Weekly Health Care Policy Update – July 12, 2024

July 19, 2024

In this update: 

  • Federal Agencies
    • CMS Releases Medicare Physician Fee Schedule Proposed Rule
    • ONC Releases HTI-2 Proposed Rule
    • CMMI Announces Making Care Primary Participants
    • CMS Releases Proposed CY 2025 OPPS and ASC Payment Rule
    • CMS Names First Cohort of AHEAD States
    • CMS to Hold AHEAD Financial Specifications Webinar
    • CMS Sends Letter to Hospital Associations on EMTALA
    • CMMI Launches GUIDE Model and Announces Participants
    • Biden Administration Releases 2024 Spring Unified Agenda
    • CMS Proposes Rule to Implement DME Fix for ACOs
    • CMS Issues Updated MA Quality Scores
    • FTC Releases Interim Report on PBMs
  • Other Updates
    • Judge Delays FTC Noncompete Rule
    • Coalition for Health AI Publishes Framework for Assurance Standards
    • RNC Releases 2024 Platform
  • New York State Updates
    • DOH Finalizes Rule on SHIN-NY Statewide Data Infrastructure and Participation Agreement
    • DFS Finalizes Guidance on Insurers’ Use of AI and External Consumer Data
    • DOH Proposes Update to EMS Equipment and Waiver Regulations
    • OPWDD Announces New Acting Commissioner Willow Baer
    • Governor Hochul Signs Bills on HIV/AIDS Prevention and Care
    • DOH Releases Tenth Monthly PHE Dashboard
    • CWE Announces Webinars on CFTSS Evidence-Based Practice Implementation
    • DOH Announces Dual Enrollment Option for Children’s Health Home and Early Intervention Services
    • DOH Proposes to Maintain MCO Contingent Reserve Requirement at 7.25%

Federal Agencies

CMS Releases Medicare Physician Fee Schedule Proposed Rule 
On July 10th, the Centers for Medicare and Medicaid Services (CMS) released the Calendar Year (CY) 2025 Medicare Physician Fee Schedule (PFS) proposed rule. As required by current statute, the 2025 PFS would reduce average payment rates by 2.93% relative to CY 2024. Key policies in the proposed rule include: 

  • Conversion Factor: CMS is proposing the CY 2025 PFS conversion factor to be $32.36, representing a decrease of $0.93 from the CY 2024 PFS conversion factor of $33.29. This number may only be increased by Congressional action.
  • Improving Ambulatory Specialty Care RFI: CMS is requesting stakeholder input to design an ambulatory specialty care model that utilizes the Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs).
  • Caregiver Training Services (CTS): CMS is proposing new coding and payment for caregiver training for direct care services and supports.
  • Services Addressing Health-Related Social Needs (HRSN) RFI: CMS is requesting stakeholder input on the new Community Health Integration services, Principal Illness Navigation services, and Social Determinants of Health (SDOH) Risk Assessment.
  • Office/Outpatient (O/O) Evaluation and Management (E/M) Visits: CMS is proposing payment for the O/O E/M visit complexity add-on code in certain circumstances.
  • Telehealth Services under the PFS: CMS is proposing several new services to the Medicare Telehealth Services List. Additionally, CMS is proposing a continuation of the suspension of frequency limitations for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations. If finalized, CMS would allow real-time audio-only care in certain circumstances. The proposed rule includes other technical changes, including site and supervision regulations, including with teaching physicians.
  • Advanced Primary Care Management Services (APCM) and RFI: CMS is proposing payment for a new set of APCM services through three codes: Principal Care Management, Transitional Care Management, and Chronic Care Management. Additionally, CMS is requesting stakeholder input on additional payment policies that could better support the delivery of these services.
  • Cardiovascular Risk Assessment and Management: CMS is proposing coding and payment for an Atherosclerotic Cardiovascular Disease (ASCVD) risk assessment service and risk management services, after previous success with the Million Hearts Model.
  • Strategies for Improving Global Surgery Payment Accuracy: CMS is proposing to broaden transfer of care modifiers for global packages and require the use of existing modifiers for all 90-day global surgical packages in certain circumstances to more accurately reflect the time and resources spent furnishing services.
  • Behavioral Health Services: CMS is proposing new codes for suicide safety planning, digital mental health treatment devices, and specialty provider billing. CMS is requesting stakeholder input on whether coding and payment for Intensive Outpatient Program (IOP) could apply to other settings.
  • Opioid Treatment Programs (OTPs): CMS is proposing new telecommunication flexibilities for opioid use disorder (OUD) services in OTPs, payment increases for intake activities, and payment for new opioid agonist and antagonist medications approved by the Food & Drug Administration (FDA).
  • Medicare Part B Payment for Preventive Services: CMS is proposing measures to expand access to the Hepatitis B vaccine and Pre-Exposure Prophylaxis (PrEP).
  • Expand Colorectal Cancer Screening: CMS is proposing the inclusion of new screening technologies for colorectal cancer.
  • Medicare Prescription Drug Inflation Rebate Program: CMS is proposing to codify policies established in the revised guidance for the Medicare Part B Drug Inflation Rebate Program and Medicare Part D Drug Inflation Rebate Program, including provisions pertaining to 340B units and reconciliation processes.

