Complete Story


The Pulse: May 11, 2012


MCA Submits Comments to CMH Regarding ICDS Proposal for Duals

On May 4, Midwest Care Alliance (MCA) submitted comments to CMS regarding Ohio Medicaid's Integrated Care Delivery System (ICDS) for individuals dually eligible for Medicare and Medicaid. In the comments, MCA stated support for the Kasich Administration's goals to appropriately rebalance long-term care services and find ways to maximize coordination of MME benefits. However, MCA continues to have concerns with the ICDS proposal. These concerns include a lack of alignment of goals, poorly defined structural processes, loss of a Medicare beneficiaries rights, and poorly described global evaluation methods.

Among MCA's comments to CMS include those that we have been discussing with Ohio Medicaid throughout the ICDS process:
- The state should enact a moratorium of any new home care or hospice providers, other than expansion of established providers, within the demonstration regions.
- The proposal may be detrimental to small, independent businesses and bias toward large institutional companies providing an unfair advantage. This will reduce individual choice and access to appropriate care.
- All providers rendering home- and community-based care should maintain a deemed status accreditation through an appropriate accrediting body.
- There needs to be greater transparency between services and dollars available to provide care.
- There needs to be an annual overview describing the level of service and dollars spent on disease, disease trajectory, and services needed to treat the individual to meet expected outcomes.
- There needs to be an expanded model of care developed to meet the 24/7 care management model expected within the proposal. This includes direct support from the MCO on a 24/7/365 calendar with appropriate level of nursing and physician involvement.
- Patient liability should be centralized and collected by the ICDS or MCOs.

MCA also provided comments specific to home care and hospice members. Click here to read MCA's full comments to CMS.  The comment period to CMS is now closed, and next steps include Ohio Medicaid choosing ICDS plans based on the Request for Applications (RFA) they released last month. For more details on the RFA, which are due from plans by May 25, click here.  MCA will continue to keep you informed of the ICDS plan's progress. For more information contact Jeff Lycan at or (614) 545-9016, or Katie Rogers at or (614) 545-9032.

MCA Collaborates with 27 States in Member Readiness Survey

To help members better understand how they are positioned relative to Healthcare Reform, MCA collaborated with Artower Advisory Services, LLC and 27 other states to distribute a “readiness” survey.  Following the completion of the survey each member will receive a report with helpful suggestions on how you might look to better position your agency to be successful under Healthcare Reform.

Predicting how Medicaid reform, the Affordable Care Act – or other subsequent Healthcare Reform legislation – is implemented is indeed much more uncertain than the reality that all healthcare providers in the US will need to do more – with less – while improving the overall level of quality care.  As impact on your organization becomes clearer, MCA is positioning it’s programming to develop similar self-assessment tools to better assist members.  Following the survey, the next step in MCA’s plan to support members is at the MCA Annual Meeting on June 14th.  The meeting brings Jeannee Parker Martin, President of The Corridor Group, to Ohio to work with member’s leadership teams as she shares leadership tools and skills that are needed to move to the next level.

If you have any questions regarding the survey or would like additional information on how MCA is working to help our members prepare for Healthcare Reform, please don’t hesitate to contact Jeff personally at (614) 545-9016 or

MBR Budget Moves to Senate with SNF Dollars for Quality

The week before last, the Ohio House of Representative passed House Bill 487, the Mid-Biennial Review Budget. The biggest health related piece of the bill includes a provision added by the House that attempts to return unspent nursing facility dollars to nursing facilities based on quality scores. This provision, which is only for fiscal year 2013, is because of fiscal year 2012’s over-budgeted Medicaid bed days which has resulted in at least a $30 million underspend for the nursing facility reimbursement line item.

Since the provision was added, representatives from Governor Kasich’s office have expressed concerns about the unspent dollars being used towards skilled nursing facilities in 2013. This week, the bill moved to the Senate, and had hearings before the Senate Finance Committee. There, Budget Director Tim Keen and Director of the Office of Health Transformation, Greg Moody, both provided testimony expressing the administration's opposition to spending any revenue overages. Director Moody also committed that any unspent money for such a purpose violates a "core philosophy" of the biennial budget's health care reforms -the notion that money should follow the needs and desires of patients rather than simply be given to one provider group or another at the outset.

Midwest Care Alliance continues to support the General Assembly’s and the administration’s emphasis on quality-based reimbursement as well as supporting increase spending in the Home and Community Based Services arena. We will continue to keep our members informed about the status of this bill and quality provision. If you have any questions, contact Katie Rogers, Director of Public Policy, at or (614) 545-9032.

