Dear Health Care Provider:
Thank you for your participation in Medicare and the services you and your colleagues provide to more than 55 million people with Medicare. You are integral to our work at the Centers for Medicare & Medicaid Services (CMS) to combat the opioid epidemic.
We recently published an opioids roadmap at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Opioid-epidemic-roadmap.pdf outlining our efforts to address this issue of national concern. In this roadmap, we detail our three-pronged approach, focusing in on preventing new cases of opioid use disorder, treating patients who have opioid use disorders, and using data from across the country to target prevention and treatment activities.
CMS is working with the U.S. Department of Health and Human Services (HHS) to encourage health care providers to co-prescribe naloxone to certain at-risk patients who use opioids. We are also strengthening Medicare drug plan policies to promote care coordination and safe use of prescription opioids, and encouraging health care providers to promote a range of safe and effective pain treatments, including courses of action other than opioids.
HHS issued guidance at https://www.hhs.gov/opioids/sites/default/files/2018-12/naloxone-coprescribing-guidance.pdf and recommended a set of indications for naloxone prescriptions. As a provider, you can have important conversations with your patients about pain management, and opioid safety. You can help expand naloxone access and awareness by co-prescribing naloxone for certain patients who get opioids for pain management and who may be at-risk for an opioid overdose. In concert with standing pharmacy orders, pharmacist prescriptive authority, and other naloxone laws, regulations and policies, your action can help ensure your high-risk patients have naloxone more readily available to them, and, when needed, to their families and caregivers.
New Medicare Part D Opioid Policies
CMS recently finalized new policies for Medicare drug plans, effective January 1, 2019. The policies broaden our partnership with providers to address the opioid crisis while maintaining access to needed medications. It’s very important you understand the new policies to minimize additional burden on you and your patients. It is also critical in avoiding adverse and unintended impacts on your patients’ access to prescribed opioids.
Our approach centers on increasing communication tools to improve safety, especially as we process opioid prescriptions. The new policies include improved safety alerts (pharmacy claim edits) when a patient fills an opioid prescription at a pharmacy, and drug management programs to help coordinate care for patients with high-risk opioid use, such as those receiving high levels of opioids from multiple prescribers and/or pharmacies.
Detailed training materials about these new policies are available:
• A Prescriber’s Guide to the New Medicare Part D Opioid Overutilization Policies for 2019: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18016.pdf.
• Information for Prescribers, such as slide deck and tip sheet: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/RxUtilization.html
Starting January 1, 2019, Medicare drug plans will employ the following safety alerts at the pharmacy:
• 7 day supply limit for opioid naïve patients: This is a policy to limit an initial opioid prescription supply to 7 days or less until the pharmacy gets an override from the plan for Medicare patients who have not recently filled an opioid prescription (e.g., within 60 days). The pharmacist can fill part of the initial prescription (e.g., a 7 day supply) per state and federal regulations. If a prescriber writes another prescription for the remainder of the days-supply, or any subsequent prescriptions, those prescriptions are not subject to the 7 day supply limit because the patient is no longer considered opioid naïve.
However, if a prescriber believes that an opioid naïve patient will initially need more than a 7 day supply initially, the prescriber can contact the plan to request a coverage determination on behalf of the patient attesting to the medical need for a supply greater than 7 days. The prescriber can also request an expedited or standard coverage determination in advance of prescribing an opioid.
• Opioid care coordination alert: This is an alert for pharmacists to review when the patient’s cumulative morphine milligram equivalents (MME) reaches 90 mg or greater per day across all opioid prescriptions. Some plans use this alert only when the patient uses multiple opioid prescribers and/or opioid dispensing pharmacies.
