-OPs are designed to give consumers and small businesses control over their own health insurance.  CO-OPs are private, non-profit insurers governed by their members and offering affordable, consumer-friendly health insurance options. CO-OPs will use any profits to benefit its members, including actions to lower premiums, improve health benefits, improve the quality of members’ health care, expand enrollment, or otherwise contribute to the stability of coverage for members.

Working from the recommendations of the public advisory committee, the rules proposing the framework were developed with significant input from many stakeholders, including testimony at public meetings from consumers, small businesses and health care providers. The proposed rule is only a first step. CMS is taking public comment on the proposal and expects to release a Funding Opportunity Announcement regarding the availability of loans to start up CO-OPs soon.

For more information and to read the fact sheet, visit HERE.  

July 11, 2011. The U.S. Department of Health and Human Services (HHS) recently announced three new initiatives to help states improve the quality and lower the cost of care for the approximately nine million Americans who are eligible for both Medicare and Medicaid. The announcement comes as part of the Obama Administration’s ongoing efforts to provide states with flexibility and resources to better serve high-need, high-cost enrollees. Initiatives include:

  • A technical resource center available to all states to help them improve care for high-need high-cost beneficiaries.  

States and the federal government spend more than $300 billion each year to care for Americans eligible for Medicare and Medicaid. In Medicaid, these individuals represented 15 percent of enrollees and 39 percent of all Medicaid expenditures. In Medicare, they represented 16 percent of enrollees and 27 percent of program expenditures.

For more information about these initiatives, visit HERE and to see a blog posting on this topic by Dr. Don Berwick, CMS Administrator, visit HERE.

June 27, 2011. The Centers for Medicare & Medicaid Services (CMS) has issued a final rule that will reduce or prohibit Medicaid payments to doctors, hospitals or other healthcare providers for services that resulted in preventable healthcare-acquired illness or injury.
This rule, which was intended to lower states' Medicaid costs, is based on successful Medicare policies placed on hospitals. According to CMS, the rule better aligns Medicare and Medicaid payment policy, while offering states some flexibility. States will be allowed to expand the list of preventable conditions and identify which healthcare settings Medicaid may or may not deny payment. Preventable conditions include falls and trauma, blood incompatibility, catheter-associated urinary tract infections, pressure ulcers, poor glycemic control and others.

The final rule is effective July 1, 2011 but gives states the option to implement between its effective date and July 1, 2012. To view the regulation, visit HERE.

May 23, 2011. On May 17, National Association of Children’s Hospitals (N.A.C.H.) met with Centers for Medicare and Medicaid Services (CMS) Medicaid/CHIP staff to discuss pediatric quality activities. The discussion centered on how the Association and agency could work together to ensure children are not left out of agency-wide quality initiatives and innovations occurring as a result of health reform. Specifically, participants discussed the Partnership for Patients and how Medicaid would be included in this effort. Also discussed were the ways in which the Association and federal agency could work together to influence the Center for Medicare and Medicaid Innovation and produce projects focused on improving quality of care for children, reducing unnecessary health care costs. Dr. Marlene Miller, National Association of Children’s Hospitals and Related Institutions’ (NACHRI) Vice President for Quality Transformation, participated in the meeting and shared information on the successes of the collaborative that children’s hospitals have spearheaded to reduce catheter-associated blood stream infections. CMS staff members were interested in this effort and have begun to review ways of increasing the visibility of the program with states and other parts of CMS. CMS staff agreed to regular meetings/communication with N.A.C.H. to keep each other updated on ongoing work and to explore opportunities to move the pediatric quality agenda ahead.

May 16, 2011. Centers for Medicare and Medicaid Services (CMS) has published a proposed rule that would require a standardized, transparent process for states to determine if provider payments create access problems for Medicaid beneficiaries. Until now, CMS had not issued any regulations specifying what states must do to assure access to Medicaid services.

The rule would clarify that beneficiary access must be considered in setting and adjusting payment methodologies for Medicaid services. It would require periodic reviews of compliance with the access requirements and obligate state Medicaid agencies to review and monitor service access. By January 1 of each year, every state would be required to conduct access reviews for a subset of selected Medicaid services and release results publically. Each Medicaid service must be reviewed at least once every five years. The proposed rule only applies to the fee-for-service program and does not extend to services provided through managed care arrangements.

Governors will likely be highly critical of the proposed rule arguing that it limits their options for managing state Medicaid costs, beyond the constraints on changes to eligibility or benefits already imposed by the federal health reform law.

May 9, 2011. The Centers for Medicare and Medicaid Services (CMS) has released a final rule entitled “Medicaid Program; Federal Funding for Medicaid Eligibility Determination and Enrollment Activities,” which outlines how the federal government will aid states as they prepare their enrollment systems for the Medicaid expansion in 2014. Specifically, through December 31, 2015, the federal government will cover 90 percent of the cost of developing and upgrading IT systems that aid individuals in enrolling in Medicaid and the Children’s Health Insurance Program. Additionally, in 2016 and beyond, states may continue to receive 75 percent of the ongoing operational cost for these systems from CMS. Both rates are an increase from the 50 percent federal financial matching rate previously available for most Medicaid administrative expenses. However, in order for states to receive these additional funds, eligibility systems must meet the performance standards which are outlined HERE.

August 7, 2009. It was announced this week that the Centers for Medicare and Medicaid Services (CMS) will be restoring the $1.5 million cut to Capital Indirect Graduate Medical Education (IME) in FY2010 (starting October 1). CMS released the final Inpatient Prospective Payment Systems (IPPS) rule this past week. Originally, the proposed rule included the 100% reduction to this fund. VCU has worked with our Congressional delegation as well as CMS on this issue over the past two years.

May 15, 2009. Fifty-six senators yesterday asked the Centers for Medicare & Medicaid Services to withdraw a proposed payment cut to teaching hospitals scheduled to take effect October 1 under the proposed inpatient prospective payment system rule. The rule would phase out the indirect medical education adjustment paid to teaching hospitals for their capital expenditures. Senator Mark Warner’s signature was included on the letter.

May 8, 2009. On May 1, the Centers for Medicare & Medicaid Services (CMS) issued its hospital inpatient and long-term care prospective payment system proposed rule for FY 2010. The rule proposed a 1.9 percent cut to eliminate what CMS claims is the effect of coding or classification changes the agency says do not reflect real changes in case-mix. In total, this proposal would cut $1.9 billion for FY 2010 and $22.1 billion over 10 years. Due to the coding offset cut, with other policy changes, hospitals will see their FY 2010 payments decrease by 0.5 percent on average compared to FY 2009.

In this rule, CMS also reiterates that it will eliminate the adjustment for capital indirect medical education (IME) for FY 2010 and beyond. Although Congress retroactively prevented CMS from reducing the IME adjustment to capital payments by 50 percent in FY 2009, it did not prevent the agency from going forward with its already-finalized plan to eliminate the IME adjustment completely in FY 2010. The elimination of this payment would result in a loss to VCUHS of approximately $1.5 million annually. VCU is working with our Congressional delegation to sign on to a letter to the acting CMS Administrator to halt these cuts.

If you have questions, contact Mark Rubin ( Our office phone number is: 804-828-1235.