According
to authors Jung and Feldman, the introduction of Home Health Compare, a
public reporting program initiated by Medicare in 2003, had a very
small and weak effect on selective exits by home health agencies between
2002 and 2004,. A 10-percent increase in reporting, the equivalent to
reporting one more indicator per agency, increased the probability of a
home health agency leaving an area with less-educated people by 0.3
percentage points, compared with leaving an area with high education.
This small level of market-area exits under public reporting is unlikely
to be practically meaningful, suggesting that Home Health Compare did
not lead to a disruption in access to home health care through selective
exits during the initial year of the program. Read the full paper,
“Medication Days’ Supply, Adherence, Wastage, and Cost Among Chronic
Patients in Medicaid,” published in Volume 2, Issue 4 of the Medicare
& Medicaid Research Review.
Friday, January 18, 2013
Countdown to Affordable Health Insurance
January is the perfect month for looking forward to new and great things around the corner.
I’m feeling that way about the new Health Insurance Marketplace.
Anticipation is building, and this month we start an important
countdown, first to October 1, 2013, when open enrollment begins, and
continuing on to January 1, 2014, the start of new health insurance
coverage for millions of Americans. In October, many of you’ll be able
to shop for health insurance that meets your needs at the new
Marketplace at HealthCare.gov.
This is an historic time for those Americans who never had health
insurance, who had to go without insurance after losing a job or
becoming sick, or who had been turned down because of a pre-existing
condition. Because of these new marketplaces established under the
Affordable Care Act, millions of Americans will have new access to
affordable health insurance coverage.
Over the last two years we’ve worked closely with states to begin
building their health insurance marketplaces, also known as Exchanges,
so that families and small-business owners will be able to get accurate
information to make apples-to-apples comparisons of private insurance
plans and, get financial help to make coverage more affordable if
they’re eligible.
That is why we are so excited about launching the newly rebuilt HealthCare.gov
website, where you’ll be able to buy insurance from qualified private
health plans and check if you are eligible for financial assistance —
all in one place, with a single application. Many individuals and
families will be eligible for a new kind of tax credit to help lower
their premium costs. If your state is running its own Marketplace, HealthCare.gov will make sure you get to the right place.
The Marketplace will offer much more than any health insurance
website you’ve used before. Insurers will compete for your business on a
level playing field, with no hidden costs or misleading fine print.
It’s not too soon to check out HealthCare.gov for new information about the Marketplace
and tips for things you can do now to prepare for enrollment. And,
make sure to sign up for emails or text message updates, so you don’t
miss a thing when it’s time to enroll.
There is still work to be done to make sure the insurance market
works for families and small businesses. But, for millions of Americans,
the time for having the affordable, quality health care coverage,
security, and peace of mind they need and deserve is finally within
sight.
Mental Health Parity Guidance
Today
in connection with the President’s announcement regarding the national
response to the Sandy Hook tragedy, the Centers for Medicare & Medicaid Services (CMS) released a State Health Official letter on the
application of the Mental Health Parity and Addiction Equity Act to
Medicaid managed care organizations, the Children’s Health Insurance
Program, and alternative benefit (benchmark) plans.
The State Health Official letter is available online at http://www.medicaid.gov/
CMS NEWS
Millions of Americans newly eligible for quality, affordable health coverage in 2014
Administration proposes guidance for Medicaid, health insurance marketplaces
Because
of the Affordable Care Act, millions of Americans will be newly
eligible to receive quality, affordable health care through Medicaid and
the new health insurance marketplaces (also known as the Exchanges) in
2014. Health and Human Services (HHS) Secretary Kathleen Sebelius today
released a proposed rule that promotes consistent policies and
processes for eligibility notices and appeals in Medicaid, the
Children's Health Insurance Program (CHIP), and Exchanges and give
states more flexibility when operating their Medicaid programs. HHS
encourages all Americans to review and submit comments on the proposed
rule.
