The Next Step – Making the Most of Your Coverage

By: Cara V. James, Ph.D., Director of the Office of Minority Health at the Centers for Medicare and Medicaid Services

Millions of Americans are gaining health coverage every year. Between 2013 and 2014, African Americans and Latinos saw the largest declines in uninsured rates[1]. During the 2016 open enrollment period, over 2.2 million individuals of color selected plans through the Marketplace[2]. Getting coverage is a big accomplishment, but it is just the first step. Regardless of your race or ethnicity, taking advantage of your coverage so you and your family stay healthy is an equally important step.

You may be getting coverage for the first time, or you may have coverage but do not use it very often. Regardless of how long you have had health coverage or where your coverage comes from (e.g., your employer, the Marketplace, or other sources of coverage), you may have a lot of questions on how you and your family can best use it to get the care you need. In 2014, the Centers for Medicare & Medicaid Services (CMS) launched, From Coverage to Care (C2C) to help individuals do just that – move from getting coverage to receiving the care they need. C2C is an ongoing initiative designed to help individuals achieve better health and navigate their way through the health care system.

C2C includes a number of resources such as the Roadmap to Better Care and a Healthier You and the newly released 5 Ways to Make the Most of Your Health Coverage, is designed to help you figure out what you can do to put your health first for a long and healthy life. One of the first ways is to confirm your coverage. Make sure your enrollment is complete and that you have paid your premium if you have one. This way you can use your health coverage when you need it.

The next step is to know is where to go for answers if you have questions about your enrollment and coverage. If you have questions about your enrollment status or premium, contact your health plan. Your health plan will also be able to tell you what services are covered and what your costs are likely to be. The Roadmap can help explain key health insurance terms, like “coinsurance”,” and “deductible”. The Roadmap also provides information on establishing and maintaining a healthy lifestyle, finding a provider, and helping patients engage in their health care. The Roadmap is available for download in eight languages, a tribal version, and in video format on the C2C website.

It’s important to remember that health insurance isn’t just for when you are sick. You can use your coverage to get recommended health screenings and preventive services which can help you stay healthy. You can find out which screenings may be right for you by visiting, MyHealthfinder.gov. Seeing your healthcare provider also provides an opportunity to ask questions about what you can do to stay healthy. When choosing a provider and making an appointment, it is important to pick someone who is in your network, if your plan has one. If the provider you select is out-of-network, the visit may end up costing more. If illness does take you to the doctor’s office, be sure to fill any prescriptions that the doctor may prescribe. Some drugs cost more than others, so if you are concerned about potential costs, ask in advance how much the prescription is and if there are more affordable options.

Insurance can be confusing, but there is help. Check out all of the From Coverage to Care resources and find out what you need to do to make the most of your coverage so you can live a long and healthy life.

 

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[1] Office of the Assistant Secretary for Planning and Evaluation (2015). ASPE Data Point: Health Insurance Coverage and the Affordable Care Act. Retrieved from: https://aspe.hhs.gov/pdf-report/health-insurance-coverage-and-affordable-care-act-september-2015

[2] Office of the Assistant Secretary for Planning and Evaluation (2016). ASPE Issue Brief: Health Insurance Marketplaces 2016 Open Enrollment Period: Final Enrollment Report. Retrieved from:

https://aspe.hhs.gov/sites/default/files/pdf/187866/Finalenrollment2016.pdf

Extending participation in the Bundled Payments for Care Improvement initiative

by Dr. Patrick Conway, Acting Principal Deputy Administrator and Chief Medical Officer

The Centers for Medicare & Medicaid Services is pleased to offer the awardees in the Bundled Payments for Care Improvement (BPCI) initiative the opportunity to extend their participation in Models 2, 3 and 4 through September 30, 2018.

The first cohort of awardees in Models 2, 3, and 4 that began in October 2013 were scheduled to end their participation on September 30, 2016. This extension means that they, along with other organizations that joined later in 2014, have the opportunity to continue their participation in the Bundled Payments for Care Improvement initiative up until September 30, 2018. In addition, by extending their participation, CMS will be able to provide a more robust and rigorous evaluation of the initiative and determine whether the efforts of bundling payments are successful in providing better care while spending health care dollars more wisely. This would build on the first year evaluation.

As of April 1, 2016, the Bundled Payments for Care Improvement initiative has 1,522 participants, comprised of 321 Awardees and 1,201 Episode Initiators. In Models 2, 3 and 4 there are 48 clinical episodes from which participants are able to choose when considering their opportunities for care redesign, improving quality, and achieving savings.

