The Centers for Medicare & Medicaid Services (CMS) will issue a final rule that places new requirements on Medicare Advantage (MA) organizations, Medicaid managed care plans, Children’s Health Insurance Program (CHIP) managed care entities, state Medicaid and CHIP Fee-for-Service (FFS) programs, and Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs) to improve the electronic exchange of healthcare data and streamline processes related to prior authorization. This final rule will also add a new measure for eligible hospitals and critical access hospitals (CAHs) under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System (MIPS) eligible clinicians under the Promoting Interoperability performance category of MIPS.

Weblinks

• Press Release: https://www.cms.gov/newsroom/press-releases/cms-finalizes-rule-expand-access-health-information-and-improve-prior-authorization-process
• Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f
• Final Rule: https://www.cms.gov/files/document/cms-0057-f.pdf

The U.S. Department of Health and Human Services, through the Centers for Medicare & Medicaid Services (CMS), announced a new model to test approaches for addressing the behavioral and physical health, as well as health-related social needs, of people with Medicaid and Medicare. The Innovation in Behavioral Health (IBH) Model’s goal is to improve the overall quality of care and outcomes for adults with mental health conditions and/or substance use disorder by connecting them with the physical, behavioral, and social supports needed to manage their care.  The model will also promote health information technology (health IT) capacity building through infrastructure payments and other activities.

The IBH Model will be tested by the Center for Medicare and Medicaid Innovation (CMS Innovation Center). Under IBH, community-based behavioral health practices will form interprofessional care teams consisting of behavioral and physical health providers, as well as community-based supports. This new model supports the President’s mental health strategy and implements an action item in the HHS Roadmap for BH integration.

Read more.

From Becker’s

CMS has finalized a rule to streamline the prior authorization process and improve the electronic exchange of health information that it estimates will save $15 billion over 10 years.

The requirements generally apply to Medicare Advantage organizations, state Medicaid and Children’s Health Insurance Program agencies, Medicaid managed care plans, CHIP-managed care entities and qualified health plan insurers on the federally facilitated exchanges, according to a Jan. 17 CMS news release. The agency proposed the rule in December 2022.

Beginning primarily in 2026, certain payers will be required to include a specific reason when denying requests, publicly report certain prior authorization metrics and send decisions within 72 hours for urgent requests and seven calendar days for standard requests.

The rule also requires affected payers to implement a Health Level 7 Fast Healthcare Interoperability Resources standard application programming interface to support electronic prior authorization.

“Together, these new requirements for the prior authorization process will reduce administrative burden on the healthcare workforce, empower clinicians to spend more time providing direct care to their patients and prevent avoidable delays in care for patients,” CMS said in the release.

The rule also finalizes API requirements to “increase health data exchange and foster a more efficient healthcare system for all.” CMS is delaying the dates for compliance from generally Jan. 1, 2026, to Jan. 1, 2027. Beginning in January 2027, affected payers will be required to expand their current patient access API to include information about prior authorizations and to implement a provider access API that providers can use to retrieve their patients’ claims, encounter, clinical and prior authorization data. CMS is requiring affected payers to exchange, with a patient’s permission, most of the same data using a payer-to-payer FHIR API when a patient moves between payers or has multiple concurrent payers.

The rule also adds a new electronic prior authorization measure for eligible hospitals and critical access hospitals under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System eligible clinicians under the promoting interoperability performance category.

From Becker’s Hospital Review

Pittsburgh-based Duquesne University opened its College of Medicine on January 17.

The college will welcome its inaugural class of 85 students in July with plans to grow enrollment to 170 students per year beginning in 2026, according to a university news release. The college will provide doctor of osteopathic medicine degrees.

Duquesne said it received significant gifts from foundations, corporations and government entities to support building the medical college. The building includes advanced simulation, augmented reality anatomy labs and other technology.

Kevin Stansbury, the CEO of Lincoln Community Hospital in the 800-person town of Hugo, Colorado, is facing a classic Catch-22: He could boost his rural hospital’s revenues by offering hip replacements and shoulder surgeries, but the 64-year-old hospital needs more money to be able to expand its operating room to do those procedures.

“I’ve got a surgeon that’s willing to do it. My facility isn’t big enough,” Stansbury said. “And urgent services like obstetrics I can’t do in my hospital, because my facility won’t meet code.”

Rural hospitals throughout the nation are facing a similar conundrum. An increase in costs amid lower payments from insurance plans makes it harder for small hospitals to fund large capital improvement projects. And high inflation and rising interest rates coming out of the pandemic are making it tougher for aging facilities to qualify for loans or other types of financing to upgrade their facilities to meet the ever-changing standards of medical care.

Read more.

Every five years, Pennsylvania Department of Health’s Title V Maternal and Child Health Services Block Grant requires that the Bureau of Family Health conduct a state-level, comprehensive assessment of the health status of women, birthing people, children, adolescents, and children and youth with special health care needs to identify the priority health needs that will guide state and local public health work funded by Title V. During this assessment, the Bureau of Family Health also evaluates its capacity to serve the maternal and child health populations. The results from the assessment will be used to identify seven to 10 specific priorities that can be positively impacted by strategic public health work over the next five years. State and local Title V staff will identify and implement evidence-based strategies with the goal of making a positive impact on the selected priorities and the health of the maternal and child health populations.

Over the next four months, the Bureau of Family Health will be hosting in-person and virtual regional events across Pennsylvania to engage maternal and child health stakeholders, including providers, service recipients and their families, and anyone interested in maternal and child health in Pennsylvania in discussions about health needs in Pennsylvania and how to prioritize those needs for the next five years.

Please join us at the event in your region and share your voice!

Northcentral:

Tuesday January 30, 2024, 10 AM @ The Penn Stater Hotel & Conference Center, 215 Innovation Blvd, State College, PA 16803 Registration Link and Flyer[pdf]

Southcentral:

Tuesday February 13, 2024, 10 AM @ The Community Center at Camp Hill GIANT, 3301 Trindle Rd., Camp Hill, PA 17011 Registration Link and Flyer[pdf]

Southeast:

Thursday, March 7, 2024, 3 PM @ The Community Center at Willow Grove GIANT, 315 York Rd. Willow Grove, PA 19090 Registration Link and Flyer[pdf]

Northeast:

Thursday, March 14, 2024, 3 PM @ The Woodlands Inn, Ascend Hotel Collection, 1073 Hwy 315, Wilkes-Barre, PA 18702 Registration Link and Flyer[pdf]

Northwest:

Tuesday, March 26, 2024, 3 PM @ The Ambassador Banquet & Conference Center, 7794 Peach St., Erie, PA 16509 Registration Link and Flyer[pdf]

Southwest:

Wednesday, March 27, 2024, 3 PM @ The Kovalchick Convention & Athletic Complex, 711 Pratt Dr., Indiana, PA 15705 Registration Link and Flyer[pdf]

A meal will be provided at each event, and we request that you pre-register if you are planning to attend.

The attached flyers provide additional details, please share with others who may be interested in attending!

Frequently Asked Questions

• Is registration required to attend an event? We strongly encourage you to pre-register if you intend to join us at an event so that we can plan accordingly. Please register by clicking on the registration link associated with the date you plan to attend or sending an email to RA‑DHPATITLEV@pa.gov indicating which event you will be attending.
• Can clients/service recipients attend these events to provide input? Absolutely! These will be family friendly events, and all are welcome. We welcome the participation of clients, service recipients and their families. Parents and caregivers, families with special needs, birthing people and their partners, and youth are all welcome to participate. Maternal and child healthcare and other professionals, and organizations serving this population in Pennsylvania are also welcome to share their thoughts! We are relying on providers and partners to share information about these events with the families that they serve. We greatly appreciate your assistance!
• Can we post these flyers in our office and/or send them to our own email distribution lists? Yes! Please share widely and advertise these events as you see fit. We have attached a flyer for each in-person event.
• These events are not convenient for me. Can I still provide input? We will be holding two virtual events between January and April 2024. Information about those events will be sent out in the coming weeks. If you are not able to attend any of the events, please complete the online prioritization survey which will be sent at later date, or you can send comments via email to RA‑DHPATITLEV@pa.gov or via mail to Department of Health, Bureau of Family Health, Attn. Title V Health Priorities, 625 Forster St., 7th Floor East, Health & Welfare Building, Harrisburg, PA 17120.

If you have any questions about these events or other aspects of the Title V Five Year Needs and Capacity Assessment, please contact Morgan Williams-Fake at mwilliamsf@pa.gov and Caryn Decker at cadecker@pa.gov

The Pennsylvania Department of Human Services (DHS) is developing an 1115 Medicaid program, Bridges to Success: Keystones of Health for Pennsylvania (Keystones of Health). DHS hopes to use this program to make health care more accessible, improve quality of care and services, and design and evaluate innovative strategies in health care to help people live healthier lives. DHS’ goal and vision for the waiver is to address Pennsylvania’s Medicaid participants’ health-related social needs with interventions that are both lifesaving and cost saving. Keystones of Health will focus on four key areas: reentry from correctional facilities; housing supports; food and nutrition supports; and multi-year continuous eligibility for children up to age six. Visit the Keystones of Health webpage for more details, including an opportunity to submit comments.