The rule will remain open for comment until September 9th. The proposed rule is available here. The fact sheet is available here.

ONC Releases HTI-2 Proposed Rule
On July 10th, the Office of the National Coordinator for Health IT (ONC) released the Health Data, Technology, and Interoperability: Patient Engagement, Information Sharing, and Public Health Interoperability (HTI-2) proposed rule, which builds on HTI-1. This rule is a culmination of recent ONC efforts to enhance interoperability between patients, providers, payers, and public health authorities. This sweeping proposed rule includes provisions from the 21st Century Cures Act as well as novel regulations. Key policies in the proposed rule include:   

  • CMS: The proposed rule includes technical support for new requirements in CMS’ Interoperability and Prior Authorization final rule.
  • Public Health: The proposed rule includes two sets of new certification criteria to support health IT for public health and payers certified under the ONC Health IT Certification Program.
  • U.S. Core Data for Interoperability (USCDI): The proposed rule would require that USCDI version 4 be adopted by the start of 2028.
  • Real-Time Prescription Benefit Tool: The proposed rule includes provisions from the Consolidated Appropriations Act, 2021 that would create a new real-time prescription benefit tool certification criterion to support patient and provider decision making.

The proposed rule will be open for comment until September 9th. The announcement is available here, and the proposed rule is available here.

CMMI Announces Making Care Primary Participants 
On July 10th, CMMI announced the participants in the Making Care Primary (MCP) Model. MCP is a voluntary, progressive, three-track model meant to bolster care management and coordination while addressing unmet medical and social needs across eight states (Colorado, North Carolina, New Jersey, New Mexico, New York, Minnesota, Massachusetts and Washington). MCP includes three tracks: Building Infrastructure, Implementing Advanced Primary Care, and Optimizing Care and Partnerships. Overall, CMS announced 133 participants including small primary care organizations and Federally Qualified Health Centers (FQHCs), the majority of whom (66%) will begin in Track 1. Nineteen providers will initially participate in New York State, all located north of the New York City metropolitan area.

More information is available here.

CMS Releases Proposed CY 2025 OPPS and ASC Payment Rule 
On July 10th, CMS released the Calendar Year (CY) 2025 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) Payment System Proposed Rule. Overall, CMS proposes updating OPPS and ASC payment rates for hospitals by 2.6%. This proposed update reflects a projected hospital market basket percentage increase of 3.0%, reduced by 0.4 percentage points for the productivity adjustment. Additional key policies in the proposed rule include: 