Bundling payment for services that patients receive across a single episode of care – such as a heart bypass surgery or a hip replacement – is one way to encourage doctors, hospitals and other health care providers to work together to better coordinate care for patients, both when they are in the hospital and after they are discharged. The initiative is part of the Administration’s broader strategy to improve the health care system by paying providers for what works, unlocking health care data, and finding new ways to coordinate and integrate care to improve quality and reduce costs.

We are excited to offer the opportunity for awardees in the Bundled Payments for Care Improvement initiative to continue their participation, and we look forward to further working with them in providing high quality, coordinated care to Medicare beneficiaries.

For more information about the Bundled Payments for Care Improvement initiative, please visit: http://innovation.cms.gov/initiatives/bundled-payments.

Check your 2015 Open Payments data

By Shantanu Agrawal, M.D, Deputy Administrator and Director of CMS’ Center for Program Integrity

The Centers for Medicare & Medicaid Services’ continues to publish data from applicable manufacturers and group purchasing organizations (GPOs) about payments they make to physicians and teaching hospitals on its website, https://openpaymentsdata.cms.gov/. We’re pleased that the public has searched Open Payments data more than 6.3 million times. Doctors, teaching hospitals and others receiving payments or other transfers of value that are sent to us from reporting entities, should take steps to ensure that this information about you, your related research, ownership, and other financial concerns are accurate.

Doctors and teaching hospitals have the chance to review and dispute the information shared about them before we post the new and updated Open Payments data on June 30, 2016. The data we post on June 30th is now available for review through May 15, 2016. Since April 1, this is the only chance for these health care providers to dispute inaccurate or incomplete data before we post it. After that they only have until the end of the year that this financial data is published to review and dispute any payment records and how it was attributed from GPOs, drug and device manufacturers.

Any doctor or teaching hospital that wants to look at the financial information reported on them by manufacturers and GPOs can register on the Open Payments website to create an account or log if they already have an account. Visit our website for instructions and quick tips.

Last June, we posted payments and ownership interests reported in 2014 about more than 607,000 physicians and 1,122 teaching hospitals, valued at $6.45 billion. Health care practitioners and teaching hospitals were paid for items like medical research, conference travel and lodging, gifts and consulting.

The Open Payments program is one way we can give patients, their families and caregivers transparency and information that helps them:

  • Become better informed health care consumers.
  • Talk to their doctors and other care professionals.

If you want to learn more about the program, visit the Open Payments program website or send questions to openpayments@cms.hhs.gov

Mapping Medicare Disparities

By: Cara V. James, Ph.D., Director of the Office of Minority Health at the Centers for Medicare and Medicaid Services

In 2014, two-thirds of Medicare beneficiaries had multiple chronic conditions and accounted for 94 percent of Medicare spending.1 Racial and ethnic minorities experience disproportionately higher rates of disease, inferior quality of care, and reduced access to care as compared to their white counterparts.2 Understanding disparities and their geographic variations is important to inform policy decisions and to identify populations and localities to target for interventions.

As health care delivery system reform continues, the Centers for Medicare and Medicaid Services (CMS) has an important opportunity and a critical role to play in promoting health equity.  In September 2015, the CMS Office of Minority Health (OMH) released the first CMS Equity Plan for Improving Quality in Medicare. In March 2016, CMS OMH launched a newly developed interactive tool to increase understanding of geographic disparities in chronic disease among Medicare beneficiaries.  The Mapping Medicare Disparities (MMD) Tool presents health-related measures from Medicare claims by sex, age, dual eligibility for Medicare and Medicaid, race and ethnicity, and state and county. It provides users with a quick and easy way to identify areas with large numbers of vulnerable populations to target interventions that address racial and ethnic disparities. The MMD Tool is expected to help government agencies, policymakers, researchers, community-based organizations, health providers, quality improvement organizations, and the general public analyze chronic disease disparities, identifying how a region or population may differ from the state or national average.

Mapping Tool Map

Please, take a moment to explore the MMD Tool.  Investigate what health care disparities look like in your county or state, then pick a priority and develop a plan that could be used to help provide better care for every individual in the United States.

  1. Centers for Medicare & Medicaid Services (CMS). Chronic Conditions among Medicare Beneficiaries, Chartbook, 2014 edition. Baltimore, MD: CMS, 2014.
  2. Agency for Healthcare Research and Quality (AHRQ), 2014 National Healthcare Quality and Disparities Report, Publication No. 15-0007. Rockville, MD: AHRQ, May 2015.

