Archive for the ‘HealthCare Reform’ Category

Pre-Existing Condition Insurance Plan – Apply Now!

July 20, 2011
The Pre-Existing Condition Insurance Plan makes health insurance available to people who have had a problem getting insurance due to a pre-existing condition. 
The Pre-Existing Condition Insurance Plan:Apply for Insurance if you have pre-existing condition
  • Covers a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs.
  • Does not charge you a higher premium just because of your medical condition.
  • Does not base eligibility on income

Insurance Exchanges: Q and A

July 18, 2011

Exchanges are marketplaces where consumers can do comparison shop for health insurance, similar to shopping online for airline tickets.

Sliding subsidies for private insurance on the exchanges will be available for residents who Healthcare Reformearn up to 400% of the poverty level, about $43,560 this year.  Those who qualify for Medicaid, the state-federal program for the poor, will be able to sign up for it through the exchanges.  Proponents of exchanges claim that buying health insurance in a free market could possibly lower prices because of increased competition.

The following are answers to some common questions about exchanges:

What is an exchange, as envisioned by the health law?

It’s a marketplace where individuals and small employers will be able to shop for insurance coverage. They must be set up by January 1, 2014. The exchanges will also direct people to Medicaid if they’re eligible.

Will all states have exchanges?

States have the option of setting up their own exchanges, forming coalitions with other states to create regional exchanges – or opting out altogether. In that case, the federal government will run the exchanges for their residents.

Will anyone be allowed to buy from the exchanges?

No. Initially, exchanges will be open to individuals buying their own coverage and employees of firms with 100 or fewer workers (50 or fewer in some states). Most Americans will continue to get insurance through their jobs, not via the exchanges. The Congressional Budget Office estimates 8.9 million people will use the exchanges in 2014 and 23.4 million in 2018. Most will be people who are eligible for subsidies, which will average an estimated $4,600 per person in 2014. Undocumented immigrants will be barred from buying insurance on the exchanges.

What about federal workers?

Members of Congress and their staffs will be required to buy through exchanges if they want coverage from the federal government.  Other federal employees won’t be required to use an exchange.

Will exchanges be like travel websites or some existing health insurance sites?

In some ways. People will be able to compare policies sold by different companies. Purchasing insurance is complex and can be confusing, so information on the plan benefits will be standardized in an effort to make it easier to compare cost and quality. Plans will be divided into four different types, based on the level of benefits: bronze, silver, gold and platinum.

What will the coverage sold on the exchanges look like?

Plans will have to offer a set of “essential benefits.” Those details, still being developed by the Obama administration, will include hospital, emergency, maternity, pediatric, drug, lab services and other care. Annual cost-sharing, or the amount consumers must fork over before insurance payments kick in, will be capped at the amounts allowed for health savings accounts — currently, nearly $6,000 for individual policies and $12,000 for family plans.

How much will the policies cost?

The premiums will vary by type of plan and location. Insurers won’t be able to charge more based on gender or health status. They will be able to charge older people up to three times more than younger ones.

Will the states negotiate premiums with the insurers?

The law doesn’t require states to set or negotiate premiums. However, states may have some influence over prices. For example, states can decide whether to open exchanges to all insurers, or to limit the number. State insurance commissioners will be able to recommend whether specific insurers should be allowed to sell in the exchange, partly based on their patterns of rate increases.

What if I can’t afford the premiums?

People who earn less than 133 percent of the federal poverty level, $14,484 this year, will qualify for Medicaid in all states, under the law. Above that, sliding scale subsidies for private insurance on the exchanges will be available for residents who earn up to 400 percent of the poverty level, about $43,560 this year. Most people will be required to have coverage of some sort beginning in 2014.

Will all insurers have to offer policies through the exchange?

No. Insurers won’t be required to sell through the exchanges.

Will all state exchanges be the same?

No. States can design their exchanges differently, an issue that’s sparking debate in statehouses nationwide. Some states may choose to set additional standards for insurers beyond the federal law. Another important issue: The makeup and power of the governing boards overseeing the exchanges. Some states, such as Maryland, are considering barring insurance industry and sales agents from their governing boards. Others, like North Carolina, have pending legislation that includes representatives from those groups on their governing boards.

