Exchange Open Enrollment Continues Through February 15, 2015

January 7, 2015

Exchange Open Enrollment Continues Through February 15, 2015

The Exchange is currently enrolling people for subsidized commercial insurance through February 15, 2015, through the Washington Healthplanfinder. Enrollment in Apple Health (Medicaid) is not subject to the open enrollment period, and eligible recipients can be enrolled at any time. WSHA urges hospitals to continue their outstanding efforts to enroll people in these coverage opportunities. (Barbara Gorham,

HCA Seeks Health System Applicants for State Employee Accountable Care Program

The Washington State Health Care Authority (HCA) released a Request For Application for clinically integrated health care health provider entities or groups of partners to participate in an Accountable Care Program option for Public Employee Benefits Board enrollees. HCA plans to make the program available effective January 1, 2016, to enrollees in contiguous counties, with preference for King, Snohomish, Skagit, Pierce and Thurston Counties. HCA hopes to expand the program to additional counties in future years. Successful entities will need to agree to financial and quality performance incentives and disincentives, implementing effective care delivery models and aligning health system reimbursement and financial incentives. The program marks an effort by the state as a health care purchaser to be a prime mover in influencing the delivery and payment of health care.
Applications are due to HCA no later than 2:00 p.m. January 27, 2015. (Andrew Busz, 

IRS Publishes Final “Section 501(r)” Regulations for Tax-Exempt Hospitals

On December 29, 2014, the Internal Revenue Service and Department of Treasury issued final regulations implementing requirements for 501(c)(3) tax-exempt hospitals under the Affordable Care Act. As a condition of their tax-exempt status under 501(c)(3), hospitals are required to take an active role to improve the health of their communities and provide eligible patients with financial assistance. The final regulations largely adopt previously proposed regulations, but include changes in the areas of collections practices, amounts generally billed to qualifying patients, and hospital community health needs assessment strategies. WSHA will soon provide further guidance and detail on these important regulations. (Zosia Stanley,

CMS Announces Changes for RAC Program

Last week, the Centers for Medicare & Medicaid Services (CMS) announced changes to its Recovery Audit Contractor (RAC) program, which will apply as new RAC contracts are signed. CMS believes the changes will reduce the risk and burden to hospitals and providers going forward, and provide a greater level of accountability for RACs. These are changes the American Hospital Association, WSHA and hospitals, and providers have sought for several years. Unfortunately, the changes will not address issues related to prior periods, in particular the current backlog of appealed claims. Changes to the program include:

  • RACs will be limited to a six-month look-back period for patient status reviews, provided the hospitals bills within three months of the date of service. Currently RACs have a three-year look-back period and can deny inpatient claims well after a hospital’s window to re-bill services as an outpatient claim expires.
  • CMS will establish hospital-specific additional documentation request limits based on the hospital’s denial rates. Hospitals with low denial rates will see reductions in the amount of requests the RACs can make.
  • RACs will be required to maintain certain performance standards or be faced with reductions in the amount of their documentation requests. 
  • Going forward, RACs will not receive a contingency fee on appealed claims until the second level of appeals has been exhausted. Currently, the RACs receive their fee upon recoupment by the Medicare administrative contractor, even if the denial is being appealed.  

It is unclear how quickly renewal of contracts with the RACs will be finalized as protests by some of the RAC firms will extend into summer 2015. In the meantime, CMS has extended the existing RAC contracts. (Andrew Busz, 

CMS Releases Proposed Changes to ACO Risk-Sharing – Comments Solicited

On December 8, 2014, the Centers for Medicare & Medicaid Services (CMS) published, in a proposed rule, changes to the Medicare Shared Savings Program (MSSP) for accountable care organizations (ACOs). The proposed changes are intended to encourage participation in the program. Hospitals and systems considering participation should review the proposed changes, which include:

  • Track 1 ACOs, which share in savings but not losses, may re-enroll in Track 1 for a second three-year agreement period but at a lower potential sharing rate.
  • Modifying the savings and loss thresholds under Track 2 to allow greater savings or losses before risk sharing occurs.
  • Creating a new Track 3, a two-sided risk model with expanded upside and downside risk for the ACO. Unlike the other tracks, CMS would prospectively assign to Track 3 ACOs a specific and stable set of Medicare beneficiaries.
  • Changes to the ACO attribution method and the amount of data available to ACOs on their prospectively assigned beneficiaries.

Entities that are considering MSSP participation may comment electronically at by 5:00 p.m. February 6, 2015. (Andrew Busz,


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