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Reflecting on Our Journey towards Health Equity

By: Dr. Cara James, Director of the CMS Office of Minority Health

Each April, in recognition of National Minority Health Month, we commemorate past achievements, acknowledge current efforts, and outline our continued journey towards health equity and equality for all. Fifty years ago, our journey included stops in Independence, Missouri where Medicare and Medicaid became law; in Selma and Montgomery, Alabama; and in Washington, D.C. for the signing of the Voting Rights Act and Civil Rights Act.

Since then, there have been many more landmark achievements in health equity. Events such as the publication of the Secretary’s report on Black & Minority Health (the Heckler Report) and the creation of the HHS Office of Minority Health illustrate the increased national attention on the need to address health and health care disparities. The publication of the Agency for Healthcare Research and Quality’s annual National Healthcare Quality and Disparities Report illustrates our commitment to track our progress. The passage of the Affordable Care Act and the enrollment of millions of Americans, including many people of color in health plans, illustrate our continued advancement towards better care and healthier communities.

Five years ago, the Affordable Care Act established three additional offices of minority health within six HHS agencies. While several HHS agencies already had offices of minority health, the Office of Minority Health (OMH) at the Centers for Medicare & Medicaid Services (CMS) was an office newly established through the Affordable Care Act. The principal aim for CMS is better care, healthier people, and smarter spending. To help achieve this aim, the CMS Office of Minority Health ensures that the voices and needs of minority and underserved populations are present in the development, implementation, and evaluation of CMS programs and services. We are dedicated to working on behalf of all CMS beneficiaries, while strategically focusing on racial and ethnic minorities, individuals with disabilities, and Lesbian, Gay, Bi sexual and Transgender (LGBT) minorities. CMS OMH activities include: From Coverage to Care, the CMS Equity Plan for Improving Quality in Medicare, strengthening CMS data collection and analysis, and working across the agency to embed a focus on health equity into new and existing programs and policies.

From Coverage to Care is an ongoing initiative designed to help consumers understand their healthcare coverage and how to access the care they need. Additionally, the CMS Equity Plan for Improving Quality in Medicare is CMS’ first strategic equity plan. Launched in 2015, this equity plan identifies six priorities and provides an action-oriented, results-driven approach for advancing health equity by improving the quality of care provided to racial and ethnic minority and other underserved Medicare beneficiaries. Last month, CMS OMH launched an interactive web based tool for mapping Medicare disparities. The Mapping Medicare Disparities Tool contains health outcome measures for disease prevalence, costs, and hospitalization for 18 specific chronic conditions, emergency department utilization, readmissions rates, mortality and preventable hospitalizations.

We know we cannot achieve health equity on our own. It will take the support of partners from the federal to the community level.  We encourage you to join us on the path to health equity by using the resources discussed in this blog, bookmarking the CMS OMH website, joining our listserv, and of course building on your own health equity activities!

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Our Hopes for the Comprehensive Care for Joint Replacement Model

By Patrick Conway, CMS Principal Deputy Administrator and Chief Medical Officer

Today’s launch of the Comprehensive Care for Joint Replacement Model (CJR) is a major step toward transforming care delivery in Medicare. Why? Because this model looks to improve care and quality for the most common procedures that Medicare beneficiaries have, hip and knee replacements. In 2014, more than 400,000 Medicare beneficiaries received a hip or knee replacement, costing more than $7 billion for the hospitalizations alone. Despite the high volume of these surgeries, quality and costs of care for these hip and knee replacement surgeries still vary greatly among providers. For instance, the rate of complications, like infections or implant failures, after surgery can be more than three times higher for procedures performed at some hospitals than at others.

The model aligns with what matters to beneficiaries—better outcomes for a whole episode of care. The model includes patient-reported outcomes after surgery and incentivizes better care coordination. One beneficiary said it best when she described that what she cared about for her hip replacement was getting out of the hospital as quickly as possible without an infection or complication and then being able to go back to playing with her grandkids and gardening. The model incentivizes a system that aligns with her goals and the goals of so many beneficiaries.

We are excited about the CJR model’s potential to improve the quality and efficiency of care for Medicare beneficiaries, to contribute toward a health care system that delivers better care, spends our dollars more wisely, and leads to healthier Americans.