Joint Committee Gets Medicaid Update

Ohio's Medicaid Director John McCarthy provided an update on the latest developments in the program to two members of the Joint Legislative Committee for Unified Long-Term Services and Supports on Thursday. He told co-chairmen Rep. Jeff McClain (R-Upper Sandusky) and Sen. David Burke (R-Marysville) that the state has just learned it has been selected as one of seven participants nationwide in the federal Centers for Medicare and Medicaid Services (CMS) Comprehensive Primary Care Initiative. He said this involves Medicaid's collaborating with private health care payers to strengthen primary care. This will be implemented in the Cincinnati/Dayton region of the state.

He also discussed the proposal to the federal Centers for Medicare and Medicaid Services (CMS) to implement the Integrated Care Delivery System (ICDS) for both Medicaid and Medicare beneficiaries. Set to begin in February 2013 in selected regions of the state, this demonstration program, McCarthy said, will be operated by competitively selected health plans with the "Request for Applications" having been released on April 24. Those plans will do the following:

  • Arrange for care and services by specialists, hospitals and providers of long-term services and supports.
  • Allocate increased resources to primary and preventive services in order to reduce utilization of more costly Medicare and Medicaid benefits.
  • Cover all administrative processes including consumer outreach, education, grievances and appeals.
  • Use "a person-centered care coordination model that promotes an individual's ability to live independently" that includes the individual in the development of their care plan.
  • "Utilize a payment structure that blends Medicare and Medicaid funding and mitigates the conflicting incentives that exist" between the two programs.

Director McCarthy added that "the reduction in costs through this model will allow Ohio to continue to expand its investment in home- and community-based services, as evidenced by the exclusion of enrollment caps on home- and community-based waiver participation in this proposal."

In addition, he talked about the effort to modernize the eligibility determination system. Noting that "Ohio uses more than 160 categories to determine eligibility just for Medicaid and two separate processes are used to determine Medicaid eligibility based on disabling conditions," McCarthy told the committee members that the current computer system used to determine eligibility "will not be capable of administering eligibility for the estimated 935,000 Ohioans who will be newly eligible for Medicaid in 2014 as a result of the federal health care law." As such, his office and that of the Governor's Office of Health Transformation are working to simplify eligibility determination and "develop an integrated system." He said the state has been awarded approximately $300,000 in federal planning dollars. He said the new system will be implemented "prior to the federally mandated Medicaid eligibility expansion in January 2014."

In regards to the new Medicaid Managed Care contracts awarded for the new three regions across the state covering ABD and CFC Medicaid, he said the Medicaid office announced the selection of the managed care plans that will serve Medicaid clients beginning Jan. 1, 2013 and that five plans not chosen have filed protests. "... we expect to rule on the protests soon." McCarthy went on to explain, "The contracts Ohio Medicaid signs [by the end of August] with the selected health plans will increase expectations regarding the national performance standards the plans must meet to receive financial incentive payments and plans will be required to develop incentives for providers that are tied to improving quality and health outcomes for enrollees."

In addition, McCarthy said his office has begun drafting rules, due July 1, to recognize pediatric accountable care organizations, noting that the Mid-Biennium Review (MBR) bill includes language delaying enrollment of children with hemophilia, cystic fibrosis and cancer into managed care until either Jan. 1, 2014 or "when ODJFS [Ohio Department of Job and Family Services] requires adults under the Medicaid grouping of ABD [Aged, Blind and Disabled] covered under managed care."

They are also proceeding with adopting payment reforms for Medicaid inpatient hospital reimbursement, explaining that language in the MBR "will expand this effort by linking some of the funds in the hospital reimbursement pool to meeting or exceeding new quality benchmarks."

On hold, until the ICDS demonstration project is implemented, are efforts to expand and streamline home- and community-based waivers for disabled and elderly needing a nursing home level of care.

Asked by McClain what he has learned as they have worked through these changes, McCarthy said that they discovered their original timeline for accomplishing many of the changes was "very aggressive," particularly as they have had to juggle a number of initiatives as well as negotiations with CMS.


Click here for a list of key legislation Midwest Care Alliance is monitoring and its status, as well as news from around the state that affects legislation, regulations, and policy.


Monitor Your Patients to Ensure That They Are Part D Patients and Not Hospice Patients

Pharmacists and Part D plans are being instructed by CMS that Part D should not be paying for claims for medications that are the responsibility of a hospice provider, particularly in long-term care facilities. CMS does suggest that unless the plan has information available at point-of-sale to determine payment responsibility, Part D sponsors should pay the claims for drugs furnished to members enrolled in a hospice program that may be covered under the hospice benefit and retrospectively determine payment responsibility. This means that Part D sponsors may seek recoupment from the pharmacies if the claims are processed incorrectly through Part D.

CMS will be providing future guidance regarding how sponsors should identify hospice drugs and whether sponsors should establish a point-of-sale prior authorization edit, or pay the claim at point-of-sale and make a retrospective Part A vs. D payment determination. To avoid potential recoupment issues, hospices should be diligent in determining what medications are related as well as medically appropriate for the terminally ill patient.  Hospices should also provide assistance to their patients in notifying their pharmacists that they are a hospice patient and which medications are related or not and which are Part D appropriate.  For example, a determination to not pay for a drug due to its cost and/or aggressive symptom management and yet having Part D reimburse for the more aggressive therapy could result, upon third-party review, in a determination that the aggressive therapy is related to the terminal illness and thus the responsibility of the hospice. 