“Before
the health care law was passed, millions of Americans were unable to
obtain or afford quality health coverage,” Secretary Sebelius said.
“Today, we are proposing a rule to provide Americans with access to
affordable, high quality health coverage and give states more
flexibility to implement the law in a way that works for them.”
Beginning
in 2014, the health care law provides new opportunities for Medicaid
coverage for adults who earn up to 133 percent of poverty -- $14,865 for
an individual or $30,656 for a family of four. Other Americans looking
for coverage will be eligible to buy it through a health insurance
marketplace, where many will be eligible for tax credits to make
coverage more affordable. The rules proposed today will help develop
systems that will make it easy for consumers to determine if they are
eligible for Medicaid or tax credits that make insurance more
affordable.
Today’s
proposed rule includes information on how consumers will receive
coordinated communications on eligibility determinations and can appeal
eligibility determinations. It gives states flexibility in designing
benefits and determining cost sharing in the Medicaid program. The
proposed rule also provides flexibility to state-based Exchanges by
allowing them to choose to rely on HHS for verifying whether an
individual has employer-sponsored coverage and conducting some types of
appeals.
For more information on this proposed rule, please visit: http://www.cms.gov/apps/media/
Medicaid Eligibility, Benefits, and Appeals
We are pleased to announce that today CMS put on display in the Federal Register
a Notice of Proposed Rulemaking (NPRM) titled “Medicaid Eligibility
Expansion Under the Affordable Care Act of 2010, Part 2” (CMS-2334-P).
The NPRM provides further guidance to assist states with implementing
the Affordable Care Act’s plan for achieving a simple, streamlined
system of affordable health care for nearly all Americans. It will be
formally published on January 22, 2013. See attached for more
information.
For more information: Download
Health Home Core Quality Measures Guidance
The Centers for Medicare & Medicaid Services (CMS) is pleased to announce the
availability of new guidance today related to health homes, authorized
by section 2703 of the Affordable Care Act. Health homes provide an
opportunity to build a person-centered care delivery model that focuses
on improving outcomes and disease management for beneficiaries with
chronic conditions and obtaining better value for state Medicaid
programs. See attached for more information.
Tuesday, January 15, 2013
Medicare doctor pay freeze until 2014 — 26.5% cut averted
Washington Congress on New Year’s Day stopped a massive reduction to Medicare doctor payments by freezing rates at 2012 levels for one year.
Late on Jan. 1, the House voted for a measure the Senate approved early that morning that overrides a 26.5% cut to Medicare pay that technically went into effect at the beginning of the day. The bill preventing the steep reduction in pay for services passed Congress as part of a larger legislative package that also extends certain tax cuts and postpones across-the-board spending reductions.
President Obama had urged Congress to adopt the compromise bill and said he would sign it into law, meaning the Medicare rate cut will not apply to any 2013 claims.
The patch alleviates the problem only temporarily, said American Medical Association President Jeremy A. Lazarus, MD. Congress delayed the cut until 2014, when payment rates will be reduced by about 25% without further congressional action, according to current projections. The unstable Medicare pay system must be dealt with permanently over the coming months, Dr. Lazarus added.
“This last-minute action on the part of Congress is a clear example of how the Medicare program is increasingly unreliable for physicians and patients,” he said. “This instability stalls progress in moving Medicare toward new health care delivery models that can improve value for patients through better care coordination. Physicians want to work with Congress to move past this ongoing crisis and toward a Medicare program that ensures access to care and the best health outcomes for patients, and a stable, rewarding practice environment for physicians.”
The package also delays by two months a separate 2% cut to Medicare physician pay mandated under the automatic spending reduction process known as budget sequestration. Congress must act again by March 1 if it wants to prevent that reduction from taking place.
