CMS Updates

The following posts are updates and press releases from Centers for Medicare & Medicaid Services.

The Medicare Shared Savings Program Final Rule: Implications for Medicaid Accountable Care Organizations

Posted January 8, 2019

With the publication of the Medicare Shared Savings Program (MSSP) Final Rule on December 21, the Centers for Medicare & Medicaid Services (CMS) clearly signaled that the Trump administration is serious about holding accountable care organizations (ACOs) in Medicare more financially accountable for costs and quality. However, Medicare ACOs may not be the only ACOs affected by this change.

Medicaid tends to follow Medicare’s lead in many areas related to payment and delivery system reform, and ACOs are no exception. Many state-led Medicaid ACO payment models are based on an MSSP foundation, as states prefer to align closely with the Medicare model to encourage participation in the Medicaid models, reduce provider burden, and allow ACOs to create operational efficiencies across payers. Since there are now significant changes to the MSSP, it is worth exploring how these changes may affect Medicaid ACO models that are already in place, as well as those that are currently under development.
The MSSP Final Rule

The final rule made a number of significant changes to the MSSP model. Some of the more notable changes include:

  • Redefining the MSSP Tracks.  The final rule replaces the existing MSSP tracks (1, 1+, 2, and 3) with a BASIC Track and an ENHANCED Track. While the ENHANCED Track is very similar to Track 3, the BASIC Track has five separate “Levels” that create a glide path toward the ENHANCED Track.  An outline of these new tracks is shown below:
Comparison of Risk and Reward Under Basic Track and Enhanced Track

  •   Less Shared Savings Available for Upside-Only Models.  ACOs that are in BASIC levels without downside risk (A and B) will earn 10 percentage points less than the current upside-only Track 1 model.
  •   Accelerating the Transition to Downside Risk.  In previous years, MSSP ACOs could stay in an upside-only track for up to six years. The final rule curtails this amount of time, allowing existing Track 1 MSSP ACOs to spend only one additional year in an upside-only arrangement (Level A or B) before accepting some downside risk. New MSSP entrants will have two years before they are required to transition. New ACOs that qualify as “low-revenue” or “physician-led” can take three years.
  •   Choosing Attribution Method.  The final rule allows new flexibility for all MSSP ACOs to choose between a retrospective or prospective attribution methodology.  Previously, Tracks 1+ and 3 were prospectively attributed, and Tracks 1 and 2 had retrospective attribution.
  •   Beneficiary Incentives.  The final rule allows ACOs in a downside risk track to offer Medicare beneficiaries incentives (such as vouchers or in-kind services) for engaging in healthy behaviors.

Implications for Medicaid ACO Programs

States with existing Medicaid ACO programs, and those currently developing such models, can respond to the changes in the MSSP program in many ways, including not changing a thing. However, since many states have chosen to align their Medicaid ACO programs closely with the MSSP, states and other interested stakeholders will likely consider a number of these questions:

  • Will states push Medicaid ACOs toward greater risk? Many Medicaid ACO programs do not currently require ACOs to accept downside risk or transition to accept risk over time. However, since many Medicaid ACOs are currently participating in the MSSP program and will likely have to move to downside risk in that program, states may use this opportunity to create greater accountability in their ACOs as well, either by requiring, further incentivizing, or otherwise hastening a transition.  Yet, since the Medicaid population has a greater proportion of patients with behavioral health and social needs than Medicare patients, and many of its ACO participants are “low-cost providers” (which the MSSP grants additional time to move to downside risk), states may also consider a longer transition period to downside risk than the MSSP allows.
  • Will states take a greater share of savings from upside only tracks? While some states may be tempted to follow the MSSP’s lead in lowering the savings rate for upside-only rates in their programs, either to capture greater savings or push ACOs toward greater accountability, some caution should be taken. Participating in a Medicare ACO may have more appeal to providers than many of Medicaid ACO models. This is likely because of: (a) higher Medicare reimbursement rates; (b) the program’s relaxed referral and antitrust provisions; and (c) the need to satisfy MACRA Quality Payment Program requirements.
  • Will ACOs drop out of the MSSP? While the incentives (and disincentives) listed above are compelling for MSSP ACOs, some ACOs may still choose to drop out of the program. By doing so, these ACOs may have less incentive to manage total cost of care across other patient populations, including Medicaid, and consider dropping out of their Medicaid ACO program as well.
  • Can FQHC-led ACOs take downside risk? Though not as prevalent in the MSSP, one of the types of safety-net provider organizations that participate in Medicaid ACOs are federally qualified health centers (FQHCs), which are paid through a prospective payment system (PPS). Under current federal regulations, FQHCs are not allowed to take downside risk below their PPS rates. Therefore, if a state does transition to requiring downside risk in its Medicaid ACO program, the participation of FQHC-led ACOs in such a model would need to be addressed.
  • Will beneficiary incentives be increasingly utilized in Medicaid?  Currently, Medicaid ACO programs are limited in what incentives they can provide beneficiaries. While some programs include non-medical “flexible services” such as air conditioners and home asthma remediation, these services are not “rewards” for healthy behaviors. Some Medicaid ACO programs may consider pursuing similar programs either through a CMS waiver or state plan amendment based on the precedent set by the MSSP.


The MSSP Final Rule has shaken up the pace at which providers participating in Medicare ACO programs will need to accept financial risk and move toward greater accountability. Given the similarity between MSSP models and many Medicaid ACO models, it is likely that these Medicaid models will adjust to conform to Medicare regulations over time, especially if some of the shifts are viewed by states as particularly attractive. However, states may decide to be cautious about shifting quickly to conform to these standards. Not all of the Medicare changes may make sense for states, their Medicaid ACOs, and their Medicaid populations. Further, many Medicaid ACO programs are performing well; hence, states may not want to disrupt the momentum by enacting new policies that may not be popular or efficacious. Finally, it remains to be seen how the MSSP ACOs will react to these new regulations.

