Greater Flexibility in e-Prescribing Means Greater Success

By Patrick Conway, M.D., MSc, CMS Chief Medical Officer and Director of the Office of Clinical Standards & Quality

Electronic prescribing plays a vital role in improving patient care and helping make our health care system more efficient.  With electronic prescribing, providers can better manage patient prescriptions, reducing drug interactions or other preventable prescription errors. We’ve made several changes in the newly released final rule for the 2011 Electronic Prescribing (eRx) Incentive Program that will encourage more doctors and other health care professionals to adopt this technology and give them the added flexibility to help them succeed.  In particular, the changes will better recognize those circumstances when the ability of professionals to meet the eRx requirements is limited and when the requirements clearly pose a significant hardship.

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) required an adjustment to payments, beginning in 2012, for eligible professionals who aren’t successful electronic prescribers. After we published the 2011 Medicare Physician Fee Schedule Final Rule last fall, we heard about additional circumstances that could keep physicians and other health professionals from being successful e-prescribers. For example, some providers weren’t sure whether certified electronic health record (EHR) technology that the Medicare and Medicaid EHR Incentive Programs require is also a “qualified” electronic prescribing system as required by the Medicare eRx Incentive Program. Others providers brought up additional hardship situations that the 2011 MPFS final rule didn’t address.

Here’s how we’re addressing those additional concerns:

  • We’re modifying the 2011 electronic prescribing measure to say that a qualified electronic prescribing system for the purpose of the Medicare eRx Incentive Program includes certified EHR technology under the Medicare and Medicaid EHR Incentive Programs.
  • We’re adding four additional significant hardship exemptions that will make professionals exempt from the 2012 payment adjustment: (1) eligible professionals who register to participate in the Medicare or Medicaid EHR Incentive Program and adopt certified EHR technology; (2) eligible professionals who are unable to electronically prescribe due to local, state, or federal law or regulation; (3) eligible professionals who have limited prescribing activity; and (4) eligible professionals who have insufficient opportunities to report the e-prescribing measure due to limitations of the measure’s denominator.  The two hardship exemptions already available to professionals are (1) eligible professional or group practice practices in rural areas with limited high speed internet access; and (2) eligible professional or group practice practices in an area with limited available pharmacies for electronic prescribing.
  • We’re extending the deadline for requesting significant hardship exemptions to November 1, 2011.
  • We’re allowing providers to report significant hardship exemptions to the 2012 eRx payment adjustment via a Web-based tool for eligible professionals or via a mailed letter for group practices that are participating in the eRx group practice reporting option for 2011.

We remain committed to the many benefits that come to patients with successful electronic prescribing, and we continue to encourage health care professionals to adopt this practice.  However, we also can appreciate and acknowledge that this technology poses challenges to some providers. Changes in the final rule will help doctors and other health care providers in their efforts to become successful e-prescribers, ultimately leading to fewer errors and better care for patients.

Making Medicare Advantage and Medicare Drug Coverage Continue to Work for You

By Jonathan Blum, CMS Deputy Administrator and Director of the Center for Medicare

Today, CMS is finalizing rules implementing the Medicare Improvements to Patients and Providers Act (MIPPA) of 2008 that help people with Medicare receive high quality, coordinated care and choose the coverage they want.   Under these final rules, the Medicare program will provide:

Stronger Consumer Protections in Choosing Plans

Under these rules, we’ve strengthened our requirements for what agents and brokers selling Medicare Advantage and Medicare Prescription Drug plans can and can’t do when they are selling you a plan.  There are limits on the commissions agents and brokers can receive, so plans will compete on the basis of benefits and quality, and not the size of their agent commissions. This rule also makes sure that agents and brokers aren’t rewarded if they sell you a plan that doesn’t meet your needs and you leave the plan within the first 90 days.

The rules also now require that Private Fee-for-Service (PFFS) plans in most parts of the country have contracts with medical providers like hospitals and specialists. PFFS plans allow you to see any provider who agrees to accept payment from the plan. These new requirements give you greater security that you will be able to use the hospitals or specialists you need when you join a PFFS plan.

Better Care for People with Special Needs

These final rules ensure that Medicare Special Needs Plans (SNPs) are improving the quality of care they provide and making sure that care meets the needs of individual patients. SNPs are a type of Medicare Advantage plan for people who are enrolled in both Medicare and Medicaid, people who have certain serious chronic conditions, or who need institutional care, like in a nursing home.

Under these rules, SNPs must develop a Model of Care that ensures your health care needs are assessed, a plan of care is developed specifically for you, and a team of health care providers manages your care. SNPs must also have a quality improvement program that measures whether the care being provided is actually making you healthier.

The rules play a key part in CMS’s overall strategy to improve the care people receive in SNPs and in all Medicare Advantage plans. Under the Affordable Care Act, starting in 2012 SNPs must be approved by the National Committee for Quality Assurance (NCQA). And, also as a result of Affordable Care Act, all Medicare Advantage plans can receive bonuses from Medicare if they rate highly on the quality of care they deliver.

These are just a few ways we are helping to protect you from being sold a policy you don’t really want, and ensuring you feel safe and confident about the health care coverage decisions you make. Under the Affordable Care Act, CMS now sets limits on how much your Medicare Advantage plan can increase your premiums and copays each year. This helps make sure what you pay out-of-pocket does not skyrocket after you join the plan.

