🔥🔥🔥 Advanced Competency Assessment (ACA)

Friday, November 05, 2021 2:05:09 PM

Advanced Competency Assessment (ACA)

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What is a Competency Assessment?

For mail-order pharmacy claims: Express Scripts P. Box St. Louis MO As part of your plan, we're at your service. If you have questions about your medications, contact us. We have information about side effects, and how some medications interact with other medications. We can let you know how to handle or store them too. Your doctor's office submits a claim for payment to Cigna after you see your doctor or receive other medical care.

If your provider is not submitting a claim on your behalf, you must send a completed claim form and an itemized bill to the address listed on your ID card. It tells you how your claim was paid, including the amount that was paid and to whom it was paid. EOBs are available for you to look at online at www. You'll also find:. Remember to save your EOBs for tax purposes and as a record of health care dates and services. When two plans cover the same service they may coordinate benefits. This is so that neither plan duplicates the other plan's payment. Coordination of Benefits rules can vary from state to state.

Please refer to your policy for more information on "Coordination of Benefits. If you visit an out-of-network dentist or other provider , you may pay more for services. You may have to pay the difference between what the plan allows and the amount billed by the dentist. Balance Billing is the difference between the out-of-network dentist's charge and Cigna's allowed amount for the service s. An in-network dentist may not bill you for the difference between their charge and Cigna's negotiated rate.

For in-network dental claims, your provider will submit your claim. Cigna will process the claim according to the terms of your insurance plan and any payment due will be made to the provider directly. For out-of-network dental claims, Cigna must receive your claim within 12 months after the date of service, except in absence of legal capacity. If your dentist is not submitting a claim on your behalf, you must send a completed claim form and itemized bill to Cigna. View Cigna's dental claim forms. To keep your dental insurance coverage in effect, you must pay the monthly bill. If you do not pay your monthly bill, then there is a grace period. If you bought your plan from a state or federal marketplace AND you qualify for federal financial assistance and receive an advanced premium tax credit:.

Did you go to a dentist and your claim was paid by Cigna, but then later denied? If you overpaid your insurance premium you may qualify for a refund. You or your dentist's office will submit a claim for payment to Cigna after you visit your dentist. It's simple and clear, so you can see what was submitted, what's been paid and what you owe. EOBs are available for you to look at online at myCigna. Remember to save your EOBs for tax purposes and as a record of dental care dates and services. Some insured people may have two dental plans.

If you do, your Cigna dental plan will cover services according to the terms of your Cigna dental plan. Cigna does not coordinate benefits for dental coverage. All insurance policies and group benefit plans contain exclusions and limitations. For availability, costs and complete details of coverage, contact a licensed agent or Cigna sales representative. This website is not intended for residents of New Mexico. Selecting these links will take you away from Cigna. Cigna may not control the content or links of non-Cigna websites. For the best experience on Cigna. Overview Medicare Coverage Options. Individuals and Families. Plans and Services. What does transparency in coverage mean? Out-of-network non-emergency services Your health plan does not cover non-emergency services from an out-of-network provider.

Enrollee claim submission How you get your bill paid when visiting an in-network provider When you visit an in-network provider, show your ID card and pay any required copay. How you get your bill paid when visiting an out-of-network provider When you visit an out-of-network provider, show your ID card and ask the provider if they will bill your insurance company. Medical Claims must be received by Cigna within 15 months of the original date of service, except in the event of a legal incapacity. Pediatric Vision Claims must be received by Cigna within 12 months of the original date of service, except in the event of a legal incapacity.

Claim forms Access the required claim forms for medical, behavioral, pharmacy, vision and dental. Mail your completed claim form s and the original itemized bill s to Cigna. You will receive an Explanation of Benefits after your claim is processed. If you are unable to find a claim form or need help, please call Customer Service. The toll-free number 1 Cigna24 1 Grace periods and claims pending policies during the grace period What is a grace period? If your claim is not approved or denied it is referred to as pending. As long as initial payment for coverage has been paid and the plan is active, you have 31 days to pay your bill or premium.

Coverage will continue during the grace period. If you fail to pay premium within the applicable grace period, your coverage may be rescinded or cancelled. As long as initial payment for coverage has been paid and the plan is active, you have 3 months to pay your bill or premium. Services received during the grace period. If you receive services during the grace period and receive an Advanced Premium Tax Credit: Cigna will pay claims for covered services during the first 30 days of the grace period. Cigna will hold or pend claims for covered services received during the second and third month of the grace period.