Therefore, state Medicaid agencies should: (a) weigh the perceived benefit of the changes against the ACOs’ reactions to these changes; (b) determine whether these savings would allow the ACO program to continue to achieve savings and improve quality; and (c) predict how the changes would affect the number of ACOs participating in the program. Before making changes of this magnitude to Medicaid ACO programs, states may want to solicit stakeholder input on proposed changes before they are implemented and wait to see how things play out in Medicare.

Pathways to Success Final Rule Redesigns Medicare’s ACO Program 

Posted January 5, 2019

News & Announcements

  • Medicare Shared Savings Program: Final Rule Creates Pathways to Success
  • Physician Compare Preview Period Extended to January 7
  • Hospice Provider Preview Reports: Review Your Data by January 9
  • Medicare Shared Savings Program: Submit Notice of Intent to Apply by January 18
  • Laboratory Date of Service Exception Policy: Enforcement Discretion Exercised until July 1
  • Quality Payment Program: 2019 Resources
  • eCQM Resource: The Collaborative Measure Development Workspace
  • Medicare Enrollment Application Fee for CY 2019
  • Delivery of Initial Prescriptions of Immunosuppressive Drugs
  • Antipsychotic Drug Use in Nursing Homes: Trend Update
  • Get Your Patients Off to a Healthy Start in 2019

Provider Compliance

  • Coding for Specimen Validity Testing Billed in Combination with Urine Drug Testing — Reminder

Claims, Pricers & Codes

  • Medicare Diabetes Prevention Program: Valid Claims

Upcoming Events

  • ESRD Quality Incentive Program: CY 2019 ESRD PPS Final Rule Call — January 15
  • Clinical Diagnostic Laboratories to Collect and Report Private Payor Rates Call —January 22
  • Home Health Patient-Driven Groupings Model Call — February 12

Medicare Learning Network® Publications & Multimedia

  • Claim Status Category and Codes Update MLN Matters Article — New
  • Ensuring Only the Active Billing Hospice Can Submit a Revocation MLN Matters Article — New
  • Guidance for MACs Processing BFCC QIO 2MN SSR Determinations MLN Matters Article — New
  • I/OCE Version 20.0: January 2019 MLN Matters Article — New
  • FISS/DDE: New Search Features MLN Matters Article — New
  • Quality Payment Program in 2018: Group Participation Web-Based Training — New
  • SNF PPS Call: Audio Recording and Transcript — New
  • IRF Medical Review Changes MLN Matters Article — Revised
  • New Physician Specialty Code for Undersea and Hyperbaric Medicine MLN Matters Article — Revised
  • Repetitive, Scheduled Non-emergent Ambulance Prior Authorization Model MLN Matters Article — Revised
  • Looking for Educational Materials?

The MIPS 2018 Data Submission Period is Now Open

Posted January 4, 2019

MIPS Eligible Clinicians Can Start Submitting Data for 2018 through April 2

MIPS Eligible Clinicians Can Start Submitting Data for 2018 through April 2
The Centers for Medicare & Medicaid Services (CMS) has officially opened the data submission period for Merit-based Incentive Payment System (MIPS) eligible clinicians who participated in Year 2 (2018) of the Quality Payment Program. With the exceptions noted in the paragraph below, data can be submitted and updated any time from January 2, 2019 to April 2, 2019.

Please note, CMS Web Interface users need to report their Quality performance category data between January 22 and March 22, 2019. Also, for clinicians who reported Quality measures via Medicare Part B claims throughout the 2018 performance year, we’ll receive your quality data from claims processed by your Medicare Administrative Contractor, and claims for services furnished during 2018 must be processed within 60 days after the end of the 2018 performance period.

How to Submit Your 2018 MIPS Data
Clinicians will follow the steps outlined below to submit their data:

  1. Go to the Quality Payment Program website
  2. Log-in using your QPP access credentials (see below for directions) 
  3. Submit your MIPS data for Year 2 (2018)

How to Log In to the Quality Payment Program Data Submission System
To log in and submit data, clinicians will need to use the new HCQIS Authorization Roles and Profile (HARP) system. Previously, clinicians received their credentials through the Enterprise Identity Management (EIDM) system. Clinicians are encouraged to log in early to familiarize themselves with the system.

  • Previous EIDM Accounts: For all clinicians who previously had an EIDM account, you were automatically transitioned to HARP, and will use your existing EIDM user ID and password to sign in to the QPP website.
  • New Clinicians: For all clinicians who didn’t have an EIDM account, you’ll need to enroll with HARP. For a step-by-step guide to signing up for a HARP account, refer to the QPP Access User Guide.

Note: Clinicians who are not sure if they are eligible to participate in the Quality Payment Program can check their eligibility status using the QPP Participation Status Tool.

For More Information
To learn more about how to submit data, please review the 2018 MIPS Data Submission FAQs and other resources available in the QPP Resource Library.

If you have questions about how to submit your 2018 MIPS data, contact:

Physician Compare Preview Period Extended to January 7th

Posted December 20, 2018

The Centers for Medicare and Medicaid Services (CMS) opened the Physician Compare preview period on November 30, 2018 at 10 AM ET (7 AM PT). The 30-day preview period provides an opportunity for clinicians and groups to review their 2017 Quality Payment Program performance information before it is publicly reported on Physician Compare profile pages and in the Downloadable Database.

The preview period is extended and is now ending Monday, January 7, 2019 at 8pm ET (5 pm PT).
You can access the secured measure preview through the Quality Payment Program website. 