Spending reductions in other areas of Medicare were used to offset the $25.2 billion cost of stopping the sustainable growth rate cut for 2013. An inpatient prospective payment system adjustment cuts $10.5 billion from hospitals from 2014-18. Revisions to how Medicare calculates bundled payments for end-stage renal disease treatments would save $4.9 billion over 10 years. An expansion of the Medicare payment policy that pays less for multiple therapy services provided to the same patient on the same day secures another $1.8 billion for the program, while another provision reduces pay by $800 million for advanced imaging services. Rebasing state disproportionate share hospital payments in 2022 would produce another $4.2 billion in federal health savings.
The legislation also extends several Medicare payment provisions that were set to expire on Dec. 31, 2012. A $500 million increase to physician rates for doctors working in low-cost states will continue until 2014. Exemptions to caps on therapy services also were extended through the end of 2013.
Late on Jan. 1, the House voted for a measure the Senate approved early that morning that overrides a 26.5% cut to Medicare pay that technically went into effect at the beginning of the day. The bill preventing the steep reduction in pay for services passed Congress as part of a larger legislative package that also extends certain tax cuts and postpones across-the-board spending reductions.
President Obama had urged Congress to adopt the compromise bill and said he would sign it into law, meaning the Medicare rate cut will not apply to any 2013 claims.
The patch alleviates the problem only temporarily, said American Medical Association President Jeremy A. Lazarus, MD. Congress delayed the cut until 2014, when payment rates will be reduced by about 25% without further congressional action, according to current projections. The unstable Medicare pay system must be dealt with permanently over the coming months, Dr. Lazarus added.
“This last-minute action on the part of Congress is a clear example of how the Medicare program is increasingly unreliable for physicians and patients,” he said. “This instability stalls progress in moving Medicare toward new health care delivery models that can improve value for patients through better care coordination. Physicians want to work with Congress to move past this ongoing crisis and toward a Medicare program that ensures access to care and the best health outcomes for patients, and a stable, rewarding practice environment for physicians.”
The package also delays by two months a separate 2% cut to Medicare physician pay mandated under the automatic spending reduction process known as budget sequestration. Congress must act again by March 1 if it wants to prevent that reduction from taking place.
Spending reductions in other areas of Medicare were used to offset the $25.2 billion cost of stopping the sustainable growth rate cut for 2013. An inpatient prospective payment system adjustment cuts $10.5 billion from hospitals from 2014-18. Revisions to how Medicare calculates bundled payments for end-stage renal disease treatments would save $4.9 billion over 10 years. An expansion of the Medicare payment policy that pays less for multiple therapy services provided to the same patient on the same day secures another $1.8 billion for the program, while another provision reduces pay by $800 million for advanced imaging services. Rebasing state disproportionate share hospital payments in 2022 would produce another $4.2 billion in federal health savings.
The legislation also extends several Medicare payment provisions that were set to expire on Dec. 31, 2012. A $500 million increase to physician rates for doctors working in low-cost states will continue until 2014. Exemptions to caps on therapy services also were extended through the end of 2013.
Medicare pay reprieve in place; next threat is 2% cut in March
Washington After another year-end nail-biter on Capitol Hill in which lawmakers made preventing a massive Medicare physician pay cut their last action before adjourning, organized medicine called on Congress to chart a more rational course on the issue in 2013.
Late on Jan. 1, the House voted in favor of a legislative package approved by the Senate in the early hours of the morning that postponed a 26.5% cut to doctors’ pay rates mandated by the sustainable growth rate formula, clearing the way for President Obama’s signature on Jan. 2. Although enactment technically came after the cut officially had taken effect, the result of the retroactive measure is that all 2013 physician claims will be paid at 2012 levels. The House vote on the package was 257-167, and the Senate vote was 89-8.
Organized medicine groups, including the American Medical Association, hailed the passage of the latest SGR patch but reiterated their strong belief that Congress must approve a permanent solution that avoids the recurring year-end drama that ensues from leaving the temporary measure until the eleventh hour. The latest stopgap freezes doctor pay rates only through the end of 2013, after which the formula again will slash rates by about a quarter without a new legislative revision.