  • Intensive Outpatient Program (IOP): CMS is proposing an update to Medicare payment rates for IOP services that are provided in hospital outpatient departments and Community Mental Health Centers (CMHCs). Specifically, CMS is proposing to maintain two IOP Ambulatory Payment Classifications (APCs) for each provider type based on the number of days with either three or four or more services per day.
  • Partial Hospitalization Program (PHP): CMS is proposing to maintain the per diem calculation of both hospital outpatient and CMHC PHP payment rates based on the number of services per day.
  • Access to Non-Opioid Treatments for Pain Relief: CMS is proposing to implement a provision from the Consolidated Appropriations Act, 2023 that provides temporary, additional payments to hospital outpatient departments and ASC settings for certain non-opioid treatments for pain relief. This would sunset at the end of CY27.
  • OPPS Payment for Remote Services: CMS is proposing to clarify that requirements for services offered remotely by hospital staff align with those for Medicare telehealth.
  • Hospital Inpatient Quality Reporting (IQR) Program: CMS is proposing to continue the voluntary reporting of the core clinical data elements (CCDEs).
  • Hospital Outpatient Quality Reporting (OQR) Program: CMS is proposing to adopt the Hospital Commitment to Health Equity measure, the Screening for Social Drivers of Health measure, and the Screen Positive Rate for Social Drivers of Health measure for the Hospital OQR program, with staggered effective dates, while removing other measures. Additionally, CMS is proposing to modify the program’s immediate measure removal policy and to require that electronic health record (EHR) technology be certified to report to the OQR program.
  • Ambulatory Surgical Center Quality Reporting (ASCQR) Program: CMS is proposing to adopt the same measures as the OQR program, replacing Hospital Commitment with Facility Commitment, while similarly modifying the immediate measure removal policy. CMS is also requesting stakeholder input on the Development of a Specialty Focused Reporting and Minimum Case Number for Required Reporting framework.
  • Overall Hospital Quality Star Rating: CMS is requesting stakeholder input on whether hospitals in the bottom quartile of the Safety of Care measure group should be disqualified from receiving the highest 5-star rating.
  • Proposed Obstetrical Services Conditions of Participation: CMS is proposing new Conditions of Participation (CoPs) for hospitals and Critical Access Hospitals (CAHs) for obstetrical services to address the maternal health crisis.
  • Medicaid and Children’s Health Insurance Program (CHIP) Continuous Eligibility: CMS is proposing a permanent 12-months of continuous eligibility requirement for children under the age of 19 enrolled in Medicaid and CHIP.

The proposed rule will be open for comment until September 9th. The proposed rule is available here, and the fact sheet is available here.

CMS Names First Cohort of AHEAD States 
On July 2nd, CMS announced that Maryland, Vermont, and Connecticut will be the first states to participate in the All-Payer Health Equity Approaches and Development (AHEAD) Model. Hawaii will also participate, pending confirmation of certain requirements. In this model, up to $12 million will be available to eight award recipients, including state Medicaid agencies, state public health agencies, and state insurance agencies during the first five and a half years of implementation. Through a cooperative agreement funding structure, the model will test a flexible framework with accountability targets for all-payer and Medicare fee-for-service cost growth, primary care investments, and health equity outcomes. Up to four additional states will be selected in fall 2024.

CMS to Hold AHEAD Financial Specifications Webinar 
On July 24th, from 11am-12pm ET, CMS will host a webinar to review updates to the AHEAD Model’s CMS-designed Medicare Fee-for-Service (FFS) hospital global budget methodology. The webinar will cover Version 2.0 of the hospital global budget financial specifications, addressing key concepts, revisions from Version 1.0, calculation of the Hospital Global Budget Payment Amount, and implications and considerations for participating hospitals.

The Version 2.0 Financial Specifications will be posted on the AHEAD Model website prior to the webinar. Questions may be submitted in advance to AHEAD@cms.hhs.gov. Registration is available here.

CMS Sends Letter to Hospital Associations on EMTALA
On July 2nd, CMS sent a letter to hospital and provider associations regarding obligations under the Emergency Medical Treatment and Active Labor Act (EMTALA) in light of the Supreme Court decision in Moyle v. United States. In June, the Supreme Court dismissed Moyle v. United States, leaving in place an order by a federal judge in Idaho that temporarily blocks the state from enforcing its abortion ban, given its conflict with EMTALA. Under EMTALA, hospitals have a legal duty to offer stabilizing medical treatment to patients in need of emergency care.

The letter reminds hospitals of this duty and clarifies that CMS will continue to investigate any EMTALA complaints in Idaho while litigation continues. The letter also announces the launch of a Spanish language version of the EMTALA complaint form.

The announcement is available here.

CMMI Launches GUIDE Model and Announces Participants 
On July 8th, the Centers for Medicare & Medicaid Services Innovation Center (CMMI) announced the launch of the Guiding an Improved Dementia Experience (GUIDE) Model. At launch, CMMI has approved nearly 400 participating organizations that will build Dementia Care Programs (DCPs), serving hundreds of thousands of Medicare beneficiaries. Participating organizations must be Medicare Part B enrolled providers/suppliers, and include academic medical centers, health systems, community-based organizations, and hospice agencies.

CMMI hopes that the GUIDE Model will save Medicare funds by better bundling care coordination and management over the next eight years. Patients with dementia will have access to a care navigator, person-centered assessments, care coordination, medication management, and a 24/7 support line. Per beneficiary per month payments will be adjusted by the severity of dementia. Notable participants in New York include Columbia University, Montefiore Medical Center, the Icahn School of Medicine at Mount Sinai, and Weill Cornell Medical College.

More information on the program is available here.