For more detail about the revisions to the Medicare Advantage and Medicare Prescription Drug Benefit Programs, go to

Better Medicare Products and Services at Lower Cost

By Jon Blum, CMS Deputy Administrator and Director of the Center for Medicare. Cross-post from

For years, spiraling Medicare costs have threatened Medicare beneficiaries and their providers.  And turning to the competitive marketplace seemed to offer little respite. Until now.

On January 1, 2011, the first phase of the competitive bidding program was successfully implemented for nine product categories in nine areas of the country. This means that suppliers of certain medical supplies, such as oxygen equipment, walkers, and some types of power wheelchairs compete among each other to determine the price Medicare will pay for their services to seniors. This in turn sets new, lower payment rates for these pieces of medical equipment and supplies.

Building on that success, the Centers for Medicare & Medicaid Services (CMS) today announced that they are expanding the competitive bidding program to additional areas of the country and also expanding the list of items included in the first round of bidding. All of the product categories selected for Round Two are high cost, high volume items with large savings potential.

This program reduces Medicare spending and beneficiary cost-sharing, and it forces winners of these contracts to compete on quality and customer service. Ultimately, beneficiaries get better products and services, while paying less out of their own pocket. In fact, the Medicare actuary estimates that this program will save more than $28 billion over the first ten years of the program. The $28 billion savings comes from a combination of savings of more than $17 billion in Medicare expenditures, and savings of over $11 billion for beneficiaries as a result of lower coinsurance payments and the downward effect on monthly premium payments. .

For more information about the Medicare DMEPOS Competitive Bidding Program, please visit CMS’ Newsroom or go to

Making Insurance Plans Easier to Understand

By Don Berwick, Administrator, Centers for Medicare & Medicaid Services. Cross-post from

Having affordable, quality health insurance is incredibly important. But how can you pick the plan that is best for you and your family if insurance plans are written in words you cannot understand or in type so small you can barely read it? And how can you take advantage of the health benefits you have if you don’t know what your plan covers?

You’re not alone in your confusion. Too many Americans don’t have access to information in plain language to help them understand the health coverage they have.

Now, thanks to the Affordable Care Act, every American consumer will receive an important new tool to understand their coverage. Under proposed rules announced today, health insurers and employers who offer coverage to their workers must provide you with clear and consistent information about your health plan.

Specifically, you will have access to two important insurance forms:

  • An easy to understand Summary of Benefits and Coverage
  • A uniform Glossary of terms commonly used in health insurance coverage

This will include basic information that every person should have, including:

  • What is your annual premium?
  • What is your annual deductible?
  • What services are NOT covered by my policy?
  • What will my costs be if I go to a provider in my network versus one that is not in my network?

Below is an example of a page from the proposed new form:

These common sense rules benefit from a public process led by the National Association of Insurance Commissioners (NAIC) and a working group composed of consumer advocates, employers, insurers, and other people involved in your insurance and care. As with all changes to health care, we are giving the public a chance to review this proposal and send us their comments before we make the rules final.

But starting in March 2012, if you are one of the 180 million Americans with private health insurance, help is on the way to make sure you understand your health insurance.

And this means you and your family will have an easier time accessing the health benefits you currently have–and you will be able to make a more informed decision about purchasing the coverage you need.

For more information about this announcement, please visit:

Better Health and Lower Costs for Medicare Beneficiaries

By Don Berwick, Administrator, Centers for Medicare & Medicaid Services. Cross-post from

It’s been a big summer for the millions of Americans who are benefitting from improved Medicare coverage thanks to the Affordable Care Act. The benefits are clear: More people are getting preventive services to keep them healthy and people with high prescription drug costs are seeing the donut hole coverage gap starting to close – lowering the cost of drugs so that people don’t have to worry about being able to afford the care they need. Take a look at the past few months:

  • June:
    • Through the end of June, 899,000 Americans with Medicare have benefited from the discount on brand name drugs in the Medicare Part D “donut hole” coverage gap — an increase of over 420,000 individuals in the month of June alone.
    • These discounts have saved seniors and people with disabilities a total of $461 million, including $200 million in June alone!
  • July:
    • Through the end of July, 17.3 million people with traditional Medicare, or 51.5 percent, have received one of more free preventive services. 
    • During the same time period, over 1 million Americans with traditional Medicare have taken advantage of Medicare’s new free Annual Wellness Visit, up from 780,000 in mid-June;

To learn more about these new benefits, check out the Medicare campaign, “Share the News, Share the Health”, to learn about the importance of prevention for people with Medicare.

But the good news doesn’t stop here. Over the coming years, provisions of the Affordable Care Act will help close the donut hole coverage gap completely. Here is a sense of what Medicare beneficiaries can look forward to:

  • 2013: You will pay less and less for your brand-name Part D prescription drugs in the donut hole.
  • 2020: The coverage gap will be closed, meaning there will be no more “donut hole,” and you will only pay 25% of the costs of your drugs until you reach the yearly out-of-pocket spending limit.

The chart below shows Medicare prescription drug savings over time:

  You Will Pay This Percentage for Brand-name Drugs in the Coverage Gap YouWill Pay This Percentage for Generic Drugs in the Coverage Gap
2011 50% 93%
2012 50% 86%
2013 47.5% 79%
2014 47.5% 72%
2015 45% 65%
2016 45% 58%
2017 40% 51%
2018 35% 44%
2019 30% 37%
2020 25% 25%

Source: Centers for Medicare and Medicaid Services

This all amounts to even more examples of how the Affordable Care Act is providing better health care for people covered by Medicare and making a difference in the lives of millions of Americans.

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