Check out the resources below on how to preview your data:

For additional assistance with accessing the Quality Payment Program website, or obtaining your EIDM user role, contact the Quality Payment Program service center at

To learn more about the 2017 Quality Payment Program performance information and 2016 clinician utilization data that are available for preview, download the following documents from the Physician Compare Initiative page:

If you have any questions about Physician Compare, public reporting, or the 30-day preview period, please contact us at

Opioids Training Modules Offer CE Credit

Posted December 20, 2018

Editor's Note: 

Happy holidays from the MLN Connects team! We will release the next regular edition on Thursday, January 3, 2019.

News & Announcements

Provider Compliance

Upcoming Events

Medicare Learning Network® Publications & Multimedia

2019 Medicare Physician Fee Schedule Final Rule

Posted December 17, 2018

Prepared by Barbara J. Connors, DO, MPH and Patrick M. Hamilton, MPA - Centers for Medicare & Medicaid Services

Click HERE to download the 2019 Medicare Physician Fee Schedule Final Rule

New Online Tool Displays Cost Differences for Certain Surgical Procedures

Posted November 28, 2018


November 27, 2018
Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries

New Online Tool Displays Cost Differences for Certain Surgical Procedures
Procedure Price Lookup will help patients with Medicare consider potential cost differences when choosing among safe and clinically appropriate settings

Today, the Centers for Medicare & Medicaid Services (CMS) launched a new online tool that allows consumers to compare Medicare payments and copayments for certain procedures that are performed in both hospital outpatient departments and ambulatory surgical centers. The Procedure Price Lookup tool displays national averages for the amount Medicare pays the hospital or ambulatory surgical center and the national average copayment amount a beneficiary with no Medicare supplemental insurance would pay the provider.

“Price transparency in health care is a priority for the Trump Administration. Working with their clinicians, the Procedure Price Lookup will help patients with Medicare consider potential cost differences when choosing where to have a medical procedure that best meets their needs,” said CMS Administrator Seema Verma.

The Procedure Price Lookup tool is launching as required by Congress in the 21st Century Cures Act. Medicare’s statutes require that CMS maintain separate payment systems for different types of healthcare providers, meaning both CMS and patients may pay different amounts for the same service, depending on the site of care.

“The different payment rates are a prime example of Medicare’s misaligned financial incentives, under which providers can make more money if they see patients at one location as opposed to another,” Administrator Verma said.

Procedure Price Lookup, part of the agency’s eMedicare initiative, joins other patient-oriented transparency tools, including an overhauled version of the agency’s drug pricing and spending dashboards, which provide patients with Medicare and Medicaid spending information for thousands more drugs than ever before and, for the first time, list the prescription drug manufacturers that were responsible for price increases.

CMS recently launched the eMedicare initiative to empower beneficiaries with cost and quality information. This announcement included the launch of an enhanced interactive online decision support feature to help people better understand and evaluate their Medicare coverage options. eMedicare also offers a mobile-optimized out-of-pocket cost calculator to provide beneficiaries with information on overall plan costs and prescription drug costs.

For a blog post on the Procedure Price Lookup took by Administrator Verma, please visit:

The Procedure Price Lookup tool is available at:


Updated: QPP Participation Status Tool Now Includes Second Snapshot of 2018 Qualifying APM Participant and MIPS APMs Data

Posted November 9, 2018

QPP Participation Status Tool Now Includes Second Snapshot of 2018 Qualifying APM Participant and MIPS APMs Data

The Centers for Medicare & Medicaid Services (CMS) updated its Quality Payment Program Participation Status Tool based on calculations from the second snapshot of Medicare Part B claims data to calculate the Alternative Payment Model (APM) entities threshold scores. The second snapshot are for dates of participation between January 1 and June 30, 2018. As a reminder, the tool includes 2018 Qualifying APM Participant (QP) and MIPS APM status.

By the end of this year, CMS will release the third QP and MIPS APM status data based on snapshots of claims between January 1, 2018 and August 31, 2018. To learn more about how CMS determines QP and MIPS APM status for each snapshot, please view the QP Methodology Fact Sheet.

What Does QP Status Mean?
If you qualify as a QP, this means you are:

  • Eligible for the 5% APM incentive bonus, and
  • Exempt from participating in MIPS.

What Does MIPS APM Participation Mean?

If you are in participating in a MIPS APM you receive the benefit of being scored under the APM Scoring Standard. As a MIPS APM participant we recommend you check the QPP Participation Status Tool to see if you’re eligible for MIPS in 2018.

How Do I Check My QP or MIPS APM Status?

To view your QP or MIPS APM status as an individual:

To check your group’s 2018 eligibility at the APM entity level:

  • Log into the CMS Quality Payment Program website with your EIDM credentials
  • Browse to the Taxpayer Identification Number affiliated with your group
  • Access the details screen to view the eligibility status of every clinician based on their NPI

What APMs are Included in the QPP Participation Status Tool?

The updated Quality Payment Program Participation Status Tool includes the following 2018 Advanced APMs and MIPS APMs:

  • Bundled Payments for Care Improvement Advanced Model (BPCI Advanced)
  • Comprehensive ESRD Care (CEC) Model (LDO arrangement)
  • Comprehensive ESRD Care (CEC) Model (non-LDO two-sided risk arrangement)
  • Comprehensive ESRD Care (CEC) Model (non-LDO one-sided risk arrangement)
  • Comprehensive Primary Care Plus (CPC+) Model
  • Medicare Accountable Care Organization (ACO) Track 1+ Model
  • Medicare Shared Savings Program Accountable Care Organizations – Track 1, 2, 3
  • Next Generation ACO Model
  • Oncology Care Model (OCM) (one-sided Risk Arrangement)
  • Oncology Care Model (OCM) (two-sided Risk Arrangement)
  • Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)

For a comprehensive list of APMs, visit the QPP Resource Library.

Reducing Clinician Burden

Posted November 9, 2018

Special Edition – Thursday, November 8, 2018

Today CMS released a letter to clinicians outlining how the agency is reducing burden through reform of documentation and coding requirements. We encourage you to read and share with your stakeholders. 