Biden Administration Releases 2024 Spring Unified Agenda
On July 5th, the Office of Management and Budget (OMB) published the Spring 2024 Unified Agenda. The Unified Agenda is released twice per year and is seen as a bellwether for an Administration’s regulatory priorities. In addition to standard rate setting, the agenda sets out a number of potential CMS  rules including matters surrounding independent dispute resolution, robust coverage of preventative services, parity in mental health and addiction treatment, and transitional coverage for emerging technologies. The Agenda also proposes that the Office of Civil Rights will continue to strengthen the enforcement of the Health Insurance Portability and Accountability Act (HIPAA).

The agenda is available here.

CMS Proposes Rule to Implement DME Fix for ACOs
On June 28th, CMS released a proposed rule to address the suspected durable medical equipment (DME) fraud that affected the Medicare Shared Savings Program (MSSP) in 2023. The rule would remove payment amounts for intermittent urinary catheters (HCPCS codes A4352 and A4353) that displayed significant, anomalous, and highly suspect (SAHS) billing activity in CY 2023 from MSSP expenditure and revenue calculations. This would mean spending on these claims will not be counted in shared savings calculations for the 2023 performance year or benchmark spending measurements for ACOs using 2023 as a baseline year.

The proposal is part of CMS’s larger strategy to address SAHS billing activity within financial reconciliation for ACOs. CMS seeks to address concerns raised by ACOs about significant potential fraud related to an increase in billing to Medicare in DME claims related to such devices.

The proposed rule can be found here. Comments are due by July 29th.

CMS Issues Updated MA Quality Scores 
On July 3rd, CMS released updated Medicare Advantage (MA) 2024 Star Ratings for 2025 Quality Bonus Payments. CMS recalculated the scores of 40 insurers, collectively holding 61 MA contracts. These recalculations were ordered following a ruling that invalidated part of CMS’s new methodology in order to address the application of Tukey outlier deletion. (The Tukey methodology, newly implemented for the 2024 star ratings, identified and eliminated outliers from the data before cut points were determined.) With the recalculations, Elevance Health and SCAN Health Plan, who both brought cases against CMS over the methodology, received considerable bumps in their ratings, leading to $190 million and $250 million more in estimated bonus payments. On the whole, the recalculations had a greater impact on smaller insurers. Eleven of the plans with recalculated scores will receive the maximum quality bonus payment next year.

FTC Releases Interim Report on PBMs
On July 9th, the Federal Trade Commission (FTC) released an interim report on the impact of pharmacy benefit managers (PBMs) on prescription drug accessibility. This report is part of an ongoing inquiry launched in 2022 by the FTC, focusing on the vertical integration and concentration of PBMs in the U.S. market. The report concludes that PBMs play an outsized role in the inflationary prices of prescription drugs in the U.S., and details practices of the six largest PBMs, amounting to nearly 95% of the total U.S. market. Beyond inhibiting patient access through high prices, the report also concludes that PBM practices have considerable impacts on small, independent pharmacies as PBMs steer prescriptions to affiliated pharmacies.

The Pharmaceutical Care Management Association responded to the report, charging that the FTC “cherry-picked case studies” and lacked substantive evidence. There are comprehensive PBM reform packages in both the House of Representatives and Senate, though Congress lost momentum this year. FTC Chair, Lina Khan, testified before the House Energy and Commerce Committee on the day of the report’s release.

The announcement is available here, and the report is available here.

Other Updates

Judge Delays FTC Noncompete Rule
On July 3rd, Judge Ada Brown of the Northern District of Texas stayed the effective date of the Federal Trade Commission’s (FTC) noncompete rule and granted the plaintiffs’ motion for a preliminary injunction against the rule, though but did not impose a nationwide injunction. The court concluded that the FTC lacked substantive rulemaking authority to promulgate the noncompete rule, and that its actions were likely “arbitrary and capricious”. The court plans to rule on the merits of the case by August 30th, though Judge Brown noted that the plaintiffs are “likely to succeed on the merits”. The rule was scheduled to take effect in September.
 
Coalition for Health AI Publishes Framework for Assurance Standards
On June 26th, the Coalition for Health AI (CHAI) published a draft framework outlining standards for artificial intelligence’s (AI) use in health care. CHAI was founded in 2021, with current membership of over 1,300 organizations including Microsoft, Google, Amazon, and notable health systems. The guidelines, called the Assurance Standards Guide, are intended to harmonize AI standards in the place of federal guidance. The Guide is designed, in part, to be a checklist for AI self-reporting and self-testing efforts. Moreover, the Guide sketches an AI development life cycle with built-in guardrails and monitoring. Concurrently, a Department of Health and Human Services (HHS) task force is developing a federal regulatory structure for AI oversight in health care, which is expected by October.
 