This 90 MME threshold identifies potentially high risk patients who may benefit from closer monitoring and care coordination. It is cited in the Centers for Disease Control and Prevention (CDC) Guideline (https://www.cdc.gov/drugoverdose/prescribing/guideline.html) as the level above which primary care prescribers should generally avoid. This is not a prescribing limit. In reviewing the alert, the pharmacist may contact the prescriber to confirm medical need for the higher MME. The pharmacist may talk with the prescriber about other opioid prescribers or increasing level (MME) of opioids. After that discussion to confirm intent, the pharmacist can fill the prescription.
The prescriber who writes the prescription will trigger the alert and a pharmacist will contact the prescriber even if that prescription itself is below the 90 MME threshold. Once a pharmacist consults with a prescriber on a patient’s prescription for a plan year, the prescriber will not be contacted on every opioid prescription written for the same patient after that unless the plan implements further restrictions.
The new CMS policies also include drug management programs to encourage care coordination and safe use of opioids as required by the Comprehensive Addiction and Recovery Act of 2016. Starting in 2019, for patients who could potentially abuse or misuse prescription drugs - including opioids and benzodiazepines - a Medicare drug plan will contact prescribers through case management to review patients’ total utilization pattern of frequently abused drugs and discuss the following coverage limitation tools:
• Requiring the patient to get these medications from a specified prescriber and/or pharmacy, or
• Implementing an individualized point of sale edit that limits the amount the drug plan covers for these medications.
Medicare drug plans identify potential at-risk patients by their opioid use which involve multiple doctors and pharmacies. After the plan conducts case management with prescribers and before implementing any coverage limitation tools, the Medicare plan will notify your patients in writing. Plans must make reasonable efforts to send the prescriber a copy of the letter.
Prescribers and patients can respond to the notice within 30 days. After this 30 day time period, if the plan determines based on its review that the patient is at-risk and implements a limitation, the plan must send the patient a second written notice confirming the specific limitation and its duration.
If the plan decides to limit coverage under a drug management program, the patient and their prescriber have the right to appeal the plan’s decision. The patient or prescriber should contact the plan for additional information on how to appeal.
Promoting a range of safe and effective pain treatments
Opioids are one tool to help your patients with chronic pain. You may also want to consider other treatments when you discuss options with your patients. Medicare covers a variety of services to treat pain. Medicare covers some services across the country, including physical therapy, individual and group therapy, behavioral health integration services, psychiatric collaborative care services and electrical nerve stimulation. Local coverage of additional services may vary somewhat by jurisdiction; you can find detailed information, related coding information, and any restrictions on our website at https://www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx along with a searchable database https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx.
• Medicare also covers care management services to give patients medical care and care coordination services that can help manage their medical condition(s). Information about Chronic Care Management, Behavioral Health Integration, and Transitional Care Management at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Care-Management.html.
• Medicare’s Initial Preventive Physical Exam and subsequent Annual Wellness Visits give you other opportunities to discuss your patients’ general health issues including pain, and review and promote options for pain treatment. See more information about coverage of these services at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18004.pdf.
• There are community programs to help your Medicare patients manage their pain and other chronic conditions. Find out how to access these programs through Area Agencies on Aging and other community-based organizations at: https://eldercare.acl.gov/Public/Index.aspx.
• CMS has dedicated quality improvement contractors to work with you and community organizations to improve health care safety and reduce opioid related adverse events in every state with the Quality Innovation Network Quality Improvement Organizations (QIN-QIOs https://qioprogram.org/locate-your-qio) , and the Hospital Improvement and Innovation Network (HII https://partnershipforpatients.cms.gov/wherepartnershipsareinaction/wherepartnershipsareinaction.html #HIIN).
CMS is committed to exploring and offering viable options to address the opioid crisis, sharing information on the data we collect with other agencies and organizations, and protecting our beneficiaries and communities affected by the crisis. Together, we can make progress in addressing many aspects of the opioid epidemic. For questions on CMS opioid policies, please see our available resources at: https://www.cms.gov/about-cms/story-page/opioid-misuse-resources.html#provider.
You Have Less than 1 Month to Submit MIPS Year 2 (2018) Data for the Quality Payment Program
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. Data can be submitted and updated any time until 8:00 p.m. ET on Tuesday, April 2, 2019.