“This last-minute action on the part of Congress is a clear example of how the Medicare program is increasingly unreliable for physicians and patients,” said AMA President Jeremy A. Lazarus, MD. “This instability stalls progress in moving Medicare toward new health care delivery models that can improve value for patients through better care coordination. Physicians want to work with Congress to move past this ongoing crisis and toward a Medicare program that ensures access to care and the best health outcomes for patients, and a stable, rewarding practice environment for physicians.”
David L. Bronson, MD, president of the American College of Physicians, said it was regrettable that Congress did not pursue a more lasting solution to the chronic problem of the physician pay formula.
“In the short term, this legislation helps ensure access to high-quality medical care for Medicare beneficiaries, and ensures that physician payments under Medicare will not be cut through 2013,” Dr. Bronson said. “However, a greater bipartisan effort is still needed in the coming year to approve legislation that permanently repeals once and for all the flawed SGR formula, and transitions to payment models that provide predictable annual updates to physicians participating in Medicare, while being aligned with the provision of high-quality and efficient care.”
Medicare sequester cut still looms
The SGR patch was included in a broader legislative tax and spending package designed to address major elements of what lawmakers and others have referred to as the fiscal cliff. The measure extends some tax cuts for many Americans and postpones a series of automatic federal defense and nondefense spending reductions known as sequestration.
Medicare physician pay rates and many other federal expenditures would be affected by the sequester, the consequence of Congress and the Obama administration failing to agree on more targeted spending cuts during 2011 negotiations. If such an agreement or another delay cannot be achieved by March 1, the new sequestration deadline established by the departing 112th Congress, doctor pay will be reduced by 2% under the automatic cuts. Certain non-Medicare health programs, such as clinical research and health professions funding, will be cut by 7.8% for 2013.
“The sequestration’s 2% cut in Medicare physician payment undercuts the positive impact of the 12-month patch to the sustainable growth rate,” said Glen Stream, MD, the American Academy of Family Physicians board chair. “Such a cut perpetuates the cycle of instability that elderly and disabled Americans have suffered for more than 10 years.”
Dr. Stream added that the higher sequester cut on health professions grants would endanger the ability of the primary care work force to meet future patient demand.
Even if the 113th Congress forges an agreement with the White House over alternative spending reductions to the across-the-board cuts, federal health programs are likely to shoulder a significant portion of the load. Medicaid spending, as well as Medicare benefits and eligibility, cannot be touched by sequestration, but lawmakers are under no such restrictions when crafting an alternative plan.
Obama acknowledged Medicare as a major driver of the national debt in remarks after House approval of the fiscal cliff package.
“I agree with Democrats and Republicans that the aging population and the rising cost of health care makes Medicare the biggest contributor to our deficit,” Obama said on Jan. 1 after the House vote. “I believe we’ve got to find ways to reform that program without hurting seniors who count on it to survive. And I believe that there’s further unnecessary spending in government that we can eliminate.”
Deep partisan disagreements over allowing tax rates to rise on higher-income earners nearly torpedoed the entire Jan. 1 package, including the Medicare pay freeze. Congressional observers predicted another bruising fight over spending in the months leading up to the new sequestration deadline.
“The bill sets Congress and the White House up to revisit these battles and a major deficit reduction effort in two months,” said Eric Zimmerman, a partner in the Washington office of McDermott Will & Emery. “Sometime between now and March 1, 2013, Congress and the White House will need to come to agreement on how to reapportion sequestration, fund the federal government for the balance of [fiscal] 2013 and raise the debt ceiling, and Medicare and Medicaid spending will feature prominently in those debates.”
Hospital, dialysis, imaging pay take hits
The passage of the latest physician payment patch only delays the SGR cut by a year, but the move did not come without a significant cost. Other areas of Medicare, some of which might impact doctors’ pay directly, were subjected to cuts to help pay for the temporary solution. The $25.2 billion cost of freezing Medicare doctor pay rates at 2012 levels — as well as the roughly $4 billion cost of extending certain expiring Medicare and other health payment provisions — was paid for in large part by reducing payments to hospitals, dialysis providers and Medicare private plans.