The framework is available here.
 
RNC Releases 2024 Platform 
On July 8th, the Republican National Committee (RNC) released its official platform for 2024. The platform notes several positions on health care including a “commitment” to “Transparency, Choice and Competition,” and to “expand Access.” In other vague language, the platform also suggests that the party will “protect Medicare.”
 
The platform also includes a chapter on supporting seniors and veterans through increased focus on chronic disease management and prevention, long-term care, and further investments in primary care. Notably, the platform only mentions abortion in passing as it reaffirms the party’s commitment to opposing late-term abortions.
 
The platform is available here.

New York State Updates

DOH Finalizes Rule on SHIN-NY Statewide Data Infrastructure and Participation Agreement
On July 10th, the New York State (NYS) Department of Health (DOH) adopted final regulations related to the functions and capabilities of the Statewide Health Information Network for New York (SHIN-NY). The regulations: 

  • Create new statewide data infrastructure to improve interoperability;
  • Establish a single, statewide common participation agreement governing data exchange; and
  • Enable health care facilities that are required to connect to the SHIN-NY to do so directly, rather than through a Regional Health Information Organization (RHIO), also known as a Qualified Entity (QE).

SPG’s full summary of the proposed regulations is available here. Following an assessment of public comment, DOH made minor changes to the regulatory language. The final regulations and public comments are available here.  

DFS Finalizes Guidance on Insurers’ Use of AI and External Consumer Data
On July 11th, the New York State Department of Financial Services (DFS) issued final guidance to insurance plans regarding the use of artificial intelligence systems (AIS) and external consumer data and information sources (ECDIS) used for insurance underwriting and pricing. In January 2024, DFS issued proposed guidance for public comment; SPG’s summary of the proposed guidance is available here.

In response to public comment, the final guidance adds clarifications to the provisions regarding proxy and quantitative assessments, including clarifying that insurance plans are not expected to collect additional data from or about individuals in protected classes for such analyses. The final guidance also maintains the following, despite pushback from stakeholders: 

  • Original definitions of AIS and ECDIS;
  • The expectation that insurance plans take an appropriate, risk-based approach to utilizing ECDIS and AIS and determine for themselves the appropriate sufficiency thresholds and standards of proof based on the product and particular use of ECDIS or AIS;
  • The expectation that both senior management and the board have a responsibility for the overall outcomes of the use of ECDIS and AIS;
  • The expectation that insurance plans conduct appropriate oversight over third-party vendors, including incorporating certain terms into their contracts with third-party vendors;
  • That DFS cannot promise confidentiality of information, but that it is committed to protecting confidentiality, intellectual property, and trade secrets of insurance plans and third-parties.

DFS has also added timeframes for the required risk management assessments and consumer disclosures. DFS notes that the guidance does not apply to Child Health Plus, Essential Plan, and Medicaid managed care coverage.

The final guidance is available here.

DOH Proposes Update to EMS Equipment and Waiver Regulations
On July 10th, DOH issued proposed regulations that would update Part 800 of the Public Health Law, which regulates Emergency Medical Services (EMS), to update and consolidate requirements for equipment for EMS vehicles and to set up a framework for DOH to grant waivers from EMS regulations. Specifically, the regulations will: 

  • Update equipment requirements for EMS providers to conform with current industry standards;
  • Provide a list of required vehicle equipment for EMS vehicles based on the type of vehicle and the four below standard levels of service:
    • Basic Life Support First Response;
    • Ambulance;
    • Basic Life Support – Emergency Ambulance Service Vehicles; and
    • Advanced Life Support – First Response; and  
  • Develop a framework for “general regulatory waivers” that allow DOH to waive regulatory requirements of Part 800 upon determining that there are special circumstances that render compliance with the regulations unreasonable, burdensome, or impractical, or where compliance would result in impediment of emergency services.

The proposed regulations are available here. Public comment may be submitted to regsqna@health.ny.gov through September 9th.

OPWDD Announces New Acting Commissioner Willow Baer 
On July 1st, the Office for People with Developmental Disabilities (OPWDD) announced its new Acting Commissioner Willow Baer. Ms. Baer is serving in this role following the departure of Kerri Neifeld on June 28th. Ms. Baer most recently served as Executive Deputy Commissioner of OPWDD. Prior to OPWDD, Ms. Baer served in the Office of General Counsel at the NYS Justice Center and as a County Attorney. She also served as Deputy Commissioner and General Counsel at both OPWDD and the NYS Office of Children and Families (OCFS).