Access to Quality and Resource Use Reports and PQRS Feedback Reports Available Until December 31, 2018

Posted November 9, 2018

Access to Quality and Resource Use Reports and PQRS Feedback Reports Available Until December 31, 2018

The final performance period for the Value Modifier and Physician Quality Reporting System (PQRS) programs was 2016 and the final payment adjustment year is 2018. Therefore, the Quality and Resource Use Reports (QRURs) and PQRS Feedback Reports will no longer be available after the end of 2018. All QRURs and PQRS Feedback Reports provided under these programs will remain available for download until December 31, 2018. Authorized representatives of groups and solo practitioners can access their QRURs and PQRS Feedback Reports at using an Enterprise Identity Management (EIDM) system account with the correct role. The QRURs can be downloaded as PDF or Excel files, and the PQRS Feedback Reports can be downloaded as Excel files. For instructions on signing up for an EIDM account and accessing the QRURs and PQRS Feedback Reports, please visit the How to Obtain a QRUR webpage.

For access to PQRS Taxpayer Identification Number (TIN) or National Provider Identifier (NPI) reports from program year 2013 or earlier, please contact the QualityNet Help Desk, Monday - Friday; 7:00 a.m. - 7:00 p.m. Central Time (CT) as they are no longer available from the “Communication Support Page” section of the QualityNet Secure Portal.

The Merit-based Incentive Payment System (MIPS) under the new Quality Payment Program replaced the Value Modifier and PQRS programs. We encourage everyone to learn more about the Quality Payment Program by visiting Please note that the QRURs and PQRS Feedback Reports are not the same as the MIPS Performance Feedback that is available under the Quality Payment Program.


  • For information on your PQRS Feedback Report, visit the Analysis and Payment webpage.
  • For information on your QRUR, visit the Value Modifier webpage.
  • For assistance with Enterprise Identity Management or PQRS Feedback Reports, contact the QualityNet Help Desk at 866-288-8912 (TTY 877-715- 6222) or
  • For assistance with the QRURs or Value Modifier, contact the Physician Value Help Desk at or 888-734-6433 (select option 4).
  • Both help desks are available from 7:00 a.m. to 7:00 p.m. CT, Monday through Friday.

Now Available: Accredited Online Course; Help CMS Improve the Quality Payment Program!

Posted November 9, 2018

Now Available: Accredited Online Course - Quality Payment Program in 2018: Advanced APMs Web-Based Training Course — Revised

With Continuing Education Credit

A revised Quality Payment Program in 2018: Advanced APMs Web-Based Training Course is available through the MLN LMS.
Learn about:

  • Advanced Alternative Payment Models (APMs), including how to identify an Advanced APM and a CMS Advanced APM
  • How to participate in QPP via an Advanced APM

Participants will gain knowledge and insight on the program all while earning valuable continuing education credit. Keep checking back with us for updates on new courses. First time participants will need to register for the MLN Learning Management System. Once registered, you will be able to access additional courses without having to register.  For information on how to login or find training, please visit our MLN Learning Management System FAQ sheet.

The Centers for Medicare & Medicaid Services designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Credit for this course expires October 23, 2021. AMA PRA Category 1 Credit TM is a trademark of the American Medical Association.

Accreditation Statements

Please click here for accreditation statements

Help CMS Improve the Quality Payment Program!

Interested in providing feedback on the Quality Payment Program website to CMS as we continue to improve the Quality Payment Program experience? Email to participate in our feedback sessions.

PA Health Care Cost Containment Council Special Data Requests Update

Posted November 9, 2018

Data User Series
Impact of Type 2 Diabetes on Healthcare Utilization in Rural and Urban Pennsylvania
Dr. Trina Thompson, Director, and Konstantinos Panitsas, Research Project Manager, of the 1889 Jefferson Center for Population Health used hospital data from the Pennsylvania Health Care Cost Containment Council (PHC4) to study diabetes in rural Pennsylvania. Results of the study showed that, independent of stratification by age, gender, type of insurance and race, patients with a secondary diagnosis of diabetes had, on average, higher total expenditures when compared to patients without diabetes or to patients hospitalized specifically for diabetes–a finding consistent at the state and county level. More Details.

PHC4 Research Briefs
Cost of Care for Pennsylvania’s Heart Failure Patients
This research brief examines adult Pennsylvania residents, insured by Medicare fee-for-service, who were hospitalized for heart failure and the medical services they subsequently received for up to one-year. It includes payment amounts by type of service, and it includes county-level population-based rates. More Details

Breast Cancer Surgery in Pennsylvania
This research brief examines breast cancer surgeries performed in Pennsylvania hospitals and ambulatory surgery centers during 2017.  It includes county-level population-based rates. More Details

Hospitalizations for Opioid Overdose
Population Differences
As part of a series that examines opioid-related hospitalizations, PHC4 released a research brief focusing on demographic differences among Pennsylvania residents hospitalized for opioid overdose, including those with the highest rates and those with the highest rate increases. More Details

Opioid Overdose & Opioid Use Disorder
This brief, also part of the series on opioid-related hospitalizations, extends previous analysis on opioid overdose to include hospitalizations related to opioid use disorder. More Details

PHC4 Reports
Financial Analysis 2017 Volume 2 – Ambulatory Surgery Centers
A report with statewide and facility-specific information on the financial health of Pennsylvania’s ambulatory surgery centers. The report covers fiscal year 2017. More Details

The Quality Payment Program Resource Library is Back on QPP.CMS.GOV

Posted October 31, 2018

The Quality Payment Program Resource Library is Back on QPP.CMS.GOV

Visit the Quality Payment Program Website to Find Available Resources

The Centers for Medicare & Medicaid Services (CMS) has moved Quality Payment Program (QPP) resources from to the newly redesigned Quality Payment Program Resource Library on Following feedback from clinicians and others in the health care community, we wanted to make Quality Payment Program information and resources available in one place. We’ve also made it easier for you to find the resources you’re looking for by including a search function that allows you to search for resources by year, reporting track, performance category, and by document type (e.g., fact sheet, user guide, measure specifications).