NAHC Gets Additional Cosponsors for Home Health Care Bill

To kick off celebrating National Nurses Month this May, the National Association for Home Care & Hospice (NAHC) is asking members of Congress to support the Home Health Care Planning Improvement Act (S.227, H.R. 2267). This legislation is intended to allow nurse practitioners, clinical nurse specialists, certified nurse midwives, and physician assistants to sign home health plans of care.

NAHC included this legislation in its list of priority items to discuss with members of Congress during NAHC’s annual March on Washington conference. Since the conference, eight House members have agreed to cosponsor H.R.2267: Reps. Tim Bishop (D-NY), Suzanne Bonamici (D-OR), Cory Gardner (R-CO), Sam Graves (R-MO), Tim Holden (D-PA), Carolyn Maloney (D-NY), Carolyn McCarthy (D-NY) and Thaddeus McCotter (R-MI).

NAHC is encouraging home health advocates to keep up the momentum from the March on Washington and honor National Nurses Month by asking their members of Congress to cosponsor the Home Health Care Planning Improvement Act. To find out the name of your Representative and Senators and their contact information, you may click here. To send an email through the NAHC Legislative Action Network, you may click here: Write Your Legislators. You may visit NAHC’s Legislative Action Network for talking points and background materials. Also, you may visit S.227 to find a list of cosponsors for the Senate bill and H.R. 2267 for the list of cosponsors in the House.

NAHC also asks home care advocates to make a particular effort to reach out to the 35 members of the House who cosponsored this legislation during the 111th Congress, but who have not cosponsored the bill yet this Congress. Former Ohio cosponsors include Marcy Kaptur (D-OH).

NAHC assisted with the preparation and drafting of the Home Health Care Planning Improvement Act and has worked to gather support for its passage. In addition to NAHC, this legislation has been endorsed by AARP, the American Nurses Association, the American Academy of Physician Assistants, the American College of Nurse Practitioners, American Academy of Nurse Practitioners, the American College of Nurse Midwives, and the Visiting Nurse Associations of America.

Medicare Learning Network, MLN Matters post “A Physician’s Guide to Medicare’s Home Health Certification, including the FacE to Face Encounter”

The Centers for Medicare & Medicaid Services (CMS) recently posted an article specifically targeting physicians detailing certification requirements. The document can be found by clicking here.  The article provides relief to home health agencies and physicians as it changes CMS policy to now allow for the use of checkboxes. Specifically, the guide states: The face-to-face documentation can include, or exist as, checkboxes so long as it comes from the certifying physician.”

Additionally, the guide clearly distinguishes between the qualifications of certifying physicians (i.e. the physician who certifies that the patient is homebound and services are medically necessary and documents the face-to-face encounter), and physicians and non-physician practitioners (NPP) who may conduct a face-to-face encounter. This includes confirmation that the physician who conducts a face-to-face encounter, but does not certify the patient, is not required to be Medicare enrolled.

American Pain Foundation Closes After Senators Launch Investigation of Drugmakers

As the U.S. Senate Finance Committee launched an investigation into makers of narcotic pain relievers and groups that champion them, the American Pain Foundation has shut down its operations, citing "irreparable economic circumstances," ProPublica reports.

In a previous investigation, ProPublica and the Washington Post had found that 90 percent of the funding APF received in 2010 came from the pharmaceutical and medical-device industry and that the group's guides for patients, journalists, and policy makers had played down the risks associated with narcotic painkillers such as Oxycontin, Vicodin, and Opana. Earlier this week, Sens. Max Baucus (D-MT), who chairs the Senate Finance Committee, and senior committee member Charles Grassley (R-IA) sent letters to pharmaceutical companies Purdue Pharma, Endo Pharmaceuticals, and Johnson & Johnson as well as APF, the American Academy of Pain Medicine, American Pain Society, Wisconsin Pain & Policy Studies Group, and Center for Practical Bioethics, seeking extensive records and correspondence documenting the links, financial and otherwise, between them.

In addition to payment information dating from 1997 to ten groups and eight individuals, the senators asked about any influence the companies had on a 2004 pain guide for physicians that was distributed by the Federation of State Medical Boards; on the American Pain Society's guidelines; and on the American Pain Foundation's Military/Veterans Pain Initiative. While sales of the drugs have tripled since 1999, the number of overdose deaths involving prescription painkillers has jumped to some 14,800 in 2008 alone — more than those involving cocaine and heroin combined.

In a prepared statement, Baucus said, "When it comes to these highly addictive painkillers, improper relationships between pharmaceutical companies and the organizations that promote their drugs can put lives at risk."