Retroactive denials Did you go to a provider and your claim was denied? Apply now to the second cohort of the Leading Physician Well-being Program. Applications close Nov. State Legislative Conference Oct. That's a wrap! Thanks to everyone who attended FMX With the very best in live courses, self-study products, and online learning, you can earn the CME you need on your schedule with the AAFP.

Led by expert KSA faculty, experience hands-on learning as you discuss 60 core competency questions and answers with your peers. Future dates and topics will be announced once they are finalized. Stay current with family medicine guidelines and get everything you need to pass your Boards in three and half days. The course dates will be announced once they are confirmed. Standards and requirements adopted by States must be applied uniformly to all plans in each relevant insurance market in a State.

All provisions in this subtitle take effect on January 1, Qualified health plan defined. Requires qualified health plans to be certified by Exchanges, provide the essential health benefits package, and be offered by licensed insurers that offer at least one qualified health plan at the silver and gold levels. Essential health benefits requirements. Defines an essential health benefits package that covers essential health benefits, limits cost-sharing, and has a specified actuarial value pays for a specified percentage of costs , as follows:.

For the individual and small group markets, requires the Secretary to define essential health benefits, which must be equal in scope to the benefits of a typical employer plan. For all plans in all markets, prohibits out-of-pocket limits that are greater than the limits for Health Savings Accounts. Indexes the limits and deductible amounts by the percentage increase in average per capita premiums. For the individual and small group markets, requires one of the following levels of coverage, under which the plan pays for the specified percentage of costs:. In the individual market, a catastrophic plan may be offered to individuals who are under the age of 30 or who are exempt from the individual responsibility requirement because coverage is unaffordable to them or they have a hardship.

A catastrophic plan must cover essential health benefits and at least 3 primary care visits, but must require cost-sharing up to the HSA out-of-pocket limits. Also, if an insurer offers a qualified health plan, it must offer a child-only plan at the same level of coverage. Voluntary Choice of Coverage of Abortion Services. Abortion cannot be a mandated benefit as part of a minimum benefits package. A qualified health plan would determine whether it will cover: no abortions, only those abortions allowed under Hyde rape, incest and life endangerment , or abortions beyond those allowed by Hyde.

The Secretary may not determine that the public plan provide coverage for abortions beyond those allowed by Hyde unless the Secretary: 1 is in compliance with the provision prohibiting the use of Federal funds to pay for abortions beyond those allowed by Hyde ; 2 guarantees that, according to three different accounting standards, no Federal funds will be used; and 3 takes all necessary steps to ensure that the United States does not bear the insurance risk for abortions that do not meet the Hyde exceptions in the public plan. States may require the coverage of additional benefits in the Community Health Insurance Option, but must assume costs associated with covering these benefits.

A State may elect to require coverage of abortions beyond those allowed by Hyde only if no Federal funds are used for this coverage. The U. Abortions currently permitted by Hyde shall be covered in the Community Health Insurance Option to the same extent as they are under Medicaid. Assured Availability of Varied Coverage through the Exchanges. The Secretary would ensure that in each State Exchange, at least one plan provides coverage of abortions beyond those permitted by Hyde and at least one plan does not provide coverage of abortions beyond those permitted by Hyde.

Prohibition on the Use of Federal Funds. No tax credit or cost-sharing credits may be used to pay for abortions beyond those permitted by the Hyde Amendment. Segregation of Funds. Actuarial Value of Optional Service Coverage. The Secretary would be required to estimate, on an average actuarial basis, the basic per enrollee, per month cost of including coverage of abortions beyond those permitted by the Hyde Amendment. In making such estimates, the Secretary may take into account the impact of including such coverage on overall costs, but may not consider any cost reduction estimated to result from providing such abortions, such as prenatal care.

Provider Conscience Protections. No individual health care provider or health care facility may be discriminated against because of a willingness or an unwillingness, if doing so is contrary to the religious or moral beliefs of the provider or facility, to provide, pay for, provide coverage of, or refer for abortions. Application of State and Federal Laws.