Additional resources including materials from educational webinars will be added to the new Quality Payment Program Resource Library soon. Stay tuned for more information!

For More Information

Contact the Quality Payment Program at or 1-866-288-8292 (TTY: 1-877-715-6222)

Register for Medicare Diabetes Prevention Program (MDPP) Office Hours: Crosswalk Guidance

Posted October 25, 2018

Register Today!

Medicare Diabetes Prevention Program (MDPP)
Crosswalk Guidance Webinar
October 31, 2018
11am ET

MDPP suppliers are required to maintain a crosswalk file that lists beneficiary identifiers used for the Centers for Disease Control and Prevention (CDC) performance data submissions and the corresponding Medicare identifiers for each beneficiary who receives MDPP services. This requirement will facilitate the evaluation of the MDPP expanded model.

During this webinar, we will walk through the recently released MDPP Crosswalk Guidance, which outlines the form and manner in which all MDPP suppliers must maintain the crosswalk file. Register here.

CMS model addresses opioid misuse among expectant and new mothers

Posted October 24, 2018

October 23, 2018
Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries

CMS model addresses opioid misuse among expectant and new mothers
Goals are to improve quality of care, increase access to treatment based on state-specific needs, and reduce expenditures

Today the Centers for Medicare & Medicaid Services (CMS) announced the Maternal Opioid Misuse (MOM) model, an important step in advancing the agency’s multi-pronged strategy to combat the nation’s opioid crisis. The model addresses the need to better align and coordinate care of pregnant and postpartum Medicaid beneficiaries with opioid use disorder (OUD) through state-driven transformation of the delivery system surrounding this vulnerable population. By supporting the coordination of clinical care and the integration of other services critical for health, wellbeing, and recovery, the MOM model has the potential to improve quality of care and reduce expenditures for mothers and infants.

“Too many barriers impede the delivery of well-coordinated, high-quality care to pregnant and postpartum women struggling with opioid misuse, including lack of access to treatment and a shortage of providers in rural areas, where the opioid crisis is especially destructive,” said HHS Secretary Alex Azar. “The MOM model will support state Medicaid agencies, front-line providers and healthcare systems to help ensure that mothers and infants afflicted by the opioid epidemic get the care they need.”

Substance use-related illness and death is now a leading cause of maternal death.  Pregnant and postpartum women who misuse substances are at high risk for poor maternal outcomes, including preterm labor and complications related to delivery; these problems are frequently exacerbated by malnourishment, interpersonal violence, and other health-related social needs. Infants exposed to opioids before birth are at greater risk for negative health outcomes such as higher risk of being born preterm, having a low birth weight, and experiencing the effects of neonatal abstinence syndrome (NAS), a group of conditions caused when an infant withdraws from certain drugs s/he is exposed to in the womb. In addition, Medicaid pays the largest portion of hospital charges for maternal substance use, as well as a majority of the $1.5 billion annual cost of NAS.

The primary goals of the model are to:

  • Improve quality of care and reduce expenditures for pregnant and postpartum women with OUD as well as their infants;
  • Increase access to treatment, service-delivery capacity, and infrastructure based on state-specific needs; and
  • Create sustainable coverage and payment strategies that support ongoing coordination and integration of care.

The CMS Innovation Center will execute up to 12 cooperative agreements with states, whose Medicaid agencies will implement the model with one or more “care-delivery partners” in their communities. The MOM model will serve pregnant Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries with OUD who have elected to participate, during the prenatal, peripartum (i.e., surrounding labor and delivery), and postpartum periods. Awardees will be responsible for ensuring that beneficiaries participating in the model have access to a set of essential physical and behavioral health services, such as medication-assisted treatment (MAT) for OUD, maternity care, relevant primary care services, and other mental and behavioral health  services beyond MAT.

The MOM model will have a five-year period of performance with different types of funding. Specifically, implementation funding, transition funding, and the opportunity for milestone funding will be provided in three distinct model periods: Pre-implementation (Year 1), Transition (Year 2), and Full Implementation (Years 3-5).

Care delivery will begin in Year 2, or the Transition Period, of the model. During this year, funding for care-delivery services that are not otherwise covered by Medicaid will be provided by Innovation Center funds. By Year 3, the start of the Full Implementation Period, states must implement coverage and payment strategies. This overall structure seeks to balance rapid model initiation and state flexibility, while minimizing administrative burden. In particular, the MOM model design supports each awardee’s ability to quickly begin delivering coordinated and integrated care to pregnant and postpartum women with OUD during the Transition Period, while supporting states in developing a long-term coverage and payment strategy that aligns with their state Medicaid program.

CMS anticipates releasing a Notice of Funding Opportunity (NOFO) in early 2019 to solicit cooperative agreement applications to implement the MOM model. The state Medicaid agency will be expected to complete the application, which must demonstrate that it has partnered with at least one care-delivery partner. A maximum of $64.6 million will be available across up to 12 state awardees over the course of the five-year model. The NOFO will contain all model requirements and eligibility criteria for potential applicants.

In August, CMS announced the Integrated Care for Kids (InCK) Model, a child-centered local service delivery and state payment model aimed at reducing expenditures and improving the quality of care for children covered by Medicaid and CHIP through prevention, early identification, and treatment of priority health concerns like behavioral health challenges, including substance abuse. The model will empower states and local providers to better address these needs through care integration across all types of healthcare providers. CMS anticipates releasing a NOFO for the InCK Model at the same time as it does for the MOM Model.

