IMPLEMENTATION OF THE AFFORDABLE CARE ACT AND FINAL RULE – PROGRAM INTEGRITY

STAKEHOLDER MEETINGS

Department of Health Care Services | Provider Enrollment Division

Session 1Wednesday, March 28, 20129:30 A.M. to 11:30 A.M

Session 3Thursday, March 29, 20129:30 A.M. to 11:30 A.M.

Session 2Wednesday, March 28, 20121:30 P.M. to 3:30 P.M.

New Federal Requirements for State Medicaid Agencies

42 CFR 455 Subpart E - Provider Screening and Enrollmento State Medicaid agencies must comply with the process for

screening providers under sections 1902(a)(39), 1902(a)(77) and 1902(kk) of the Affordable Care Act and 42 CFR Section 455.400 et seq.

New Federal Requirements for State Medicaid Agencies

Where did they come from? o March 2010

─ The Patient Protection and Affordable Care Act (ACA) was passed by Congress and signed by the President

o September 2010─ Proposed Rule published

o October/November 2010 ─ States’ Comment Period

o February 2, 2011─ Final Rule published in the Federal Register

o March 25, 2011─ Changes to the Code of Federal Regulations (CFR) became

effective

Steps Towards Implementation

Legislation – SB 1529 (Alquist)o Introduced February 24, 2012o Statutes would become effective January 1, 2013 o Only “minimum necessary” changes will be made

State Plan Amendment (SPA)o Due to CMS – April 1, 2012o Required for most of the CFR provisions

Provider/Regulatory Bulletin(s)o Regulatory and informational

January 1, 2013o Target date for full implementation

of new requirements

Steps Towards Implementation

Coordinating with other Divisions and Departments

Stakeholder Meetings

Making necessary changes to currentpolicy and procedures

Developing and updating forms in order to collect the required provider information

SESSION 1: Wednesday, March 28, 2012

9:30 A.M. to 11:30 A.M.

SCREENING LEVELS FOR MEDICAID PROVIDERS

42 CFR § 455.450

CRIMINAL BACKGROUND CHECKS INCLUDING FINGERPRINTING

42 CFR § 455.434

TERMINATION OR DENIAL OF ENROLLMENT AND REPORTING

42 CFR § 455.416

Screening Levels for Medicaid Providers 42 CFR § 455.450

42 CFR § 455.450 requires states to screen providers according to limited, moderate and high risk categories.

Federal law designates specific provider types within the three categories at 42 CFR § 424.518.

The State Medicaid agency must screen providers in accordance with the federal designations.

Screening Levels for Medicaid Providers 42 CFR § 455.450

42 CFR § 424.518: Provider types designated as limited categorical risk include:

oPhysiciansoNonphysician practitionersoAmbulatory surgical centersoFederally qualified health centers (FQHC)oHospitals, including critical access hospitals, Department of Veterans

Affairs hospitals, and other federally owned hospital facilitiesoHealth programs operated by an Indian Health ProgramoPharmaciesoRural health clinicsoSkilled nursing facilities

Screening Levels for Medicaid Providers 42 CFR § 455.450

42 CFR § 424.518: Provider types designated as moderate categorical risk include:

oAmbulance service suppliersoCommunity mental health centersoComprehensive outpatient rehabilitation facilitiesoHospice organizationsoIndependent clinical laboratoriesoIndependent diagnostic testing facilitiesoPhysical therapists (individual & groups)oPortable x-ray suppliersoRevalidating home health agenciesoRevalidating DME suppliers

Screening Levels for Medicaid Providers 42 CFR § 455.450

42 CFR § 424.518: Provider types designated as high categorical risk include:

oProspective (newly enrolling) home health agenciesoProspective (newly enrolling) DME suppliers