State laws regarding the prohibition of or requirement of coverage or funding for abortions and State laws involving abortion-related procedural requirements are not preempted. The provision similarly provides that Federal conscience protections and abortion-related antidiscrimination laws would not be affected by the bill. The rights and obligations of employees and employers under Title VII of the Civil Rights Act of would also not be affected by the bill. Related definitions. Defines the small group market as the market in which a plan is offered by a small employer that employs employees. Defines the large group market as the market in which a plan is offered by a large employer that employs more than employees. Before , a State may limit the small group market to 50 employees.

Defines a State as one of the 50 States and the District of Columbia. Affordable choices of health benefit plans. Requires the Secretary to award grants, available until , to States for planning and establishment of American Health Benefit Exchanges. Requires the Secretary to:. Establish certification criteria for qualified health plans, requiring such plans to meet marketing requirements, ensure a sufficient choice of providers, include essential community providers in their networks, be accredited on quality, implement a quality improvement strategy, use a uniform enrollment form, present plan information in a standard format, and provide data on quality measures.

Determine an initial and annual open enrollment period, as well as special enrollment periods for certain circumstances. Allows States to require benefits in addition to essential health benefits, but States must defray the cost of such additional benefits. Requires Exchanges to certify qualified health plans, operate a toll-free hotline and Internet website, rate qualified health plans, present plan options in a standard format, inform individuals of eligibility for Medicaid and CHIP, provide an electronic calculator to calculate plan costs, and grant certifications of exemption from the individual responsibility requirement. Beginning in , requires Exchanges to be self-sustaining and allows them to charge assessments or user fees.

Allows Exchanges to certify qualified health plans if they meet certification criteria and offering them is in the interests of individuals and employers. Allows regional or interstate Exchanges if the States agree to, and the Secretary approves, such Exchanges. Requires Exchanges to award grants to Navigators that educate the public about qualified health plans, distribute information on enrollment and tax credits, facilitate enrollment, and provide referrals on grievances, complaints, or questions. Consumer choice.

Allows qualified employers to offer a choice of qualified health plans at one level of coverage; small employers qualify to do so, and States may allow large employers to qualify beginning in Requires insurers to pool the risk of all enrollees in all plans except grandfathered plans in each market, regardless of whether plans are offered through Exchanges. Requires the offering of only qualified health plans though Exchanges to Members of Congress and their staff. Requires the Secretary to establish procedures under which States may allow agents or brokers to enroll individuals in qualified health plans and assist them in applying for tax credits and cost-sharing reductions. Financial integrity. Requires Exchanges to keep an accurate accounting of all expenditures and submit annual accounting reports to the Secretary.

Requires Exchanges to cooperate with Secretarial investigations and allows for Secretarial audits of Exchanges. If the Secretary finds serious misconduct in a State, allows the Secretary to rescind up to 1 percent of Federal payments to the State. State flexibility in operation and enforcement of Exchanges and related requirements. Requires the Secretary, in consultation with NAIC, to set standards for Exchanges, qualified health plans, reinsurance, and risk adjustment.

Requires States to implement these standards by If the Secretary determines before that a State will not have an Exchange operational by , or will not implement the standards, requires the Secretary to establish and operate an Exchange in the State and to implement the standards. Presumes that a State operating an Exchange before meets the standards, and establishes a process for the State to come into compliance with the standards. Federal program to assist establishment and operation of nonprofit, member-run health insurance issuers. Requires the Secretary to award loans for start-up costs and grants to meet solvency requirements, until July 1, , to member-run nonprofits that will offer qualified health plans.

Establishes an Advisory Board with members appointed by the Comptroller General, to terminate by Prohibits health insurance issuers that existed on July 16, or governmental organizations from qualifying for the program. Allows participants to form a private purchasing council to enter into collective purchasing arrangements for items and services, but which may not set provider payment rates. Prohibits government representatives from serving on the board of directors of participants or the council.

Community health insurance option. Allows States to enact a law to opt out of offering the option. Requires the option to cover only essential health benefits; States may require additional benefits, but must defray their cost. Requires the Secretary to set geographically adjusted premium rates that cover expected costs. Requires the Secretary to negotiate provider reimbursement rates, but they must not be higher than average rates paid by private qualified health plans. Subjects the option to State and Federal solvency standards and to State consumer protection laws.