For more information, please visit or the fact sheet:

PHC4 Embargoed Release: Financial Analysis 2017 Volume Two

Posted October 11, 2018

The Pennsylvania Health Care Cost Containment Council (PHC4) will release Financial Analysis 2017 Volume Two on Thursday, October 11, 2018.  The report includes statewide and facility-specific information about the financial health of Pennsylvania’s ambulatory surgery centers for fiscal year 2017.

Click HERE to access the embargoed report and press release. 

Joe Martin if you have any questions.
Joe Martin
Executive Director
PA Health Care Cost Containment Council
Commonwealth of Pennsylvania
Suite 400 | 225 Market Street
Harrisburg, PA 17101
Phone: 717-232-6787 | Fax: 717-232-3821

Centers for Medicare & Medicaid Services (CMS) Measures Management System Update

Posted October 10, 2018

Measures Management and You

Centers for Medicare & Medicaid Services

October 2018 [Volume 3, Edition 10]


This month’s newsletter provides an overview of the Qualified Clinical Data Registry (QCDR). Every edition includes links to the CMS Blueprint (the version in use at the time of publication), as well as a calendar of upcoming events and opportunities.

We hope you find this newsletter useful and we welcome any feedback or suggestions to make it even better. Please send comments or suggestions for future newsletters to

Qualified Clinical Data Registry (QCDR) Overview

A Qualified Clinical Data Registry (QCDR) is a Centers for Medicare & Medicaid Services (CMS) approved third-party intermediary that is defined at 42 CFR 414.1305 and generally in the business of improving health care quality. QCDRs may include specialty societies, regional health collaboratives, large health systems, or software vendors working in collaboration with one of these medical entities. One of the ways QCDRs can help to improve the quality of care patients receive is by collecting clinical data from clinicians and reporting this data to CMS on their behalf for purposes of MIPS. QCDRs differ from Qualified Registries because, in addition to collecting and reporting data, they can develop QCDR measures. In addition to submitting this data for purposes of the Quality performance category under MIPS, QCDRs may also submit data on behalf of clinicians for two additional MIPS performance categories: the Promoting Interoperability and Improvement Activities performance categories.

QCDR measures are to be developed in accordance with the Blueprint, but do not need to go through the Pre-Rulemaking process.

Annually, CMS puts out a call for QCDR self-nomination. The 2019 Self-Nomination Toolkit for QCDRs and Qualified Registries is now available. QCDRs must self-nominate annually, even if previously approved.

There are several benefits of using a QCDR to submit measures under MIPS. For example, because many QCDRs are specialty-based, QCDR measures may be more meaningful and applicable to the eligible clinician. QCDRs may also streamline data collection and manage the submission of the three MIPS performance categories for which data is required to be submitted to CMS. Eligible clinicians may be able to earn bonus credit in multiple performance categories. The clinicians may receive benchmark information so they can see how they are performing in comparison with their peers. QCDRs generally provide quarterly feedback reports to their participating clinicians, which provides the clinicians the opportunity to make rapid changes to improve quality of care. For more information about QCDRs, see the full article on the Measures Management System (MMS) website.

Special Announcements

Updated CMS Measures Inventory Tool (CMIT)

We are excited to share the latest update for the CMS Measures Inventory Tool (CMIT)! This update reflects measure information from the proposed and final Federal Rules for 20 programs published between June 1 through August 20, 2018. The CMS Measures Inventory currently includes 2,179 unique measures from 37 programs/initiatives and spans the measurement lifecycle including Measures under Development (MUD), those that have been published on a Measures under Consideration (MUC) List, and measures that are currently used in or have been removed/retired from a program.

A few of CMIT’s new features and functions:

  • Lists similar measures for each measure in the inventory

  • An improved filtering interface that will help you refine your search for relevant measures

  • Shows “Upcoming Status Changes” for measures in specific programs

  • Assists you in identifying gaps via a measure comparison tool

  • Application of common synonyms when searching; for example, a search for “juvenile” will also find measures that mention “adolescents”

  • The ability to view and export tables that count measures by category in the Measure Summary view; for example, by program and current status or by program and meaningful measure area

Visit today to check it out!

We always welcome feedback on the CMS Measures Inventory – for any questions or comments, please contact

Cooperative Agreements Announcement

On September 21, 2018, the Centers for Medicare & Medicaid Services selected seven applicants to receive cooperative agreements through the “Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Funding Opportunity: Measure Development for the Quality Payment Program.” The awardees and the measure(s) they are developing, improving, updating, or expanding can be found at . Thank you to the applicants that applied. We look forward to continuing to engage with the healthcare community to improve the quality and value of healthcare delivered to our beneficiaries.

All times shown are Eastern Time zone

  • The Measure Authoring Tool and Bonnie Training

    • Register for the training session on October 11, 2018 at 11:00 AM here

    • Register for the training session on October 15, 2018 at 2:00 PM here

  • Leveraging Patient-Centered Clinical Decision Support: Addressing the National Opioid Crisis and Beyond on October 15, 2018

    • Register for event here

  • Patient Relationship Categories and Codes Webcast on October 17, 2018 at 1:30-3:00 PM

    • Register for event here

  • Physician Compare: Preview Period and Public Reporting Webcast on October 30, 2018 at 1:30-3:00 PM

    • Register for event here

  • Cooking with CQL: or How to Incorporate CQL into HQMF for eCQMs on October 25, 2018 at 4:00 PM

    • Register for event here

Upcoming Opportunities

Opportunities for Public Comment on quality measures

Currently there are no open public comments. Please check the CMS Quality Measures Public Comment Web Page for current Public Comment announcements and summary reports.

Opportunities to participate in a Technical Expert Panel (TEP)

  • Development of Two Outpatient Outcome Measures for the Merit-based Incentive Payment System (MIPS)

    • The Clinician Committee nomination period opened on September 25, 2018 and closes on October 10, 2018.