Screening Levels for Medicaid Providers 42 CFR § 455.450

Screening procedures required of the categorical risk levels:o Limited

─ Requires license verifications (§ 455.412) ─ Database checks (§ 455.436)

o Moderate ─ Requires onsite inspections (§ 455.432) ─ All screening procedures required of the Limited risk level

o High ─ Requires fingerprinting/criminal background checks

(§ 455.434) ─ All screening procedures required of the Limited and

Moderate risk levels

Screening Levels for Medicaid Providers 42 CFR § 455.450

All providers, regardless of provider type, must be screened at the high categorical risk level if any of four conditions exist: o Payment suspension that is based on a credible allegation of

fraud, waste or abuseo Existing Medicaid overpaymento Excluded by OIG or another State’s Medicaid program within

the previous 10 years o A Moratorium was lifted within previous six months prior to

applying and the provider would have been prevented from enrolling due to the moratorium

Criminal Background Checks Including Fingerprinting

42 CFR § 455.434

42 CFR § 455.434:o Requires all providers designated as high categorical risk to

submit fingerprints

o Defines providers as any person or entity that holds 5% or more ownership or control interest

o Requires providers to submit a set of fingerprints in the “form and manner” determined by the State Medicaid agency

o Requires fingerprints to be submitted within 30 days of a request from CMS or the Medicaid agency

Termination or Denial of Enrollment and Reporting

42 CFR § 455.416

42 CFR § 455.416 specifies causes for the denial and/or termination of enrollment of providers.

This section broadens the State’s current authority to deny and/or deactivate the enrollment of providers.

States have discretion in some situations when denial or termination can be documented as “not in the best interest of the Medi-Cal program.”

Termination or Denial of Enrollment and Reporting

42 CFR § 455.416

New denial/termination causes:o Provider is terminated on or after January 1, 2011, under Medicare,

Medicaid or CHIP of any other State

o Provider, or agent or managing employee fails to submit timely and accurate information & doesn’t cooperate with required screening procedures

o Provider fails to submit fingerprints within 30 days of a CMS or a State Medicaid request

o Provider fails to permit access to provider locations for any site visits

o Provider falsifies any information on an application or their identity cannot be verified

Termination or Denial of Enrollment and Reporting

42 CFR § 455.416

Reporting provider terminationso California is required to report terminated providers on the Medicaid

and Children’s Health Insurance Program State Information Sharing System (MCSIS) so that other States and Medicare can determine which providers have been terminated by California.

42 CFR § 455.101 states that a Medicaid or CHIP provider is terminated when: o The State has taken action to revoke billing privileges

o The provider has exhausted all applicable State appeal rights

o The revocation is not temporary

o The provider must re-enroll (and be re-screened per Section 455.420) to establish billing privileges

IMPLEMENTATION OF THE AFFORDABLE CARE ACT AND FINAL RULE – PROGRAM INTEGRITY

Department of Health Care Services | Provider Enrollment Division

QUESTIONS?

PEDACA@dhcs.ca.gov

SESSION 2: Wednesday, March 28, 2012

1:30 P.M. to 3:30P.M.

ORDERING AND REFERRING PROVIDERS42 CFR § 455.410

TEMPORARY MORATORIA42 CFR § 455.470

Ordering and Referring Providers42 CFR § 455.410

42 CFR § 455.410 requires all providers, including ordering or referring physicians or other professionals providing services under the State plan or under a waiver of the plan to be enrolled as participating providers.

42 CFR § 455.440 requires all claims for items and services ordered or referred to contain the National Provider Identifier (NPI) of the ordering or referring provider.

States are permitted to rely on the results of provider screening performed by any Medicare contractor or Medicaid agency or CHIP of other States when enrolling ordering and referring providers.