Establishes a Start-Up Fund to provide loans for initial operations, to be repaid with interest within 10 years. Authorizes the Secretary to contract with nonprofits for the administration of the option. Level playing field. Requires qualified health plans offered under the CO-OP program, as a Community Health Insurance Option, or as a nationwide plan, to be subject to all Federal and State laws that apply to private health insurers. State flexibility to establish basic health programs for low-income individuals not eligible for Medicaid. Allows States to contract, through a competitive process that includes negotiation of premiums, cost-sharing, and benefits, with standard health plans for individuals who are not eligible for Medicaid or other affordable coverage and have income below percent of the Federal Poverty Level FPL.

Requires the Secretary to certify that participating individuals do not have to pay more in premiums and cost-sharing than they would have paid under qualified health plans, and that the plans cover essential health benefits. Requires the Secretary to transfer to participating States 85 percent of the tax credits and cost-sharing reductions that would have been provided to individuals enrolled in standard health plans if they were enrolled in qualified health plans.

Waiver for State innovation. Beginning in , allows States to apply for a waiver for up to 5 years of requirements relating to qualified health plans, Exchanges, cost-sharing reductions, tax credits, the individual responsibility requirement, and shared responsibility for employers. Requires States to enact a law and to comply with regulations that ensure transparency. Requires the Secretary to provide to a State the aggregate amount of tax credits and cost-sharing reductions that would have been paid to residents of the State in the absence of a waiver.

Requires the Secretary to determine that the State plan for a waiver will provide coverage that is at least as comprehensive and affordable, to at least a comparable number of residents, as this title would provide; and that it will not increase the Federal deficit. Provisions relating to offering of plans in more than one State. By July 1, , requires the Secretary, in consultation with NAIC, to issue regulations for interstate health care choice compacts, which can be entered into beginning in Requires States to enact a law to enter into compacts and Secretarial approval, but only if the Secretary determines that the compact will provide coverage that is at least as comprehensive and affordable, to at least a comparable number of residents, as this title would provide; and that it will not increase the Federal deficit or weaken enforcement of State consumer protection laws.

Allows insurers in the individual and small group markets to offer a qualified health plan nationwide, which is subject to only the State benefit mandate laws of the State in which the plans are issued; but requires such plans to provide the essential benefits package. Allows States to enact a law to opt out of allowing the offering of nationwide plans. Requires insurers to file plan forms with each State in which they will offer nationwide plans for review. Transitional reinsurance program for individual and small group markets in each State.

For , , and , requires States to establish a nonprofit reinsurance entity that collects payments from insurers in the individual and group markets and makes payments to such insurers in the individual market that cover high-risk individuals. Establishment of risk corridors for plans in individual and small group markets. Requires the Secretary to establish risk corridors for qualified health plans in , , and Risk adjustment. Requires States to assess charges on health plans with enrollees of lower-than-average risk, and to provide payments to health plans with enrollees of higher-than-average risk. Risk adjustment applies to plans in the individual and small group markets, but not to grandfathered health plans. Refundable tax credit providing premium assistance for coverage under a qualified health plan.

Amends the Internal Revenue Code to provide tax credits to assist with the cost of health insurance premiums. Refundable credit for coverage under a qualified health plan. The premium assistance credit amount is calculated on sliding scale starting at two percent of income for those at or above percent of poverty and phasing out to 9. The reference premium is the second lowest cost silver plan available in the individual market in the rating area in which the taxpayer resides. The premium assistance credits do not take into account benefits mandated by States. This section also provides for reconciliation of the premium assistance credit amount at the end of the taxable year and for a study on the affordability of health insurance coverage by the Comptroller General.

Reduced cost-sharing for individuals enrolling in qualified health plans. The cost-sharing assistance does not take into account benefits mandated by States. Procedures for determining eligibility for Exchange participation, premium tax credits and reduced cost-sharing, and individual responsibility exemptions. Advance determination and payment of premium tax credits and cost-sharing reductions.

Allows for the advanced payment of premium assistance tax credits and cost-sharing reductions for eligible individuals. Prohibits any Federal payments to individuals who are not lawfully present in the United States. Requires the Secretary to establish a system for the residents of each State to apply for enrollment in, receive a determination of eligibility for participation in, and continue participation in, applicable State health subsidy programs. Disclosures to carry out eligibility requirements for certain programs. Allows for limited disclosure of tax return information to Exchanges or State agencies to carry out eligibility requirements for certain programs listed in the Act.