  • Impact Assessment of CMS Quality and Efficiency Measures 

    • The TEP nomination period opened on September 27, 2018 and closes on November 2, 2018.

  • MACRA Episode-Based Cost Measures – Call for Clinical Subcommittee

    • The TEP nomination period closed on March 20th, but nominations are being accepted on a continuous basis.

Please check the CMS Quality Measures Call for TEP Web Page for current TEP membership lists and meeting summaries.

New to the listserv or missed a month? Find all our announcements as well as printer-friendly versions of past newsletters here.

Please send comments and suggestions to

CMS to Strengthen Oversight of Medicare’s Accreditation Organizations

Posted October 8, 2018

October 4, 2018

Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries 

CMS to Strengthen Oversight of Medicare’s Accreditation Organizations
Agency’s website will increase transparency into Accrediting Organization performance, and CMS will streamline and strengthen the validation of Accrediting Organization surveys

Today, the Centers for Medicare & Medicaid Services (CMS) took action to improve quality and safety in healthcare facilities and empower patients with information to make decisions about where to receive care.

“Today we are taking action to improve our oversight of Accrediting Organizations, including by increasing transparency for patients on the organizations’ performance,” said CMS Administrator Seema Verma.  “The public trusts CMS to ensure the quality and safety of patient care, and we take this responsibility very seriously.  Today's changes will bolster the processes for overseeing how effective Accrediting Organizations, who work on CMS’ behalf, are in evaluating healthcare facilities.”

Currently, Medicare-participating healthcare providers and suppliers are surveyed either by State survey agencies or by Accrediting Organizations (AOs) to ensure that they meet CMS’ quality and safety standards. AOs receive deeming authority from CMS, which affirms that AOs’ health and safety standards meet or exceed those of Medicare. Only facilities and suppliers that have been deemed by state or AO surveyors to meet CMS’ standards may receive payments from Medicare. There are currently 10 CMS-approved AOs, each of which surveys one or more different types of facilities.

CMS will enhance and strengthen its oversight and quality transparency of AOs in three ways:  1) the public posting of AO performance data; 2) a redesigned process for AO validation surveys and 3) the release of the Annual Report to Congress. Taken together, these efforts will provide important insights to the public and assist AOs, providers, and suppliers in ensuring patient health and safety. 

Posting AO Performance Data Online

To increase transparency for consumers, CMS will post new information on the CMS.Gov website, including:  The latest quality-of-care deficiency findings following complaint surveys at facilities accredited by AOs; a list of providers determined by CMS to be out of compliance, with information included on the provider’s AO; and overall performance data for AOs themselves. To view AO performance data, visit:

Today, the public relies on accreditation status as a way to gauge providers’ and suppliers’ quality of care. By posting more detail—accredited hospitals’ complaint surveys, out-of-compliance information, and performance data for AOs themselves—CMS will offer the public more nuanced information than accreditation status alone provides.  The agency is currently prohibited by law from disclosing the actual surveys done by AOs, except for surveys of home health agencies and surveys related to an enforcement action.

Pilot Testing Direct Observation for AO Validation Surveys

CMS is testing a more streamlined, efficient way to assess AOs’ ability to ensure that facilities and suppliers comply with CMS requirements.

CMS evaluates the ability of AOs to accurately assess providers’ and suppliers’ compliance with health and safety standards through a validation survey process. Historically, CMS has measured the effectiveness of AOs by choosing a sample of facilities, performing state-conducted assessment surveys within 60 days following AO surveys, and comparing results of the state surveys with the AO surveys. In a pilot test, CMS will eliminate the second state-conducted validation survey and instead use direct observation during the original AO-run survey to evaluate AOs’ ability to assess compliance with CMS’s Conditions of Participation.

Direct observation will enable CMS not only to evaluate AO performance more effectively, but also to suggest improvements and address concerns with AOs immediately. This approach will relieve providers from having to undergo the burden of a state’s follow up assessment.  The approach is another example of the wide-ranging effort at CMS to eliminate duplication and relieve burden, reducing the amount of time that healthcare facilities must spend on compliance activities.

CMS will also analyze and incorporate State complaint investigations of accredited facilities as part of the agency’s strengthened validation program. This work will focus on identifying and monitoring accredited facilities that are out of compliance with Medicare health and safety requirements. CMS will use this information as an additional indicator of AO performance.

Posting the Most Recent Annual Report to Congress Regarding AO Performance

CMS has also posted the most recent annual Report to Congress, the “Review of Medicare’s Program for Oversight of Accrediting Organizations and the Clinical Laboratory Improvement Validation Program Fiscal Year 2017,” on the CMS website.  As the changes announced today inform and bolster our oversight of AOs, CMS will continue to publish this report online annually to demonstrate the impact of these changes on the oversight of AOs and to provide greater transparency for the public. The FY 2017 Report to Congress is posted online:


SHO: Key Provisions of Legislation Extending Federal Funding for CHIP

Posted October 5, 2018

Today, the Centers for Medicare & Medicaid Services (CMS) issued a letter to state Health Officials describing some key provisions of the HEALTHY KIDS and ACCESS Acts that are related to the Children’s Health Insurance Program (CHIP) as well as other children’s coverage and quality provisions.

The letter can be accessed on at For more information on CHIP, visit

CMS Blog: Better Data Will Serve as the Foundation in Modernizing the Medicaid Program

Posted October 3, 2018


October 2, 2018
By Seema Verma, Administrator, Centers for Medicare & Medicaid Services

Better Data Will Serve as the Foundation in Modernizing the Medicaid Program

Between 2013 and 2016, Federal spending on Medicaid grew by over $100 billion. The program is often the first or second largest line item in state budgets. Just recently, CMS’ independent Office of the Actuary released their Medicaid financial report, confirming what we have already known for quite some time – that our healthcare spending, particularly in Medicaid – is forecast to continue growing, averaging 5.7% annually over the next 10 years to reach over $1 trillion by 2026.