A message from the Acting Commissioner is available here.

Governor Hochul Signs Bills on HIV/AIDS Prevention and Care 
On June 28th, Governor Hochul signed the following legislation to support individuals living with HIV/AIDS: 

  • S8144C/A8834B codifies guidance to prohibit insurance plans from refusing to insure, refusing to continue to insure, limiting coverage for, or charging a different rate to individuals who are prescribed pre-exposure prophylaxis (PrEP) medication for the prevention of HIV infection.
  • S9842/A10461 clarifies that insurance plans cannot impose copayments on PrEP or post-exposure prophylaxis (PEP).
  • S7809/A8475 expands the allowable options for providing the required notice that an HIV-related test will be performed (i.e., verbally, in writing, by electronic means), requires the notice to specify that HIV testing is voluntary, and requires notification on the availability of PrEP and PEP.
  • S1001A/A1619A prohibits insurance plans from using prior authorization to restrict access to antiretroviral drugs for the treatment or prevention of HIV or AIDS.

The Governor’s press release is available here.

DOH Releases Tenth Monthly PHE Dashboard
On June 1st, DOH released the tenth issue of the State’s Public Health Emergency (PHE) Unwind Dashboard, a monthly enrollment report on the renewal process for New York’s Medicaid, Child Health Plus, and Essential Plan populations.

The tenth issue includes the renewal status, demographics, and program transitions of enrollees who had an April 30th coverage end date. The report shows that 75 percent of the 641,958 individuals in this cohort have renewed their coverage across the NYSOH marketplace and Local Departments of Social Services. The report does not include information on former enrollees who found coverage through non-public sources, such as employer-based insurance.

The tenth issue and previous issues may be accessed here. This process will continue each month until each enrollee cohort has had their eligibility redetermined.

CWE Announces Webinars on CFTSS Evidence-Based Practice Implementation
Last year, the NYS Office of Mental Health (OMH) piloted the inclusion of evidence-based practices (EBPs) within Children and Family Treatment and Support Services (CFTSS) programs through the NYU Center for Workforce Excellence (CWE). As part of this initiative, Functional Family Therapy (FFT) and Parent-Child Interaction Therapy (PCIT) are implemented under Other Licensed Practitioner (OLP) and Community Psychiatric Supports and Treatment (CPST) services within CFTSS.

CWE will be hosting the following webinars that will provide more information about the EBP models, application process, and training details for the new fall 2024 cohort launch: 

  • July 8th from 1:30pm-3pm – introductory webinar for designated CFTSS providers (registration here)
  • August 6th 2pm-3pm – application process office hours (registration here)

DOH Announces Dual Enrollment Option for Children’s Health Home and Early Intervention Services
Effective July 1st, children who are eligible for Health Home and Early Intervention services may be enrolled in both programs and providers may submit claims for all services delivered, including case management. Providers may use one of the following three options for service delivery: 

  1. Dually Designated Agency, in which the agency submits claims for Health Home care management and for Early Intervention service coordination.
  2. Separate Health Home and Early Intervention Providers, in which the child/family is served by both a Health Home Care Manager and an Early Intervention Ongoing Service Coordinator and each entity bills separately.
  3. Sub-contracting, in which Health Home care management providers currently in a sub-contracting relationship for delivery of early intervention service coordination can continue this relationship; however, Health Home care management agencies cannot separately bill for the early intervention services delivered by the sub-contractor.

The DOH guidance is available here. Questions may be submitted here for Health Homes and to beipub@health.ny.gov for Early Intervention.

DOH Proposes to Maintain MCO Contingent Reserve Requirement at 7.25%
On July 3rd, DOH issued a proposed rule to maintain the contingent reserve requirement at 7.25 percent through 2025 for Medicaid managed care organizations (MCOs), including mainstream plans, HIV Special Needs Plans (HIV SNPs), and Health and Recovery Plans (HARPs). Although the contingent reserve has been scheduled to eventually increase to 12.5%, DOH has annually continued the 7.25% level for several years now. The lower reserve requirement allows DOH to maintain the current 2 percent reduction in the premium rates while maintaining actuarial soundness.

The proposed rule is available here. Public comment may be submitted to regsqna@health.ny.gov through September 3rd.