CMS Web Interface users need to report their Quality performance category data by 8:00 p.m. EST on March 22, 2019. Clinicians who reported Quality measures via Medicare Part B claims can sign in to qpp.cms.gov to view current performance based on claims that have been processed by your Medicare Administrative Contractor.
If you are working with a third-party intermediary to submit data on your behalf, we encourage you to sign in to the Quality Payment Program website during the submission period and review the submission for accuracy. Data cannot be resubmitted after the submission period closes.
How to Sign-in to the Quality Payment Program Data Submission System to View or Submit Data
To sign in to qpp.cms.gov and submit data (or view data submitted on your behalf), you need:
If you’ve signed in to qpp.cms.gov before or have an account with one of the PV/PQRS roles that lets you submit QPP data, you can use those credentials (user ID and password) to sign in at https://qpp.cms.gov/login.
If you’ve never signed in to qpp.cms.gov before, or don’t have an account with one of the PV/PQRS roles that lets you submit QPP data, you’ll need to create an account before you can sign in. Review the QPP Access User Guide and click Register on the sign in page so you can sign in to submit, or view, data.
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, User Guide and video series available in the QPP Resource Library.
If you have questions about how to submit your 2018 MIPS data, contact:
The Centers for Medicare & Medicaid Services (CMS) released an updated version of the Medicare Part D opioid prescribing mapping tool and a new Medicaid opioid prescribing mapping tool.
The Medicare Part D opioid prescribing mapping tool is an interactive, web-based visualization resource that presents geographic comparisons of opioid prescribing rates at the state, county, and ZIP code levels. The update to the Medicare Part D mapping tool now allows users to quickly compare Medicare Part D opioid prescribing rates in urban and rural areas at the state, county and ZIP code levels. In Medicare Part D, opioid prescribing rates at the state level in 2016 range from 2.9% to 7.4% compared to the national average opioid prescribing rate of 5.32%. Opioid prescribing is slightly higher in rural areas (5.47%) compared to urban areas (5.30%).
The Medicaid opioid prescribing mapping tool is a new interactive, web-based visualization resource that presents geographic comparisons at the state level of Medicaid opioid prescribing rates. The Medicaid mapping tool allows users to quickly compare Medicaid opioid prescribing rates overall and segmented by fee-for-service and managed care programs. In Medicaid, opioid prescribing rates at the state level in 2016 range from 2.9% to 9.4% compared to the national average opioid prescribing rate of 5.4%. Opioid prescribing is slightly higher in managed care (5.44%) compared to fee-for-service (5.29%).
Are you an authorized user of Rochester RHIO? Do you use the query portal to search for patient information? Or, do you receive RHIO patient alerts? By March 31, 2019, Rochester RHIO will begin including specially protected substance use and behavioral health care data (SAMHSA, Part 2) in its health information exchange. With patient consent, authorized users and medical professionals will be able to view this data immediately in a patient’s record enabling better patient care.
Crisis in America
The opioid crisis has devastating effects on individuals, families, and communities across the United States. In 2017, 11.1 million Americans reported misuse of prescription opioids and nearly 900,000 reported heroin use. Responsible, secure sharing and use of this specially protected health information is a critical step in helping combat the opioid epidemic. The federal Substance Abuse and Mental Health Services Administration (SAMHSA) is leading efforts to support the implementation of the full range of prevention, treatment and recovery support services to advance behavioral health and reduce the impact of substance use disorders in America.
Why does this matter to me?
As an authorized user of patient information via the Rochester RHIO, it is important to understand your responsibility to be compliant with all relevant federal and state-required changes to Part 2 data delivery.
What is SAMHSA, Part 2 data?
The Substance Abuse and Mental Health Services Administration (SAMHSA) is a federal agency under the U.S. Department of Health and Human Services. SAMHSA, or Part 2, data is a term that applies to any service received at a federally-assisted facility, provider, or clinic for the treatment of a substance use disorder or behavioral health care.