Source: Kaiser Health News

CMS Paid out the First Payments for the EHR Incentive Program. Are you registered?

July 18, 2011

Since the EHR incentive program opened in January of 2011, more than $158 million has been paid for both the Medicare and Medicaid EHR incentive programs.  In total, the Federal government has paid:

  • $75 million for the Medicare EHR incentive program
  • $83.3 million for the Medicaid EHR incentive program

The following are notable differences between the Medicare and Medicaid EHR incentive programs:



Federal Government will implement (will be an option nationally) Voluntary for States to implement (may not be an option in every State)
Payment reductions begin in 2015 for providers that do not demonstrate Meaningful Use No Medicaid payment reductions
Must demonstrate Meaningful Use Year 1 Adopt, implement and upgrade option for 1st participation year
Maximum incentive is $44,000 for Eligible Professionals (10% bonus for Eligible Professional in Health Professional Shortage Area) Maximum incentive is $63,750 for Eligible Professionals
Meaningful Use definition is standard for Medicare States can adopt certain additional requirements for Meaningful Use
Last year a provider may initiate program is 2014; Last year to register is 2016; Payment adjustments begin in 2015 Last year a provider may initiate program is 2016; Last year to register is 2016
Eligible Professionals include:

  • Doctor of medicine or osteopathy
  • Doctor of dental surgery or dental medicine
  • Doctor of podiatry
  • Doctor of optometry
  • Chiropractor

…and subsection (d) hospitals and Critical Access Hospitals (CAHs).

Eligible Professionals include:

  • Physicians (primarily doctors of medicine and doctors of osteopathy)
  • Nurse practitioner
  • Certified nurse-midwife
  • Dentist
  • Physician assistant who furnishes services in a Federally Qualified Health Center or Rural Health Clinic that is led by a physician assistant.

…and acute care hospitals (including CAHs) and children’s hospitals.

In order to receive the Medicare or MediCaid EHR incentive payments, follow the steps below:

  1. Successfully register for the Medicare EHR Incentive Program;
  1. Meet meaningful use criteria using certified EHR technology (Check to see if your software is certified  under the EHR incentive program at:; and
  2. Successfully attest, using CMS’ Web-based system, that you have met meaningful use criteria using certified EHR technology.

New Exemptions for e-Prescribing

June 1, 2011

The Center for Medicare & Medicaid Services (CMS) issued a proposed rule that makes significant changes to the e-prescribing penalty program by adding more exemptions categories so that physicians are not unfairly penalized.

The previous rules required physicians in individual practices to submit at least 10 Medicare Part B claims with the electronic measure code eRx G8553 and an eligible encounter code by June 30, 2011, or face a claims payment reduction of 1 percent in 2012.

Physicians are still required to e-prescribe using a qualifying system and electronic measure code; but, through an online web portal, will have an opportunity to show eligibility for one of the following exemptions:

  • Physician’s practice is located in a rural area without high speed internet access;
  • Physician’s practice is located in an area without sufficient available pharmacies for electronic prescribing;
  • Physician is registered to participate in the Medicare or Medicaid electronic health record incentive (EHR) program and has adopted certified EHR technology;
  • Physician is unable to electronically prescribe due to local, state or federal law or regulation (e.g., prescribes controlled substances);
  • Physician infrequently prescribes (e.g., prescribe fewer than 10 prescriptions between January 1, 2011, and June 30, 2011); and
  • There are insufficient opportunities to report the e-prescribing measure due to program limitations

Physicians will have to apply for an exemption from the 2012 e-prescribing penalty via the online web-portal by October 1, 2011.

The proposed rule can be viewed at the Office of the Federal Register website. It will be published in the Federal Register on June 1, 2011. The comment period closes July 25, 2011.

EHR Incentive Program Checklists

May 23, 2011

The Medicare and Medicaid EHR Incentive Programs checklists will show you the steps to take to receive your incentive payments, but first: EHR Incentive

  1. Find out if you are eligible for either the Medicare or Medicaid EHR Incentive Programs.
    • Professionals and hospitals can visit the Eligibility page to check eligibility.
  2. Are you a professional eligible for both programs? If so, you must choose a program and follow the rest of the relevant checklist below.

Not sure which program to choose? Compare “Notable Differences between the Medicare and Medicaid EHR Incentive Programs” .

Medicare EHR Incentive Program Checklist

If you’re an eligible professional, become a meaningful user of certified electronic health records to qualify for incentive payments of up to $44,000 from Medicare. Here’s how to qualify:

  • Make sure you’re eligible for the Medicare EHR Incentive Program. View eligibility guidelines at our Eligibility page.
  • Also eligible for the Medicaid EHR Incentive Program? You can receive higher incentive payments, up to $63,750, through the Medicaid EHR Incentive Program. See the Medicaid checklist.
  • Get registered. Registration is now open to eligible professionals. Visit the Registration page for more details.

Note: Register as soon as possible. You can register before having a system installed.

  • Use certified EHR technology. To receive incentive payments, make sure the EHR technology you’re using or are considering buying has been certified by the Office of the National Coordinator for Health Information Technology. Visit our Certified EHR Technology page for details.
  • Be a Meaningful User. You have to successfully demonstrate “meaningful use” for a consecutive 90-day period in your first year of participation (and for a full year in each subsequent years) to receive EHR incentive payments. Visit our Meaningful Use page to learn about meaningful use objectives and measures.
  • Attest for incentive payments. To get your EHR incentive payment, you must attest (legally state) through Medicare’s secure Web site that you’ve demonstrated “meaningful use” with certified EHR technology. You can now get to our secure Attestation Web site through a link at our Attestation page.

Medicaid EHR Incentive Program Checklist

If you’re an eligible professional, in your first year of participation you may adopt, implement or upgrade or become a meaningful user of certified electronic health records to qualify for incentive payments of up to $63,750 from Medicaid. Here’s how to qualify:

  • Make sure you’re eligible for the Medicaid EHR Incentive Program. View eligibility guidelines at our Eligibility page.
  • Also eligible for the Medicare EHR Incentive Program? Eligible professionals can receive up to $44,000 through the Medicare EHR Incentive Program. See the Medicare checklist.
  • Get registered. Visit the “Medicaid State Information” page to see if your state is participating in the Medicaid EHR Incentive Program.
  • If your state is already participating, register now for the Medicaid EHR Incentive Program.  Visit the Registration page for more details
  • If your state has not yet begun participating in the Medicaid EHR Incentive Program: you may wish to register now for the Medicare EHR Incentive Program, if you’re eligible for both programs. See the Medicare checklist.

Note: Register as soon as possible. You can register before having a system installed.

  • Use certified EHR technology. To receive incentive payments, make sure the EHR technology you’re using or are considering buying has been certified by the Office of the National Coordinator for Health Information Technology. Visit our Certified EHR Technology page for details.
  • Get qualified. To receive EHR incentive payments in the first year under the Medicaid EHR Incentive Program, you must do at least one of the following:
    • Adopt certified EHR technology; or
    • Implement certified EHR technology you have already purchased; or
    • Upgrade your current EHR technology to the newly certified version; or
    • Demonstrate “meaningful use” of certified EHR technology for a 90-day period. Visit your state’s Medicaid agency Web site or our Meaningful Use page to learn about meaningful use objectives and measures.
  • Attest for incentive payments. To get your EHR incentive payment, you must attest (legally state) through your state’s Medicaid agency Web site that you’ve met all of the eligibility criteria, including having adopted, implemented, upgraded or meaningfully used certified EHR technology. Visit your state’s Medicaid agency Web site for more information.

Source: CMS

2011 Medicare e-Prescribing Incentives and 2012-2013 Medicare e-Prescribing Penalties

May 16, 2011

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorized a new and separate federal incentive program for eligible professionals (EPs) who are successful electronic prescribers.  This incentive is in addition to the electronic health record (EHR) program and the Physician Quality Reporting System (PQRS) program.

Providers could qualify for multiple incentive programs.  However, within the same year, providers could only qualify for the Medicare EHR incentive program OR the Medicare e-Prescribing incentive  program, not both.  Therefore, it would be advisable to participate for the e-Prescribing incentive program for 2011 and then apply for the Medicare EHR incentive program in the following year.  If the provider chooses to participate in the MediCaid EHR incentive program and the Medicare e-Prescribing incentive program in the same year, the qualified provider is eligible to receive incentives under BOTH programs.

Benefits of e-Prescribing

First, e-Prescribing is offered as a way to prevent medication errors that arise due to difficulties in reading or understanding handwritten prescriptions.  In addition, e-Prescribing could reduce adverse drug events (ADEs) by making information such as drug interactions and contraindications available to prescribers at the time they are preparing a prescription.  Finally, e-Prescribing may reduce patients’ out-of-pocket costs by placing formulary, coverage and copayment information at prescribers’ fingertips.

Reporting Period

The reporting period for the 2011 e-Prescribing incentive program will be for the entire 2011 calendar year (January 1, 2011 through December 31, 2011)

Incentive Amount

The 2011 Medicare e-Prescribing incentive program provides an incentive payment to eligible physicians who successfully e-Prescribe medications in 2011 equal to 1% of their total Medicare payments for the year.  For example, if you bill Medicare $100,000 in allowable charges in 2011 and successfully report on e-Prescribing, you would receive $1,000.

Year     Incentive Amount

  • 2011     1.0%
  • 2012     1.0%
  • 2013     0.5%
  • 2014     0.0%

Note: Payment bonuses are made after the conclusion of the calendar year in which eligible physicians e-Prescribe for their Medicare patients, not as an up front payment.

Reporting Requirements

To participate in the 2011 e-Prescribing incentive program, individual eligible physicians may choose to report on their adoption and use of a qualified e-Prescribing measure, G code, G8553.

Sample Claim Form With G-Code

In order to receive incentive payments for e-Prescribing in 2011, eligible physicians must report the e-Prescribing G-code, G8553, at least 25 times on their claim forms. At least 10 of the 25 claims should be reported between January 1, 2011 through June 30, 2011 reporting period.


According to MIPPA, physicians who are eligible but choose not to participate in the 2012 or 2013 Medicare e-Prescribing incentive program, the following penalties would apply based on their allowable charges for the year:

Year     Penalty Amount

  • 2011     -0.0%
  • 2012     -1.0%
  • 2013     -1.5%
  • 2014     -2.0%

CMS is basing the 2012 penalties on e-Prescribing activity that occurs during January 1, 2011 through June 30, 2011, and the 2013 penalties on e-prescribing activity that occurs throughout 2011.  To avoid penalties in 2013, an eligible physician must e-Prescribe and report the e-Prescribing G-Code, G8553, at least 10 times for applicable office visits and services for the January 1, 2011 through June 30, 2011 reporting period on Medicare claim forms (report at least 25 times throughout 2011 to avoid penalties in 2013).

Exceptions to Penalty for non-Participation

The 2012 and 2013 e-Prescribing penalty will not apply to:

  • An eligible physician who has less than 100 claims for dates of service between January 1, 2011 through June 30, 2011.


  • An eligible who is not a physician, nurse practitioner or physician assistant as of June 30, 2011;
  • An eligible physician for whom office visits and other services listed in the CMS e-Prescribing measure specifications represent less than 10% of their allowed charges in the first six months of 2011.


Accountable Care Organizations (ACOs)

April 29, 2011
Accountable Care Organizations (ACOs)

ACO - Healthcare Provider Network

On March 31, 2011, the Centers for Medicare & Medicaid services (CMS) proposed new rules under the Affordable Care Act to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs).  CMS has created incentives for the ACOs to coordinate patient care across care settings – including doctors’ offices, hospitals, and long-term facilities.  The Medicare Shared Savings Programs will reward ACOs based on lowering costs of providing healthcare services while meeting performance standards on quality of care.  Patient and provider participation in an ACO is voluntary.

Who are included in an ACO?

  • ACO professionals (i.e., physicians and hospitals) in group practice arrangements,
  • Network of individual practices of ACO professionals,
  • Partnerships of joint ventures arrangements between hospitals and other ACO professionals,
  • Hospitals employing ACO professionals.

How could providers participate?

Providers can participate in Medicare’s Shared Savings Program, providers must form or join an Accountable Care Organization (ACO) and apply to CMS. If accepted, ACOs would serve at least 5,000 Medicare patients and agree to participate in the program for 3 years.  Providers would continue to receive payment under Original Medicare fee-for-service (FFS) rules.

As part of the participation criteria, ACOs must establish a governing body representing ACO providers of services, supplier, and Medicare beneficiaries.

How would the Shared Savings work?

Medicare would continue to pay individual providers and suppliers as it currently does under the Original Medicare fee-for-service payment system.  In addition, CMS would develop a benchmark for each ACO against which its performance is measured to assess whether an ACO qualifies to receive shared savings, or be held accountable for losses.  The benchmark would be an estimate of what the total Medicare fee-for-service Parts A and B expenditures for ACO beneficiaries would otherwise have been in the absence of the ACO.

What are proposed quality measurements that CMS would be using?

CMS has proposed to measure quality of care by the ACOs using nationally recognized measures in 5 key areas:

  1. Patient experience;
  2. Care coordination;
  3. Patient safety;
  4. Preventive health; and
  5. At-risk population/frail elderly health.

Effective date of ACOs?

January 1, 2012.

ICD-10 / Version 5010 Timeline

April 27, 2011


Click the link for a copy of the timeline in .PDF: ICD-10 – TimeLine

ICD-10-CM: Benefits and Enhancement to ICD-9-CM

April 27, 2011

ICD10_BenefitsOn or after October 1, 2013, the current diagnosis code sets (ICD-9-CM) will be replaced with the new code – ICD-10-CM.  This article discusses the benefits of ICD-10-CM, similarities and differences between the two coding systems, and new features and and additional changes that can be found in ICD-10-CM.

Benefits of ICD-10-CM:

ICD-9-CM is 30 years old, has outdated and obsolete terminology that produce inaccurate and limited data, and is inconsistent with the current medical practice. ICD-10-CM incorporates much greater clinical detail and specificity than ICD-9-CM.  ICD-10-CM:

  • Incorporates much greater specificity and clinical information, which results in:
    • Improved ability to measure health care services;
    • Increased sensitivity when refining grouping and reimbursement methodologies;
    • Enhances ability to conduct public health surveillance; and
    • Decreased need to include supporting documentation with claims;
  • Includes updated medical terminology that is consistent with the current medical practice;
  • Provides codes to allow comparison of mortality and morbidity data; and
  • Provides better data for:
    • Measuring care furnished to patients;
    • Designing payment systems;
    • Processing claims;
    • Making clinical decisions;
    • Tracking public health;
    • Identifying fraud and abuse; and
    • Conducting research.

New Features Found in ICD-10-CM:

  • Laterality (left, right, bilateral)
  • Combination codes for certain conditions and common associated symptoms and manifestations
  • Combination codes for poisonings and their associated external cause
  • Obstetric codes identify trimester instead of episode of care
  • Character “x” is used as a 5th character placeholder in certain 6 character codes to allow for future expansion and to fill in other empty characters when a code that is less than 6 characters in length requires a 7th character
  • Two types of Excludes notes
    • Excludes 1 – indicates that the code excluded should never be used with the code where the note is located
    • Excludes 2 – indicates that the patient may have combination of conditions and both codes could be used
  • Inclusion of clinical concepts that do not exists in ICD-9-CM e.g. underdosing, blood type, blood alcohol level
  • Expansion of codes e.g. injuries, diabetes, substance abuse, postoperative complications
  • Codes for postoperative complications have been expanded and a distinctions made between intraoperative complications and postprocedural disorders

Additional Changes Found in ICD-10-CM:

  • Injuries are grouped by anatomical site rather than by type of injury;
  • Codes and categories have reorganize;
  • New code definitions; and
  • The current “V” codes (Factors influencing health status and contact with health services) and “E” codes (External causes of injury and poisoning) are incorporated into the main classification rather than separated into supplemental sections.

HealthCare Timetable

November 23, 2010
Highlights of the health care law and when major provisions take effect:
Health Care Bill Timeline
Health Care Bill Timeline


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