Hospital organizations expressed disappointment at being hit with cuts that were used as offsets for the across-the-board physician pay freeze and Medicare extensions. One offset involves changing the inpatient prospective payment system to reduce hospital payments by $10.5 billion.
“It is not in the best interest of patients or those who care for them to rob hospital Peter to pay for fiscal cliff Paul,” said Chip Kahn, the Federation of American Hospitals president and CEO. “These cuts could impact hospital services for those who need them the most.”
In addition, revisions in the way Medicare calculates the expected use of certain drugs when bundling payments for end-stage renal disease treatment providers also will result in $4.9 billion in pay reductions that the ACP’s Dr. Bronson noted will affect compensation for physicians providing care to kidney disease patients.
The American College of Radiology blasted Congress for approving an offset provision that will reduce payments for certain advanced imaging services by $800 million to help pay for the SGR patch.
“Reverting to continuous provider cuts to help pay for a morbidly flawed payment policy, in an environment that resembles more ‘Alice in Wonderland’ than ‘Mr. Smith Goes to Washington,’ is an embarrassment to our country and a disservice to our nation’s seniors,” said Paul Ellenbogen, MD, chair of the ACR Board of Chancellors. “These cuts will ultimately damage patient access to medical imaging care and may drive up long-term costs by delaying diagnosis of illness and disease to later stages where more expansive, and expensive, treatments are required.”
Dr. Bronson noted, however, that lawmakers did not pursue some ideas for savings that were floated during budget negotiations, such as rescinding a health system reform law provision that raises Medicaid rates for primary care physicians to Medicare levels in 2013 and 2014. Congress also steered clear of cuts to graduate medical education as well as evaluation and management changes that would have reduced hospital pay further.
Late on Jan. 1, the House voted in favor of a legislative package approved by the Senate in the early hours of the morning that postponed a 26.5% cut to doctors’ pay rates mandated by the sustainable growth rate formula, clearing the way for President Obama’s signature on Jan. 2. Although enactment technically came after the cut officially had taken effect, the result of the retroactive measure is that all 2013 physician claims will be paid at 2012 levels. The House vote on the package was 257-167, and the Senate vote was 89-8.
Organized medicine groups, including the American Medical Association, hailed the passage of the latest SGR patch but reiterated their strong belief that Congress must approve a permanent solution that avoids the recurring year-end drama that ensues from leaving the temporary measure until the eleventh hour. The latest stopgap freezes doctor pay rates only through the end of 2013, after which the formula again will slash rates by about a quarter without a new legislative revision.
“This last-minute action on the part of Congress is a clear example of how the Medicare program is increasingly unreliable for physicians and patients,” said AMA President Jeremy A. Lazarus, MD. “This instability stalls progress in moving Medicare toward new health care delivery models that can improve value for patients through better care coordination. Physicians want to work with Congress to move past this ongoing crisis and toward a Medicare program that ensures access to care and the best health outcomes for patients, and a stable, rewarding practice environment for physicians.”
David L. Bronson, MD, president of the American College of Physicians, said it was regrettable that Congress did not pursue a more lasting solution to the chronic problem of the physician pay formula.
“In the short term, this legislation helps ensure access to high-quality medical care for Medicare beneficiaries, and ensures that physician payments under Medicare will not be cut through 2013,” Dr. Bronson said. “However, a greater bipartisan effort is still needed in the coming year to approve legislation that permanently repeals once and for all the flawed SGR formula, and transitions to payment models that provide predictable annual updates to physicians participating in Medicare, while being aligned with the provision of high-quality and efficient care.”
Medicare sequester cut still looms
The SGR patch was included in a broader legislative tax and spending package designed to address major elements of what lawmakers and others have referred to as the fiscal cliff. The measure extends some tax cuts for many Americans and postpones a series of automatic federal defense and nondefense spending reductions known as sequestration.