Why is this change happening now?
New York State is requiring that all regional health information organizations that comprise the SHIN-NY, including Rochester RHIO, include specially protected substance use disorder and behavioral health care data (Part 2) by March 31, 2019.
What if I have additional questions?
If you have additional questions about specially protected substance use or behavioral health information (Part 2 data), you can contact your RHIO Account Manager. Or, call our Support Center at 1-877-865-7446 (RHIO).
Join us online for a 60-minute informational program on changes to specially protected substance use and behavioral health care data (Part 2) at Rochester RHIO. In this webinar, we'll explain the Part 2 data changes, how SAMHSA is different from HIPAA, and tips on how you can remain compliant while handling Part 2 data from the Rochester RHIO’s clinical query portal.
The deadline to submit 2018 attestation data for the Promoting Interoperability Programs is February 28, 2019.
Last year, the Centers for Medicare & Medicaid Services (CMS) transitioned to the QualityNet System for hospitals that attest to CMS for the Promoting Interoperability Programs. By transitioning to one system, CMS continues the effort to streamline data submission methods and reduce burden.
Specific submission details for each program is listed below.
Registering on Behalf of a Medicaid EP?
An EP can designate a third party to register and attest on his or her behalf. To do so, users working on behalf of an EP must have an Identity and Access Management System (I&A) web user account (User ID/Password) and be associated with the EP’s National Provider Identifier (NPI). If you are working on behalf of one or more EPs and you do not have an I&A web user account, please visit I&A Security Check to create one.
Note: States and territories will not necessarily offer the same functionality for registration and attestation in the Promoting Interoperability Program. Check with your state or territory to see what functionality is offered.
Friday, March 15, 2019
8:00am - 4:00pm
Monroe Community Hospital, Rochester, NY
$20/ per person, includes lunch
For more information, click here.
Annual Legislative Breakfast
Friday, March 15th, 2019
8:30am to 10:30am
Doubletree by Hilton, 1111 Jefferson Road, Rochester, NY
For More Information click here.
Monday, March 11, 2019 1:00 PM - 2:00 PM EST
The Centers for Medicare & Medicaid Services (CMS) is hosting a webinar titled “Eligible Clinician New eCQMs Finalized for 2019” on March 11, 2019. This one-hour session will provide an in-depth review of the following new electronic clinical quality measures (eCQMs) finalized for the 2019 performance period: HIV Screening (CMS349) and Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture (CMS249). CMS has transitioned the logic used in eCQMs from the previous quality data model (QDM) logic expression language to Clinical Quality Language (CQL) for the 2019 performance year. This session will provide an introduction to the new eCQMs finalized for 2019 Merit-based Incentive Payment System (MIPS) Quality performance year. As a result of the feedback received from stakeholders interviewed through the CMS eCQM Strategy Project to reduce implementation and reporting burdens, this session is intended to prepare eligible clinicians, vendors, quality, and health information technology staff for eCQM reporting, and is the last in a series of five educational sessions to provide relevant information to support successful understanding, interpretation, and implementation of eCQMs.
At the end of this session, participants will be able to:
Space is limited for this webinar. Registration will close when we have reached maximum capacity. This webinar will be recorded. If you are unable to participate, a replay of the webinar with presentation slides will be available on the eCQI Resource Center website within 2 weeks following the program.
DFS has decided to delay implementation of the recently updated WC Medical Fee Schedule until October 1, 2020 for the Auto No-Fault Program. Therefore, you will need to keep the WC fee schedule that was effective on June 1, 2012 for billing claims for the treatment of persons injured as the result of auto accidents.
Public comment should sent to Camielle.Barclay@dfs.ny.gov before April 22, 2019.
The Centers for Medicare & Medicaid Services (CMS) is currently updating the Promoting Interoperability Programs website to include new resources for the 2019 program year. Below are resources that are now available online: