Health Reform WK-EDGE Next gen ACOs offered rule waivers, can implement benefit enhancements
Tuesday, August 30, 2016

Next gen ACOs offered rule waivers, can implement benefit enhancements

By Kayla R. Bryant, J.D.

Next Generation Accountable Care Organizations (NGACOs) are able to receive payment for providing certain services that are not payable under fee-for-service (FFS) Medicare. These include SNF services provided without a prior three-day inpatient stay, telehealth services regardless of beneficiary location, and limited home visits for non-homebound patients following inpatient stays (MLN Matters, SE1613, August 16, 2016).

Next Generation ACOs. CMS created the NGACO model in order to improve care coordination and ensure that providers’ payments are tied to the quality of care provided. Some of the model’s goals include (1) protecting beneficiaries’ freedom to choose providers and services; (2) creating benchmarks that reward quality, efficiency, and are less influenced by recent expenditures; and (3) ensuring long-term financial sustainability. Section 3021 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) allows CMS to waive certain payment requirements for the NGACO model, although a particular ACO can decide if it wants to implement these waivers.

Three-day inpatient rule. Typically, a patient must have spent three days as an inpatient in a hospital before admission to a skilled nursing facility (SNF) or a hospital with swing-bed approval for SNF services. NCAGOs have the option to implement a waiver of this requirement, and beneficiaries can be admitted to qualified NGACO SNF participants and preferred providers with a shorter inpatient stay or no inpatient stay at all. To qualify for the waiver, an admission must involve a beneficiary who does not reside in a facility while receiving Medicaid, and the beneficiary must meet all other CMS criteria for admission.

Telehealth. Typically, claims for telehealth services will only be paid for beneficiaries located in a rural area and involving a certain type of originating site. The NGACO waiver allows claims to be paid for telehealth services delivered by NGACO participants and preferred providers to beneficiaries regardless of the beneficiary’s location. Claims are subject to some limits following services provided to beneficiaries at home:

  • no payment for follow-up inpatient consultations;
  • one telehealth visit every three days for subsequent hospital care services;
  • one telehealth visit every 30 days for subsequent nursing facility care services.
  • All teleheatlh services must comply with all other Medicare criteria.

Home visits. NGACOs may receive payment for home visits following inpatient discharge made to non-homebound beneficiaries by licensed clinicians under the general supervision of participants and preferred providers. Licensed clinicians can be employees, leased employees, or independent contractors. One visit is allowed during the first 10 days, with another visit allowed in the next 20-day period.

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