In this update:
- Federal Agencies
- CMS Releases First No Surprises Act Audit
- CMS Releases Second Guidance on the Medicare Prescription Payment Plan
- HRSA Launches Multi-State Social Worker Licensure Compact Initiative
- CMS to Host National Update Call on August 1st
- Other Updates
- UnitedHealthcare Earnings Rebound from Q1 Change Healthcare Losses
- U.S. News and World Report Releases Hospital Rankings
- Commonwealth Fund Releases Women’s Health Report
- New York State Updates
- OPWDD Issues Proposed Rule to Update Specialty Hospital Regulations
Federal Agencies
CMS Releases First No Surprises Act Audit
On July 15th, the Centers for Medicare & Medicaid Services (CMS) released its first audit of billing practices under the No Surprises Act. The audit reviewed air ambulance claims to Aetna Health of Texas from January to June 2022. It found that Aetna failed to properly calculate the qualifying payment amount (QPA) which helps to determine patient cost-sharing. Surprisingly, calculations errors were made in both Aetna’s and the provider’s favor. These findings may indicate broader concerns about the clarity and reliability of QPAs. Nonetheless, Aetna was found to be noncompliant with the No Surprises Act. It is not clear why this audit was the first to be released or what audits may come next. CMS is anticipating a new rule that makes operational improvements to the independent dispute resolution process (IDR) in November 2024.
The audit is available here.
CMS Releases Second Guidance on the Medicare Prescription Payment Plan
On July 16th, the CMS released the second part of its Medicare Prescription Payment Plan guidance. Once it takes effect in 2025, the Medicare Prescription Payment Plan will allow beneficiaries to opt in to a year-long payment plan for their Part D cost-sharing. Under the plan, the Medicare member would pay a monthly payment each month, rather than paying cost-sharing at the time of purchase. Both pharmacies and plans are required to inform targeted members who are “likely to benefit,” defined as meeting a threshold of $600 for point-of-service prescription drugs, of this option at the point of service.
Part Two of the guidance concerns education and outreach procedures for the program, including the responsibilities of Part D plan sponsors to inform their members about this option. It also includes educational materials for patients and caregivers. Part One of the guidance was covered by SPG here and was finalized in February 2024.
A fact sheet on the Part Two guidance is available here.
HRSA Launches Multi-State Social Worker Licensure Compact Initiative
On July 16th, the Health Resources & Services Administration (HRSA) announced inaugural Licensure Portability Grant Program investments for a multi-state social worker licensure compact, which allows providers to practice across state lines with reduced administrative burden. This $2.5 million investment will support all aspects of social work while making strategic investments in behavioral health, following the success of the Interstate Medical Licensing Compact and the Psychology Interjurisdictional Compact (PSYPACT). The awards will directly support associations representing state boards across a variety of disciplines.
The announcement is available here.
CMS to Host National Update Call on August 1st
On August 1st, from 3:30 to 4:30pm, CMS will host a Leadership National Update Call. CMS Administrator Chiquita Brooks-LaSure will be joined by her senior leadership team to discuss recent CMS initiatives and accomplishments in keeping with its Strategic Plan.
Registration is available here.
Other Updates
UnitedHealthcare Earnings Rebound from Q1 Change Healthcare Losses
On July 16th, UnitedHealth Group released its second quarter earnings. Over the course of the quarter, United reported $98.9 billion in revenues. The company credited its subsidiaries Optum Health and OptumRx for the bulk of its fiscal success this quarter. The earnings and accompanying financial reports reflect the impacts of the Change Healthcare cyberattack, which United expects will cost the payer over $2.3 billion in total. United experienced an elevated medical loss ratio (MLR) of 85.1% this quarter, due in part to changes in coding patterns following the cyberattack and easements on utilization management.
The announcement is available here.
U.S. News and World Report Releases Hospital Rankings
On July 16th, U.S. News and World Report published its 2024-2025 list of “Honor Roll” hospitals. Of the nearly 5,000 hospitals surveyed, only 160 hospitals were listed on the Honor Roll in at least one adult specialty. In New York, Honor Roll hospitals included Mount Sinai Hospital, New York-Presbyterian Hospital-Columbia and Cornell, North Shore University Hospital at Northwell Health, and NYU Langone. These hospitals scored highly by performing well among 15 specialties as well as 21 procedures and conditions. New York hospitals also rated highly on these specialty lists:
- NYU Langone: Cardiology & Heart Surgery (#2), Diabetes & Endocrinology (#5), Ear, Nose & Throat (#10), Gastroenterology & GI Surgery (#5), Geriatrics (#2), Neurology & Neurosurgery (#1), Orthopedics (#3), Pulmonology & Lung Surgery (#1), Rehabilitation (#4), Rheumatology (#9), Urology (#2)
- New York-Presbyterian: Cancer (#15), Cardiology & Heart Surgery (#5), Diabetes & Endocrinology (#3), Gastroenterology & GI Surgery (#10), Geriatrics (#8), Neurology & Neurosurgery (#4), Obstetrics & Gynecology (#8), Orthopedics (#4), Psychiatry (#3), Rheumatology (#2), Urology (#2)
- Mount Sinai: Cancer (#8), Cardiology & Heart Surgery (#4), Gastroenterology & GI Surgery (#8), Geriatrics (#1)
- North Shore University Hospital – Northwell: Diabetes & Endocrinology (#10), Orthopedics (#7)
The full rankings are available here.
Commonwealth Fund Releases Women’s Health Report
On July 18th, the Commonwealth Fund released its 2024 State Scorecard on Women’s Health and Reproductive Care. Overall, Massachusetts, Vermont, and Rhode Island topped the rankings, while Mississippi, Texas, Nevada, and Oklahoma were the poorest performing states. The rankings are based on 32 measures of health care access, quality, and health outcomes. Notably, mental health conditions were the most frequently reported cause of preventable pregnancy-related death, including death by suicide as well as overdoses related to substance use disorders. The highest maternal death rates were in Tennessee, Mississippi, and Louisiana, while the lowest were in Vermont, California, and Connecticut.
New York State ranked 5th on women’s health and reproductive care outcomes, 27th on health care quality and prevention, and 10th on coverage, access, and affordability. The full report is available here.
New York State Updates
OPWDD Issues Proposed Rule to Update Specialty Hospital Regulations
On July 17th, the New York State (NYS) Office for People with Developmental Disabilities (OPWDD) issued proposed regulations that would amend Part 680 specialty hospital regulations to remove outdated language and ensure consistency with other regulations that have been updated or amended. The amended regulations would:
- Update staffing and service requirements;
- Remove redundant regulatory requirements applicable to medical facilities;
- Change the responsibility for rate setting from OPWDD to the Department of Health (DOH); and
- Standardize language and include current terminology and nomenclature.
Specific proposed changes include, but are not limited to:
- Clarifying that the specialty hospital may offer its other agency-licensed services to specialty hospital patients;
- Clarifying that if the approved capacity of a specialty hospital is fewer than 20 individuals, an on-staff psychiatrist is not required;
- Requiring the development of emergency preparedness plans, to be reviewed at least annually;
- Including the description and usage of supported decision-making agreements;
- Adding the requirement that a treating physician must recommend a patient’s admission to a specialty hospital and include a determination that no other less restrictive environment is sufficient;
- Adding behavior support services under psychology services, which must be provided by a behavior intervention specialist; and
- Clarifying that at least one full-time physician is required to be available 40 hours per week, who may be available on-call if a licensed nurse-practitioner is on duty.
The proposed regulations are available here. Public comment may be submitted to rau.unit@opwdd.ny.gov through September 15th.