How will CJR work? About 800 hospitals located in 67 selected markets will be accountable for the costs and quality of related care from the time of the hip or knee replacement surgery through a post-hospitalization period. They will receive target prices for these joint replacement cases at the beginning of each year. The target price represents expected spending for lower joint replacement episodes, including the initial hospital stay for the procedure and 90 days after discharge from the hospital. If patients receive high quality care and spending is less than the target, a hospital may receive an additional payment from Medicare. If their spending is above the target, hospitals may be required to repay Medicare for a portion of the difference.

We expect this incentive to coordinate the services a patient receives before, during, and after surgery will encourage hospitals and clinicians to partner with nursing facilities, home health agencies and other providers of rehabilitation services to provide seamless, high quality care.

We want hospitals to be successful under this model because success means that Medicare’s beneficiaries will receive better quality care. In the run up to today’s launch, our staff individually contacted the program coordinators at all 800 hospitals to offer data and other resources to assist them on this multi-year journey. CMS will continue to collaborate with hospitals and their physicians and other clinicians to provide support and share best practices.

What will beneficiaries notice? First, beneficiaries will continue to choose their doctor, the hospital where they receive treatment, and the type and location of rehabilitation care they receive. If their hospital is a model participant, they will get a letter explaining the model. Patients whose chosen hospital participates in the model should experience improved care coordination. For instance, we expect that nursing facilities will understand a patient’s needs better before that patient is discharged from the hospital.

The CJR model offers a chance for hospitals, doctors, and other providers to partner with CMS in furthering our shared goal of improving the quality of care for beneficiaries undergoing the most common inpatient surgery, lower extremity joint replacements. The model is part of the Administration’s broader strategy to improve the health care system by paying providers for what works, unlocking health care data, and finding new ways to coordinate and integrate care to improve quality.

We are excited to begin this groundbreaking initiative and will work with hospitals, physicians, and other providers throughout the model to ensure they have the tools to succeed and improve upon what they do best: provide high quality, coordinated care to beneficiaries.

For more information about the CJR model, please visit: https://innovation.cms.gov/initiatives/cjr.

Los Impuestos y la Cobertura de Salud: Cinco Consejos al Presentar la Declaración de Impuestos

31 de marzo de 2016
Por: Kevin Counihan, Director General de los Mercados de Seguros Médicos, Centros de Servicios de Medicare y Medicaid

El año pasado, millones de personas obtuvieron cobertura de salud de calidad y a su alcance económico a través del Mercado de Seguros Médicos, y la mayoría se beneficiaron de los pagos por adelantado del crédito tributario de prima para reducir el costo de sus primas/cuotas mensuales. Ya que solo quedan unas cuantas semanas para presentar los impuestos, es un buen momento para darles un recordatorio a los consumidores nuevos y los que renovaron  sobre lo que necesitan saber cuándo presenten sus impuestos.

Para aquellos que volvieron al Mercado de seguros en 2015 para renovar su cobertura o escoger otro plan, el proceso de declaración de impuestos es generalmente el mismo al año pasado. Pero, para las personas que se inscribieron por primera vez para la cobertura del Mercado en 2015 el proceso puede ser nuevo. Todos los consumidores del Mercado deberían haber recibido ya en el correo  el Formulario 1095-A. Este documento incluye información importante que se necesita para completar y presentar una declaración de impuestos.

Los consumidores del Mercado que recibieron los pagos adelantados del crédito tributario de prima están obligados a presentar una declaración de impuestos para reconciliar dicha ayuda financiera. Esto es similar al proceso de reconciliación de los impuestos retenidos de los salarios durante el año, los consumidores reciben un reembolso mayor o menor dependiendo de si los impuestos correspondientes se retuvieron en base a los ingresos reales del contribuyente de impuestos y otros factores.

Es extremadamente importante que los que recibieron pagos por adelantado del crédito tributario de prima reconcilien estos pagos cuando presenten su declaración de impuestos. Las personas que no lo hagan por lo general tendrán un retraso en sus reembolsos, y no serán elegibles para recibir los pagos adelantados del crédito tributario de prima en los próximos años.

Los individuos que tengan cobertura de salud del Mercado u otros tipos de seguro también pueden haber recibido otros formularios adicionales llamados Formulario 1095-B o C-1095 de parte de su empleador, compañía de seguros, o el programa de gobierno que proporciona su cobertura, como Medicare o Medicaid. Los contribuyentes no necesitan incluir esta información a su declaración de impuestos o esperar a recibir el formulario antes de llenar sus impuestos federales, pero la forma debe ser conservada en un lugar seguro con otros documentos importantes de sus impuestos.

Un recordatorio importante: Como la mayoría de los declarantes de impuestos utilizan un preparador de impuestos o el software de preparación de impuestos, la mayoría de los contribuyentes sólo tendrán que responder a las preguntas cuando se les solicite.