Medicare physician pay rates and many other federal expenditures would be affected by the sequester, the consequence of Congress and the Obama administration failing to agree on more targeted spending cuts during 2011 negotiations. If such an agreement or another delay cannot be achieved by March 1, the new sequestration deadline established by the departing 112th Congress, doctor pay will be reduced by 2% under the automatic cuts. Certain non-Medicare health programs, such as clinical research and health professions funding, will be cut by 7.8% for 2013.
“The sequestration’s 2% cut in Medicare physician payment undercuts the positive impact of the 12-month patch to the sustainable growth rate,” said Glen Stream, MD, the American Academy of Family Physicians board chair. “Such a cut perpetuates the cycle of instability that elderly and disabled Americans have suffered for more than 10 years.”
Dr. Stream added that the higher sequester cut on health professions grants would endanger the ability of the primary care work force to meet future patient demand.
Even if the 113th Congress forges an agreement with the White House over alternative spending reductions to the across-the-board cuts, federal health programs are likely to shoulder a significant portion of the load. Medicaid spending, as well as Medicare benefits and eligibility, cannot be touched by sequestration, but lawmakers are under no such restrictions when crafting an alternative plan.
Obama acknowledged Medicare as a major driver of the national debt in remarks after House approval of the fiscal cliff package.
“I agree with Democrats and Republicans that the aging population and the rising cost of health care makes Medicare the biggest contributor to our deficit,” Obama said on Jan. 1 after the House vote. “I believe we’ve got to find ways to reform that program without hurting seniors who count on it to survive. And I believe that there’s further unnecessary spending in government that we can eliminate.”
Deep partisan disagreements over allowing tax rates to rise on higher-income earners nearly torpedoed the entire Jan. 1 package, including the Medicare pay freeze. Congressional observers predicted another bruising fight over spending in the months leading up to the new sequestration deadline.
“The bill sets Congress and the White House up to revisit these battles and a major deficit reduction effort in two months,” said Eric Zimmerman, a partner in the Washington office of McDermott Will & Emery. “Sometime between now and March 1, 2013, Congress and the White House will need to come to agreement on how to reapportion sequestration, fund the federal government for the balance of [fiscal] 2013 and raise the debt ceiling, and Medicare and Medicaid spending will feature prominently in those debates.”
Hospital, dialysis, imaging pay take hits
The passage of the latest physician payment patch only delays the SGR cut by a year, but the move did not come without a significant cost. Other areas of Medicare, some of which might impact doctors’ pay directly, were subjected to cuts to help pay for the temporary solution. The $25.2 billion cost of freezing Medicare doctor pay rates at 2012 levels — as well as the roughly $4 billion cost of extending certain expiring Medicare and other health payment provisions — was paid for in large part by reducing payments to hospitals, dialysis providers and Medicare private plans.
Hospital organizations expressed disappointment at being hit with cuts that were used as offsets for the across-the-board physician pay freeze and Medicare extensions. One offset involves changing the inpatient prospective payment system to reduce hospital payments by $10.5 billion.
“It is not in the best interest of patients or those who care for them to rob hospital Peter to pay for fiscal cliff Paul,” said Chip Kahn, the Federation of American Hospitals president and CEO. “These cuts could impact hospital services for those who need them the most.”
In addition, revisions in the way Medicare calculates the expected use of certain drugs when bundling payments for end-stage renal disease treatment providers also will result in $4.9 billion in pay reductions that the ACP’s Dr. Bronson noted will affect compensation for physicians providing care to kidney disease patients.
The American College of Radiology blasted Congress for approving an offset provision that will reduce payments for certain advanced imaging services by $800 million to help pay for the SGR patch.
“Reverting to continuous provider cuts to help pay for a morbidly flawed payment policy, in an environment that resembles more ‘Alice in Wonderland’ than ‘Mr. Smith Goes to Washington,’ is an embarrassment to our country and a disservice to our nation’s seniors,” said Paul Ellenbogen, MD, chair of the ACR Board of Chancellors. “These cuts will ultimately damage patient access to medical imaging care and may drive up long-term costs by delaying diagnosis of illness and disease to later stages where more expansive, and expensive, treatments are required.”