Premium tax credit and cost-sharing reduction payments disregarded for Federal and Federally-assisted programs. Precludes the premium assistance tax credits and cost-sharing reductions from being counted as income for purposes of determining eligibility for any Federal program or under any State or local program financed in whole or in part with Federal funds. Credit for employee health insurance expenses of small businesses. Amends the Internal Revenue Code to provide tax credits to small employers. Employee health insurance expenses of small employers.

To be eligible for a tax credit, the employer must contribute at least 50 percent of the total premium cost or 50 percent of a benchmark premium. Tax-exempt small businesses meeting the above requirements are eligible for tax credits of up to 25 percent of their contribution. In and beyond, eligible employers who purchase coverage through the State Exchange can receive a tax credit for two years of up to 50 percent of their contribution. Tax-exempt small businesses meeting the above requirements are eligible for tax credits of up to 35 percent of their contribution.

Requirement to maintain minimum essential coverage. Contains findings of Congress related to the individual responsibility requirement. Requires individuals to maintain minimum essential coverage beginning in For those under the age of 18, the applicable penalty will be one-half of the amounts listed above. Exceptions to the individual responsibility requirement to maintain minimum essential coverage are made for religious objectors, individuals not lawfully present, and incarcerated individuals. Exemptions from the penalty will be made for those who cannot afford coverage, taxpayers with income under percent of poverty, members of Indian tribes, those who have received a hardship waiver and those who were not covered for a period of less than three months during the year.

Reporting of health insurance coverage. Amends the Internal Revenue Code to require the reporting of health insurance coverage. Requires the reporting of coverage by individuals, employers, and governmental units. Automatic enrollment for employees of large employers. Requires employers with more than employees to automatically enroll new full-time employees in coverage subject to any waiting period authorized by law with adequate notice and the opportunity for an employee to opt out of any coverage the individual or employee was automatically enrolled in.

Employer requirement to inform employees of coverage options. Requires that an employer provide notice to their employees informing them of the existence of an Exchange. Finally, if the employee purchases a qualified health plan through the Exchange, the employee will lose the employer contribution if any to any health benefits plan offered by the employer and that all or a portion of such contribution may be excludable from income for Federal income tax purposes. Shared responsibility for employers. Reporting of employer health insurance coverage. The employer must also report the number and names of full-time employees receiving coverage. Offering of exchange-participating qualified health plans through cafeteria plans. Amends the Internal Revenue Code related to cafeteria plans.

Certain exchange-participating health plans not qualified. Plans provided through the exchange will not be an eligible benefit under an employer-sponsored cafeteria plan, except in the case of qualified employers i. Applies the definitions contained in section of the Public Health Service Act to this title. Transparency in government. Not later than 30 days after the date of enactment of this Act, the HHS Secretary shall publish on the HHS website a list of all of the authorities provided to the Secretary under this Act.

Prohibition against discrimination on assisted suicide. Prevents the Federal government, and any State or local government or health care provider that receives Federal financial assistance from subjecting any individual or institutional health care entity to discrimination on the basis that the entity does not provide assisted suicide, euthanasia, or mercy killing. Access to therapies. Prevents the HHS Secretary from promulgating certain regulations limiting access to health care services. Freedom not to participate in Federal health insurance programs. Provides that no individual, company, business, nonprofit entity, or health insurance issuer shall be required to participate in any Federal health insurance program created under this Act.

Equity for certain eligible survivors. Provides for improvements to the Black Lung Benefits Act. Protects individuals against discrimination under the Civil Rights Act, the Education Amendments Act, the Age Discrimination Act, and the Rehabilitation Act, through exclusion from participation in or denial of benefits under any health program or activity. Protection for employees. Amends the Fair Labor Standards Act to ensure that no employer shall discharge or in any manner discriminate against any employee with respect to his or her compensation, terms, conditions, or other privileges of employment because the employee has received a premium tax credit or for other reasons.