Ordering and Referring Providers42 CFR § 455.410

Provider Types that may be required to enroll as ordering/referring providers include:o Doctors of Medicine or Osteopathy

o Doctors of Dental Surgery and Dental Medicine

o Doctors of Podiatric Medicine

o Doctors of Optometry

o Physician Assistants

o Certified Clinical Nurse Specialists

o Nurse Practitioners

o Clinical Psychologist

o Certified Nurse Midwives

o Clinical Social Workers

o Doctors of Chiropractic Medicine

o Audiologists and Hearing Aid Dispensers

Ordering and Referring Providers42 CFR § 455.410

Physicians and nonphysician practitioners who will be required to enroll in Medi-Cal solely for the purpose of ordering and referring may be:o Department of Veterans Affairs employees

o Public Health Service employees

o Department of Defense Tricare employees

o IHS or tribal organization employees

o Federally Qualified Health Centers, Rural Health Clinics or Critical Access Hospital employees

o Community Clinic or Free Clinic employees

o Licensed Medical Residents or Fellows

Ordering and Referring Providers42 CFR § 455.410

Medicare began implementing the enrollment of ordering and referring providers in Fall 2011 with a new form, CMS-8550.

As of today, Medicare has not turned on the automated edits that would deny claims for items and services ordered or referred by providers not yet enrolled in Medicare.

Once the automated edits are turned on:o Claims from the “filling providers” (i.e. pharmacies) will be denied

if the ordering or referring provider’s name and NPI listed on the claim is not enrolled.

o Patients may not receive needed items or services (i.e. medication) if the “filling providers or suppliers” refuse to accept orders or referrals from providers that are not enrolled.

Temporary Moratoria42 CFR § 455.470

CMS may establish Medicaid wide temporary moratoria on the enrollment of new providers or provider types:o The State Medicaid agency must impose moratoria established by

CMS unless it would create an access to care issue

─ The State must then notify CMS in writing

The State Medicaid agency may otherwise impose moratoria, numerical caps, or other limits on the enrollment of new providers:o When fraud, waste or abuse is identified in the Medicaid program and

CMS has identified the provider type as being at high risk for fraud, waste and abuse

o The State must notify CMS and obtain concurrence with the imposition of the moratoria

IMPLEMENTATION OF THE AFFORDABLE CARE ACT AND FINAL RULE – PROGRAM INTEGRITY

Department of Health Care Services | Provider Enrollment Division

QUESTIONS?

PEDACA@dhcs.ca.gov

SESSION 3: Thursday, March 29, 2012

9:30 A.M. to 11:30 A.M.

APPLICATION FEE42 CFR § 455.460

REVALIDATION42 CFR § 455.414

Application Fee42 CFR § 455.460

42 CFR § 455.460 requires States to collect an application fee from all prospective or re-enrolling providers EXCLUDING the following: o Individual physicians or non-physician practitionerso Providers already enrolled with Medicareo Providers already enrolled in any State’s Medicaid or CHIPo Providers who have already paid an application fee to

either a Medicare contractor or another State’s Medicaid or CHIP program

Application Fee42 CFR § 455.460

CMS calculates the application fee for each Calendar Year.

The fee is adjusted annually by the percentage change in the consumer price index for all urban consumers.o 2010 ~ $500.00 o 2011 ~ $505.00o 2012 ~ $523.00

If the fees collected by the State exceed the application screening costs, the State must return the remainder to the Federal Government.

Application Fee42 CFR § 455.460

To request a waiver of the application fee:

o Individual providers may submit a request to CMS for a hardship exception in the form of a letter that describes the hardship and explains why it justifies an exception.

o The State may submit a request to CMS for a fee waiver applicable to a group or category of providers by demonstrating that the fee will have a negative impact on beneficiary access to care.

Revalidation42 CFR § 455.414

42 CFR § 455.414 requires revalidation of enrollment for all provider types at least every 5 years.

Federal regulation also allows States to rely on the results of the provider screening performed by Medicare contractors and Medicaid or CHIP programs of any State to fulfill this requirement.

California regulations already contain requirements for re-enrolling and re-certifying providers, but the “every five years” revalidation requirement is new.

IMPLEMENTATION OF THE AFFORDABLE CARE ACT AND FINAL RULE – PROGRAM INTEGRITY

Department of Health Care Services | Provider Enrollment Division

QUESTIONS?

PEDACA@dhcs.ca.gov