Estamos aquí para ayudar. Los consumidores del Mercado que tengan preguntas deben comunicarse con el Centro de Llamadas del Mercado (1-800-318-2596). Recursos adicionales e información también está disponible en https://www.cuidadodesalud.gov/es/taxes/ o https://www.irs.gov/Spanish/Disposiciones-Tributarias-de-la-Ley-de-Cuidado-de-Salud-a-Bajo-Precio.

A continuación, resumimos cinco consejos útiles para los consumidores del Mercado y otros declarantes de impuestos cuando se trata de la presentación de impuestos este año:

Cinco consejos para quienes presentan declaraciones de impuestos

  1. La mayoría de la gente sólo tiene que marcar una casilla: La gran mayoría de los declarantes de impuestos tienen una cobertura que califica (incluyendo la cobertura de un empleador, Medicare, Medicaid u otra cobertura) y sólo tendrán que marcar una casilla cuando presenten sus impuestos para indicar que cada una de las personas en su hogar tuvieron cobertura en el año 2015. Este año, muchos consumidores recibirán en el correo de parte de su empleador, compañía de seguros, o el programa de gobierno que proporciona su cobertura, como Medicare o Medicaid, un nuevo formulario llamado formulario 1095-B o un formulario 1095-C. Los contribuyentes no tienen que incluir esta información con su declaración de impuestos o esperar a recibir el formulario antes de llenar sus impuestos, pero si deben conservar este formulario en un lugar seguro con otros documentos relacionados con sus impuestos. Para obtener más información sobre todas estas formas, visite el sitio web del IRS: https://www.irs.gov/Affordable-Care-Act/Individuals-and-Families/Preguntas-y-Respuestas-acerca-de-los-Formularios-de-Informacion-de-Cuidado-Medico-para-Individuos.
  1. Los consumidores del Mercado deben presentar una declaración de impuestos para reconciliar cualquier pago anticipado del crédito tributario de prima que recibieron para poder mantener su elegibilidad para esta ayuda en el futuro: Todos los consumidores del Mercado deberían haber recibido ya en el correo el Formulario 1095-A. Este formulario incluye información importante que se necesita para completar y presentar una declaración de impuestos. Es extremadamente importante que los que recibieron pagos por adelantado del crédito tributario de prima reconcilien estos pagos cuando presenten su declaración de impuestos. Las personas que no lo hagan por lo general tendrán un retraso de su reembolso, y no podrán ser elegibles para el pago anticipado de los créditos tributarios de prima en los próximos años. 
  1. La multa por no tener cobertura aumentara. Para aquellos que podían costearse un seguro médico y optaron por no obtener la cobertura, la multa por no tener la cobertura mínima esencial en el año 2015 subió hasta un 2 por ciento de los ingresos familiares o $ 325 por persona. La multa se prorratea según el número de meses que una persona no está asegurada. La multa sube de nuevo en el año 2016. Si alguien no tiene cobertura o una exención en el año calendario 2016, pero podría pagar la cobertura, la tasa aumenta a $695 por persona o el 2,5% de los ingresos, lo que sea mayor. Para más información, visite https://www.cuidadodesalud.gov/es/fees/.
  1. Algunas personas que no tuvieron cobertura de salud en el año 2015 calificaran para una exención: Mientras que los que pueden costear la cobertura de salud pero optaron por no inscribirse por lo general tienen que pagar una multa, algunas personas que no pudieron pagar una cobertura o cumplen con otras condiciones específicas pueden recibir una exención. Usted puede encontrar más información en línea del Mercado o del IRS en https://www.cuidadodesalud.gov/es/health-coverage-exemptions/exemptions-from-the-fee/ o https://www.irs.gov/Spanish/Disposiciones-Tributarias-de-la-Ley-de-Cuidado-de-Salud-a-Bajo-Precio-para-Personas-Físicas-y-Familias. 
  1. Hay ayuda disponible. Si la gente tiene preguntas acerca de los formularios de impuestos del Mercado, como se califica para las exenciones, o la multa, deben ponerse en contacto con el Centro de Llamadas del Mercado. El centro de llamadas está abierto todo el día, todos los días llamando 1-800-318-2596. recursos adicionales e información también está disponible en https://www.cuidadodesalud.gov/es/taxes/ o https://www.irs.gov/Spanish/Disposiciones-Tributarias-de-la-Ley-de-Cuidado-de-Salud-a-Bajo-Precio.
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