The Inspector General of the Department of HHS shall have oversight authority with respect to the administration and implementation of this title as it relates to such Department. Rules of construction. Nothing in this title shall be construed to modify, impair, or supersede the operation of any antitrust laws. Nothing in this title shall be construed to prohibit an institution of higher education from offering a student health insurance plan, to the extent that such requirement is otherwise permitted under applicable Federal, State, or local law. Health information technology enrollment standards and protocols.

Requires the development of standards and protocols to promote the interoperability of systems for enrollment of individuals in Federal and State health and human services programs. These standards shall allow for electronic data matching, and electronic documentation. The Secretary may require State or other entities to incorporate such standards as a condition of receiving Federal health information technology funds. Conforming amendments. Provides for technical and conforming amendments. Creates a new State option to provide Medicaid coverage through a State plan amendment beginning on January 1, Eligible individuals include: all non-elderly, non-pregnant individuals who are not entitled to Medicare e.

Also, as of January 1, , the mandatory Medicaid income eligibility level for children ages six to 19 changes from percent FPL to percent FPL. States have the option to provide Medicaid coverage to all non-elderly individuals above percent of FPL through a State plan amendment. Newly-eligible, non-elderly, non-pregnant individuals would receive benchmark or benchmark-equivalent coverage consistent with the requirements of section of the Social Security Act.

Benchmark and benchmark-equivalent coverage would be required to provide at least essential benefits as defined for the Exchange and prescription drugs and mental health services would be added to the list of services that must be covered at actuarial equivalence. Increased Federal assistance. From through , the Federal government will pay percent of the cost of covering newly-eligible individuals.

Expansion States would receive Maintenance of income eligibility. States would be required to maintain the same income eligibility levels through December 31, for all adults. Between January 1, and January 1, , a State would be exempt from the MOE requirement for optional, non-pregnant, non-disabled, adult populations whose family income is above percent of FPL if the State certifies to the Secretary that the State is currently experiencing a budget deficit or projects to have a budget deficit in the following State fiscal year.

Income eligibility for nonelderly determined using modified gross income. Beginning January 1, , States would be required to use modified gross income to determine Medicaid eligibility, the same measure used in the State Exchanges. Income disregards and asset tests would no longer apply in Medicaid, except for long-term services and supports. Existing Medicaid income counting rules would continue to apply for certain exempted groups including 1 individuals that are eligible for Medicaid through another program, 2 the elderly or Social Security Disability Insurance SSDI program beneficiaries, 3 the medically needy, 4 enrollees in a Medicare Savings Program, and 5 the disabled. Requirement to offer premium assistance for employer-sponsored insurance.

Requires States to offer premium assistance and wrap-around benefits to all Medicaid beneficiaries who are offered employer-sponsored insurance ESI if it is cost-effective to do so, based on current law requirements. Medicaid coverage for former foster care children. Allows all individuals below the age of 25 who were formerly in foster care for at least six months to be eligible for Medicaid. Payments to territories. Increases the spending caps for the territories by 30 percent and the applicable FMAP by five percentage points — to 55 percent — beginning on January 1, and for each fiscal year thereafter.

Beginning in , payments made to the territories with respect to amounts expended for medical assistance for newly eligible individuals would not count against the spending caps. Reduces projected decreases in Medicaid funding for States that have experienced major, statewide disasters. Medicaid Improvement Fund rescission. From fiscal year to , States would receive a 23 percentage point increase in the CHIP match rate, subject to a cap of percent.

Technical corrections. Requires State Medicaid and CHIP programs and the Exchange to coordinate enrollment procedures to provide seamless enrollment for all programs. Permitting hospitals to make presumptive eligibility determinations for all Medicaid eligible populations. Allows any hospital the option, based off preliminary information, to provide Medicaid services during a period of presumptive eligibility to members of all Medicaid eligibility categories.

Coverage for freestanding birth center services. Requires coverage of services provided by free-standing birth centers. Concurrent care for children. Allows children who are enrolled in either Medicaid or CHIP to receive hospice services without foregoing curative treatment related to a terminal illness. State eligibility option for family planning services. Adds a new optional categorically-needy eligibility group to Medicaid comprised of 1 non-pregnant individuals with income up to the highest level applicable to pregnant women covered under Medicaid or CHIP, and 2 individuals eligible under the standards and processes of existing section waivers that provide family planning services and supplies.

Benefits would be limited to family planning services and supplies, including related medical diagnostic and treatment services. Clarification of definition of medical assistance. Community First Choice Option. Establishes an optional Medicaid benefit through which States could offer community-based attendant services and supports to Medicaid beneficiaries with disabilities who would otherwise require the level of care offered in a hospital, nursing facility, or intermediate care facility for the mentally retarded. Removal of barriers to providing home and community-based services. Removes barriers to providing HCBS by giving States the option to provide more types of HCBS through a State plan amendment to individuals with higher levels of need, rather than through a waiver, and to extend full Medicaid benefits to individuals receiving HCBS under a State plan amendment.

Money Follows the Person Rebalancing Demonstration. Extends the Money Follows the Person Rebalancing Demonstration through September 30, and changes the eligibility rules for individuals to participate in the demonstration project by requiring that individuals reside in an inpatient facility for not less than 90 consecutive days. Protection for recipients of home and community-based services against spousal impoverishment. This provision would apply for a five-year period beginning on January 1, Sense of the Senate regarding long-term care. Expresses the Sense of the Senate that during the th Congress, Congress should address long-term services and supports in a comprehensive way that guarantees elderly and disabled individuals the care they need, in the community as well as in institutions.

Prescription drug rebates. The flat rebate for single source and innovator multiple source outpatient prescription drugs would increase from The basic rebate percentage for multi-source, non-innovator drugs would increase from 11 percent to 13 percent. Drug manufacturers would also be required to pay rebates for drugs dispensed to Medicaid beneficiaries who receive care from a Medicaid managed care organization MCO. Total rebate liability would be limited to percent of the average manufacturer price AMP. Additional revenue generated by these increases will be remitted to the federal government.

Elimination of exclusion of coverage of certain drugs. Providing adequate pharmacy reimbursement. Requires the Secretary to calculate the Federal upper limit FUL as no less than percent of the weighted average determined on the basis of utilization of the most recently reported monthly average manufacturer prices for pharmaceutically and therapeutically equivalent multiple source drugs available nationally through commercial pharmacies.

Disproportionate share hospital payments. Clarifies that Medicaid waivers for coordinating care for dual eligible beneficiaries could be authorized for as long as five years. Providing Federal coverage and payment coordination for dual eligible beneficiaries. The purpose of the CHCO would be to bring together officials of the Medicare and Medicaid programs to 1 more effectively integrate benefits under those programs, and 2 improve the coordination between the Federal and State governments for individuals eligible for benefits under both Medicare and Medicaid dual eligibles to ensure that dual eligibles have full access to the items and services to which they are entitled.

Adult health quality measures. The Secretary and the States will report on the development of and improvements to the quality measurement program on a regular basis. Payment adjustment for health care-acquired conditions. Prohibits Medicaid payment for services related to a health care-acquired condition. The Secretary will develop a list of health care-acquired conditions for Medicaid based on those defined under Medicare as well as current State practices.

State option to provide health homes for enrollees with chronic conditions. Provide States the option of enrolling Medicaid beneficiaries with chronic conditions into a health home. Health homes would be composed of a team of health professionals and would provide a comprehensive set of medical services, including care coordination. Demonstration project to evaluate integrated care around a hospitalization. Establishes a demonstration project, in up to eight States, to study the use of bundled payments for hospital and physicians services under Medicaid. Medicaid global payment system demonstration project.

Establishes a demonstration project, in coordination with the CMS Innovation Center, in up to five States that would allow participating States to adjust their current payment structure for safety net hospitals from a fee-for-service model to a global capitated payment structure. Pediatric Accountable Care Organization demonstration project. Establishes a demonstration project that allows qualified pediatric providers to be recognized and receive payments as Accountable Care Organizations ACO under Medicaid. The pediatric ACO would be required to meet certain performance guidelines.

Pediatric ACOs that met these guidelines and provided services at a lower cost would share in those savings. Medicaid emergency psychiatric demonstration project. Participating States would be required to reimburse certain institutions for mental disease IMDs for services provided to Medicaid beneficiaries between the ages of 21 and 65 who are in need of medical assistance to stabilize an emergency psychiatric condition. Special rules relating to Indians.

Prohibits cost-sharing for Indians enrolled in a qualified health benefit plan in the individual market through a State Exchange. Elimination of sunset for reimbursement for all Medicare Part B services furnished by certain Indian hospitals and clinics.

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