Below is an update on the Congressional effort to repeal the Sustainable Growth Rate (SGR) reimbursement formula for Medicare through HR 2.The Senate started considering HR 2 yesterday.  The procedural hurdle that must be overcome before it is voted on is the amendments which are being proposed.  Leadership has said that all amendments must be submitted by tomorrow when the Senate hopes to vote on the amendments and the bill itself.

If the bill is not voted on by tomorrow, or if it voted on with amendments, the 21% reimbursement cut will go into effect, at least for now.  The amendments will need to be reconciled with the House version of the bill, which will take some time.

If LCSWs are in need of processing these claims to address cash flow, you may want to start submitting claims after tomorrow, even is the cut is in place.  There would still be a possibility that if the cut is eventually rescinded, LCSWs would receive the lost income separately when that occurs.  

Changing the SGR formula is a cumbersome, difficult process.  Hopefully it can be achieved and replaced with a more reliable payment system.  I will let you know as HR 2 gets considered what the outcome is.

The Senate has just passed HR 2 without amendments, 58-42, which means as soon as the President signs the bill, Medicare will again begin processing Medicare claims without the 21% cut that had been looming.

This is exactly the outcome that CSWA had hoped for.  Thanks to all of you for your messages to your Senators in support of HR 2.    

 As soon as the President signs HR 2, which he has indicated he will do, Medicare will begin processing claims at the current rate of reimbursement.  Those of you who have held back claims the past two weeks should now submit them.

Medicare expects processing to take up to two weeks longer than usual because of the backlog. CSWA will send you more information as it becomes available.  

I know many of you have been hearing about changes to Medicare payments and the SGR, and you may be wondering what it all means for LCSWs. Given the fact that the 158-page bill, HR 1470, now HR 2, Medicare Access and CHIP Reauthorization Act (MACRA), was created last week and released yesterday, this preliminary analysis of the bill should not be considered complete. More information will be coming but this will give you a summary of what HR 2, will and will not do, if passed.

First an important note: Without some action by Congress in the next week, all Medicare providers, including LCSWs, will receive a 21% cut in reimbursement as of April 1. That's when the SGR regulations - the ones that have been "kicked down the road" 17 times - will go into effect. Something needs to happen: the SGR cuts finally happen, an 18th postponement, or perhaps HR 1470, which looks like a real possibility.  

There are five major parts to HR 2 that are important to LCSWs as follows: 1) a new Medicare reimbursement formula; 2) a continued implementation of Medicare services based on quality measures (including PQRS); 3) an increase in premiums for higher income Medicare beneficiaries; 4) a two-year continuation of the CHIP program to provide Medicaid services for children; and 5) a more restrictive abortion policy.

Obviously the last two are not directly connected to Medicare policy, but as often happens in Congress, issues which would have difficulty passing on their own are often attached to bills that are likely to pass.

Here is what is meant by each of the five points above:

1. Medicare Reimbursement Formula - the Sustainable Growth Rate would be eliminated. The 21% cut that is looming would be handled by "splitting" the cut between providers and beneficiaries, meaning approximately a 10% cut to LCSWs and other providers and a 10% raise in premiums to higher income beneficiaries. All providers would also receive a .5% reimbursement increase for the next five years.  
   
2. Quality Measures (Merit-based Incentive Payment System) - the move from "quantity" to "quality", from fee-for-service to pay for performance, from small provider groups to large groups, from paper records to EHRs, has been in effect for the last 9 years. HR 2 integrates all these goals into Merit-based Incentive Payment System, or MIPS. This direction can be expected to continue, though CSWA will do everything possible to preserve the ability of LCSWs to be reimbursed as sole practitioners. HR 2 includes four ways to measure the ways that providers comply with the above including quality incentives (including PQRS); adequate use of resources for each condition and episode; meaningful use (does not apply to LCSWs); and use of alternate payment methods like Accountable Care Organizations (ACOs) and health homes. The last item would result in a bonus of 5%.
   
3. Higher Premiums for Higher Income Beneficiaries- this is one area where there is little debate, though the income level at which beneficiaries would need to pay higher premiums is still to be determined.
   
4. Continuation of CHIP- this inclusion of the Children's Health Insurance Program, which provides health care coverage for all children, has been a point of disagreement. The two-year inclusion is only half of what many progressive members of Congress sought, a four-year extension. This is already being challenged by the Senate.
   
5. Continuation of Abortion Limitations in Medicaid- this is an unexpected part of HR 1470 which continues the "Hyde amendment" which was due to expire this year. Many pro-choice members of Congress are opposing this provision.
   

Getting this bill passed will require enormous effort. CSWA believes that the current ambiguity of the bill makes it difficult to actively support it. As the form of the bill becomes clearer, we may be able to support or oppose the bill, or weigh in on parts of it, based on how it affects LCSWs.

CSWA hopes this summary is helpful in understanding what is a complicated, potentially helpful, bill.

As you may have heard, there is another deadline, March 31, for the Sustainable Growth Rate (SGR), the Medicare formula for creating a balanced budget, that would impose a 21% cut on reimbursement for LCSWs and all other Medicare providers. This is the 18th time that a deadline has arisen. The first 17 times the implementation of the SGR has been 'delayed', leading to short term 'fixes' to balancing the Medicare budget.  

It now appears that a new formula has been in development which would eliminate the proposed cut by reducing Medicare benefits by roughly 10% and reducing provider reimbursement by roughly 10%. This is far from what LCSWs would like to see, particularly with the already diminished reimbursement rate LCSWs receive for psychotherapy services through Medicare (see Medicare Position Paper at the CSWA website.)

An additional cause of concern is the possible loss of funding for the Children's Health Insurance Program (CHIP) which is being tied in to replacing the SGR. The President has said he would veto any effort to end CHIP.

Details are still in development in Congress. I will send you an update as I receive more information and a message to send to members of Congress.

HR 4302 passed the Senate this evening and is very likely to be signed by the President shortly.  I sent you a summary of the bill on March 26, the day before it passed the House of Representatives. 

There are two main parts of this bill that affect LCSWs positively  The first is the short term delay of a cut to Medicare reimbursement of 24%, the 17th time that the Sustainable Growth Rate cut to these payments has been stopped.  The second is a long term improvement of mental health services, the Excellence in Mental Health Care Act, long promoted by Sen. Debbie Stabenow (D-MI) and included in this bill.  Additionally, implementation the ICD-10-CM codes have been delayed until October 1, 2015.

Below is a summary of the bill's main points: 

Sustainable Growth Rate Formula (SGR) Delay - The SGR calculation is intended to update rates to maintain budget neutrality, and reduce Medicare reimbursement rates to stay within budget. HR 4302 continues the Congress's avoidance of the automatic Medicare reimbursement cuts. CSWA supports this delay as Congress works toward a more realistic reimbursement formula. 

ICD-10-CM Delay - This bill delays the ICD-10-CM implementation from October 1, 2014 to October 1, 2015. One reason is the significant cost of upgrading EHRs involved.  Another is the recent CMS survey which showed that only 40% of all providers would be "ready" to use the ICD-10-CM codes by the original date.  CSWA supports the delay which would allow more time for LCSWs to be included in incentive funding for EHRs, currently not available.

Medicaid DSH Modifications Delay- The bill will delay the start of funding cuts to the Medicaid Disproportionate Share Hospital (DSH) program from FY 2016 to FY 2017. This program offers funding to hospitals with high levels of uncompensated care.  CSWA hopes that the funding will be restored to 2016. 

Demonstration Pilot for "Certified Community Behavioral Health Clinics" - The bill would start a four-year, eight-state demonstration program in which community behavioral health organizations that meet certain criteria (to be published by September 1, 2015) would be eligible for enhanced Medicaid reimbursement. This new type of mental health provider will be called a "certified community behavioral health clinic", and planning grants for the demonstration program will be awarded by January 1, 2016, for implementation by September 1, 2017.  This plan was initially proposed by a social worker, Sen. Debbie Stabenow (D-MI) as the Excellence in Mental Health Act.  CSWA congratulates our fellow social worker on this achievement. 

Assisted Outpatient Treatment Grant Program For Individuals With Serious Mental Illness - The bill includes an assisted outpatient treatment (AOT) grant program for individuals with serious mental illness, and authorizes grant awards of up to $1 million to no more than 50 grantees. AOT has raised great controversy, as it appears to make forced hospitalization/treatment easier to accomplish.  CSWA is reviewing the details of AOT, designed to prevent the violence which has occurred as a result of mental illness.

Skilled Nursing Facility Value-Based Purchasing - The bill establishes a skilled nursing facility value-based purchasing program starting in 2019 - based on an "all-cause all-condition hospital readmission measure".  CSWA continues to work toward independent Medicare Part A coverage for LCSWs, eliminated in 1997 when SNF services were 'bundled.' 

CSWA is generally pleased with the results of this bill and will be continuing to work for better access to LCSW mental health services.

The Commission on Medicare and Medicaid Services and the Department of Health and Human Services have asked us to provide our patients and clients with information about how to sign up for the new health care plans which are available in the Affordable Care Act Exchange, now known as the Marketplace.

The summary of information about how to access the plans is on the CSWA website under the tab "Legislation and Advocacy".  Click on "ACA Marketplace Information".  This information will help anyone who wants to compare the plans at the four health care levels (Platinum, Gold, Silver, Bronze) of the Marketplace in any state.

CMS and DHHS ask us to print off some copies to keep in our waiting rooms and give to patients.

In spite of the problems with the start up of the Affordable Care Act, the value this will have to all of our citizens will be in the best interests of our patients, our practices, and the health of all citizens in our country.

The Federal Final Interim Parity Rules for the Mental Health Parity and Addiction Equity Act (MHPAEA) will be made Final Rules today when they are published in the Federal Register at 11:15 am EST.  This is a victory for the five years of work that CSWA and many other organizations have devoted to getting these rules in place, the key to enforcement of MHPAEA. 

This is not the complete victory that CSWA had hoped for to the extent that enforcement has been delegated to state insurance commissioners.  Variation in state laws and rules can make enforcement complicated and uneven.  It will be interesting to see how the state insurance commissioners assume responsibility for self-insured, i.e., ERISA, plans which had previously been overseen by the Department of Labor. 

CSWA will be tracking enforcement and pursue further legislation if the insurance commissioners are unwilling/unable to make the Final Parity Rules create the equal coverage that they are untended to provide.

The main positive impact of the parity laws and final rules are that the coverage of health plans' co-payments, deductibles and limits on mental health visits to licensed clinicians are not more restrictive or less generous for mental health benefits than for medical and surgical benefits for visits to licensed medical clinicians.  However, the 'non-quantitative' limits, i.e., requiring pre-authorizations for psychotherapy, different levels of coverage in for in-network/out-of-network, and determining what 'parity' means in comparing frequency and length of psychotherapy to medical/surgical treatment remain to be defined.

Coincidentally, Medicare co-pays will reach the same level as medical co-pays - 20% - on 1/1/14 after 4 years of gradually decreasing mental health co-pays from 50%. The rules do not cover Medicare or Medicaid.

While the rules do not apply to Medicare and Medicaid specifically, though past CMS guidance to states has been that parity should be a goal in Medicaid plans. 

While there is more work to do, this rule implementation is a good step forward.

The majority of LCSWs are choosing to submit the Quality Data Codes (QDCs) for PQRS Measures on the CMS-1500 claim forms.  The primary change is to add the QDC(s) in Section 24D under the CPT code and add $.00 or $.01 in Section 24F on the same line.  For a sample CMS-1500 with PQRS data go to http://www.facs.org/ahp/pqri/2013/cms-1500-claim.pdf .  This is for surgeons, so ignore the diagnoses, but most of the other information is the same (except for Section 24J for group billing which does not apply to LCSWs in private practice which should be left blank). 

Many LCSWs have been stymied by the fact that there is so little correlation between the PQRS measures and our diagnostic codes (DSM/ICD).  The only measures that mention a diagnostic code are #106 and #107 for major depression.  However, ALL diagnostic codes we use can be linked with whether people smoke, drink, use substances and several other behaviors that CMS is tracking.  Use the QDCs that apply to them if you are sending in information for other diagnoses, which you can find on the CSWA website at www.clinicalsocialworkassociation.org under "Clinical Practice" and then "PQRS Options".  Scroll down to find the PQRS Measures and QDCs for those Measures.   

There is NO deadline today for LCSWs who send in their QDCs on the CMS-1500.  You can wait until February 28, 2014 to do so, though getting it out of the way sooner is a good idea.  You should continue to send QDCs for Medicare patients on every claim.    

Remember, for 2013, you only need send in one QDC for one patient to be in compliance and avoid a reimbursement penalty in 2015.  It is unlikely that you will qualify for the bonus in 2015 unless you have been sending in QDCs all year OR you have very few Medicare patients. 

I know what a difficult task this has been and hope that this information is useful in navigating these rough waters.