Dr. Bronson noted, however, that lawmakers did not pursue some ideas for savings that were floated during budget negotiations, such as rescinding a health system reform law provision that raises Medicaid rates for primary care physicians to Medicare levels in 2013 and 2014. Congress also steered clear of cuts to graduate medical education as well as evaluation and management changes that would have reduced hospital pay further.
Source: http://www.ama-assn.org/amednews/2013/01/07/gvl10107.htm
Wednesday, January 2, 2013
Reconciling Medical Expenditure Estimates from the MEPS and NHEA, 2012
“Reconciling Medical Expenditure Estimates from the MEPS and NHEA, 2007,” published in Volume 2, Issue 4 of the Medicare & Medicaid Research Review, provides a comparison of health care expenditure estimates for 2007 from the Medical Expenditure Panel Survey (MEPS) and the National Health Expenditure Accounts (NHEA). The study focuses on the personal health care (PHC) sector, which includes the goods and services rendered to treat or prevent a specific disease or condition in an individual. The official 2007 NHEA estimate for PHC spending is $1,915 billion and the MEPS estimate is $1,126 billion. Adjusting the NHEA estimates for differences in underlying populations, covered services, and other measurement concepts reduces the NHEA estimate for 2007 to $1,366 billion. As a result, MEPS is $240 billion, or 17.6 percent less than the adjusted NHEA total. The reconciliation provides a consistent baseline of health expenditure data for policy simulations, enabling researchers to adjust MEPS to be consistent with the NHEA so that the projected costs, as well as budgetary and tax implications of any policy change are consistent with national health spending estimates.
www.cms.gov/Research-Statistics-Data-and-Systems/Research/MMRR/Downloads/MMRR2012_002_04_a09.pdf
CMS Announces 90-Day Period of Enforcement Discretion for Compliance with Eligibility and Claim Status Operating Rules
Today, the Centers for Medicare & Medicaid Services’ Office of E-Health Standards and Services (OESS) announced that to reduce the potential of significant disruption to the health care industry, it will not initiate enforcement action until March 31, 2013, with respect to HIPAA covered entities (including health plans, health care providers, and clearinghouses, as applicable) that are not in compliance with the operating rules adopted for the following transactions as required by the Affordable Care Act: eligibility for a health plan and health care claim status. Notwithstanding OESS’ discretionary application of its enforcement authority, the compliance date for using the operating rules remains January 1, 2013.
Industry feedback suggests that HIPAA covered entities have not reached a threshold whereby a majority of covered entities would be able to be in compliance with the operating rules by January 1, 2013. This enforcement discretion period does not prevent applicable HIPAA covered entities that are prepared to conduct transactions using the adopted operating rules from doing so, and all applicable covered entities are encouraged to determine their readiness to use the operating rules as of January 1, 2013 and expeditiously become compliant. Although enforcement action will not be taken, OESS will accept complaints associated with compliance with the operating rules beginning January 1, 2013. If requested by OESS, covered entities that are the subject of complaints (known as “filed-against entities”) must produce evidence of either compliance or a good faith effort to become compliant with the operating rules during the 90-day period. HHS will continue to work to align the requirements under Section 1104 of the Affordable Care Act to optimize industry’s ability to achieve timely compliance.
OESS is the U.S. Department of Health and Human Services’ (HHS) component that enforces compliance with HIPAA transaction and code set standards, including operating rules, identifiers and other standards required under HIPAA by the Affordable Care Act.
For copies of the operating rules for the eligibility for a health plan and health care claim status transactions, visit the Council for Affordable Quality Healthcare (CAQH) CORE website at http://www.caqh.org. Links to information on the operating rules for eligibility for a health plan and health care claim status are available at http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Affordable-Care-Act/OperatingRulesforEligibilityandClaimsStatus.html
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