Yet as program costs have continued to rise, we have failed to deliver a level of transparency and accountability for achieving positive outcomes commiserate with our significant investment. But this is finally beginning to change. Over the last several years, CMS has collaborated with states to improve how we collect and use data to modernize and measure the Medicaid and CHIP program. Through strong data and systems, CMS and states can drive toward better health outcomes and improve program integrity, performance, and financial management in Medicaid and CHIP. These efforts will provide the foundation that enables CMS to deliver on its commitment to usher in a new era of Medicaid centered on state flexibility, stronger accountability, and improved program integrity.

As one example, CMS has worked with stakeholders to identify two core sets of health care quality measures that can be used to assess the quality of health care provided to children and adults enrolled in Medicaid and CHIP.  These core sets are tools states can use to monitor and improve the quality of health care provided to Medicaid and CHIP enrollees. Under statute, state reporting on these measure sets is voluntary. In the future, we aim to increase the number of states reporting on a uniform set of measures and to support states in using these measures to drive quality improvement for the beneficiaries they serve. And ultimately, this move toward greater transparency will start an important conversation about how and when states should be held accountable for the outcomes their programs produce.

Last week, we released the latest Federal Fiscal Year 2017 quality measurement data from the Medicaid and CHIP Child and Adult Core Sets that states have voluntarily reported to CMS. We greatly appreciate the work our state partners have endured to report these measures. CMS recognizes that quality reporting can present a significant administrative burden for both states and providers, and has taken steps to reduce this burden through our Meaningful Measures initiative.  In the future, we hope to leverage existing and more automated data reporting systems to generate these Medicaid measures on behalf of states, thereby reducing reporting burden while also improving data consistency, comparability, and comprehensiveness. 

States have worked with CMS over the last few years to modernize the way in which administrative data is collected by moving from the Medicaid Statistical Information System (MSIS) to the Transformed-MSIS (T-MSIS).  T-MSIS modernizes and enhances the way states submit operational data about beneficiaries, providers, claims, and encounters.  It is the foundation of a national analytic data infrastructure to support programmatic and policy improvements and program integrity efforts and will help advance reporting on outcomes. It also enhances the ability to identify potential fraud and improve program efficiency.

I am pleased to say that all states, the District of Columbia, and Puerto Rico are now successfully submitting T-MSIS data, marking a significant and exciting milestone in the history of the Medicaid program.

With these data in hand, we are shifting our efforts to continuous data quality review and improvement--a collaboration we will sustain with states. CMS’ ongoing goal is to use advanced analytics and other innovative solutions to both improve T-MSIS data and maximize its potential for performance measurement, health care quality improvement, and program integrity, all while reducing state reporting burden.  

I appreciate our continued partnership with states. Programs as important as Medicaid and CHIP require robust, timely, and accurate data in order to ensure the highest financial and program performance, support policy analysis and ongoing improvement, identify potential fraud or waste, and enable data-driven decision making. 

We are committed to collaborating with states on improving their data submissions.


CMS announces new streamlined user experience for Medicare beneficiaries

Posted October 3, 2018


October 1, 2018

Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries

CMS announces new streamlined user experience for Medicare beneficiaries

Today, the Centers for Medicare & Medicaid Services (CMS) announced a multi-year initiative that will empower patients and update Medicare resources to meet beneficiaries’ expectation of a more personalized customer experience. The eMedicare initiative will modernize the way beneficiaries get information about Medicare and create new ways to help them make the best decisions for themselves and their families.

The eMedicare initiative’s goal is to provide a seamless online health care experience to meet the growing expectations for this generation of Medicare beneficiaries. CMS has a cohesive, multi-year strategy of consumer data integration and web product development to modernize and improve access to personal health care data. The road map for this program will enhance opportunities to go digital, offer additional self-serve options, and create a seamless multi-channel customer service experience.

“Since day one, President Trump has been committed to strengthening the Medicare program—eMedicare puts his leadership into action by giving Medicare beneficiaries a simpler, more intuitive customer experience,” CMS Administrator Seema Verma said. “Our intent is not to replace traditional channels that beneficiaries trust and depend on, but to improve and enhance them with the emerging digital options to create a user-centered, seamless consumer experience.”

Some of the new eMedicare initiatives that CMS is launching ahead of Medicare Open Enrollment are:

  • An improved coverage wizard to help beneficiaries compare options at a deeper level as a way to decide if Original Medicare or Medicare Advantage is right for them;
  • A stand alone, mobile optimized out of pocket cost calculator that will provide information on both overall costs and prescription drug costs;
  • A simplified log in for the Medicare Plan Finder ( tool using their online account (instead of the current process of entering 5 pieces of information to authenticate);
  • A webchat option, which will be available within the Medicare Plan Finder for some beneficiaries; and
  • New easy to use surveys available across so beneficiaries can continue to tell us what they want.

These changes are building on previous improvements including:

CMS launched the initiative with a new video ( that includes insights from Medicare beneficiaries on what they expect from Medicare and remarks from Administrator Verma outlining her vision for modernized program. Approximately 10,000 people join Medicare each day. The Medicare population is expected to increase to more than 80 million beneficiaries in 2030, up from 54 million in 2015. As of 2016, about two-thirds of Medicare beneficiaries indicate they use the Internet daily or almost daily (65%).

Read a blog about eMedicare:

For a royalty-free, downloadable image of the updated homepage to use for republishing, please visit:

Delaware Medical Group Management Association, Inc.
Executive Plaza II, 11350 McCormick Road, Suite 904, Hunt Valley, MD 21031
P: 410-527-0780 E:
Terms of Use |
Privacy Policy
©  2016 - 2019 Delaware Medical Group Management Association, Inc.

Powered by Wild Apricot Membership Software