Monthly series covering key subjects regarding healthcare business in the USA. This seminar covers: Affordable Care Act section 1557, HIPAA Security, Medicare Payment models and Chronic conditions.

1. HEALTHCARE UNPLUG
Taino Consultants Inc.
Dr. Jose I. Delgado

2. TOPICS
Affordable Care Act (ACA)
Medicare Access and CHIP
Reauthorization Act (MACRA)

3. AFFORDABLE CARE ACT (ACA)
 Section 1557
 Summary
 Required Actions
 Health Insurance
 Increases
 Expected Behavior
 Alternatives

4. MACRA
 Alternative Payment System
 Categories
 Compliance
 Security Risk Assessments
 Chronic Conditions
 Diabetic Care
 Weight Loss
 ICD 10

5. ACA SECTION 1557
 Prohibits discrimination in health care
activities
 Race
 Color
 National origin
 Age
 Disability, and
 Sex

6. ACA SECTION 1557 - APPLICABILITY
 Covered Entities
 “every health program or activity, any part of which
receives Federal financial assistance or made
available by”
 Example: Health care providers, such as physicians’
practices, hospitals, community health centers,
nursing facilities, home health agencies, clinical
laboratories, residential or community-based
treatment facilities, intermediate care facilities for
people with intellectual/developmental disabilities,
hospices, and organ procurement centers

7. ACA SECTION 1557 – DECISION TREE
Medicaid
Provider
Medicare
Provider
Receive
HHS $$
Receive
HIT
Funds
Covered
Entity
Doesn’t
Apply

8. ACA SECTION 1557 - ACTIONS
 Immediate
 Develop and implement an effective written
language access plan.
 Provide free, accurate, and timely language
assistance services for individuals with Limited
English Proficiency (LEP).
 Post a notice regarding non-discrimination policies.
 Provide non-discrimination notice in English and
include taglines in the top 15 languages spoken by
individuals with LEP within the state.
 If less than 15 employees just the top 2 languages other
than English

9. ACA SECTION 1557 – TAG LINE
 English
 [Name of covered entity] complies with applicable Federal civil
rights laws and does not discriminate on the basis of race,
color, national origin, age, disability, or sex.
 Spanish (Español)
 [Name of coveredentity] cumple con las leyes federales de
derechos civiles aplicables y no discrimina por motivos de
raza, color, nacionalidad, edad, discapacidad o sexo.
 French Creole (Haitian Creole)
 [Name of covered entity] konfòmaklwasoudwasivil Federal
kiaplikabyo e li pa fèdiskriminasyonsoubazras, koulè,
peyiorijin, laj, enfimiteoswasèks.

10. ACA HEALTH INSURANCE
 Average increase is 25 percent
 Carriers pulling out of the market
 1.4 million people will be lose their plan

11. ACA HEALTH INSURANCE
 Risk Corridor completely ineffective
 Insurers requested $2.87 billion
 Government paid $362 million
 17 of 23 approved healthcare cooperatives
folded
 3 of the 5 largest insurers have decided to
significantly pull back
 United, Aetna and Humana

12. ACA HEALTH INSURANCE – EXPECTED BEHAVIOR
 Consumers picking higher deductible plans
or no plans
 Employees moving to jobs with health
insurance coverage
 Narrow Networks

13. ACA HEALTH INSURANCE - ALTERNATIVES
 Increase outreach for self paying customers
 Create and nurture networks
 Be creative with benefit plans
 Life Insurance
 Long Term Care

14. MACRA
 Merit Based Incentive Payment System
(MIPS)
 Modified fee-for-service model
 Expected Model for Majority
 Alternative Payment System (APM)

15. MACRA – MIPS COMPONENTS
Quality RepAlternative
Payment System
(APM)orting (PQRS)
Resource Use or Cost
(Value-based Modifier)
Advancing Care
Information (MU)
Clinical practice
improvement activities
MIPS

16. MACRA – CHRONIC CONDITIONS
 Diabetic Care
 Identify Patients
 Annual Requirements
 Education
 Vision
 Foot Care
 Nutrition
 Weight Loss
 Documentation

17. MACRA - QUALITY REPORTING BASICS
• 50% in of total MIPS score in 2019, phases down to 30% in 2022
• Full-year reporting period
MIPS weight
• 6 measures required out of 200 available, reported by physicians
• Include one cross-cutting measure, one outcome measure (if outcome
measure not available, substitute with choice of another “high priority”
measure)
• 3 population health measures from former VBM calculated by CMS
administratively via claims (groups of 10 or more only)
Measures
• Each measure worth up to 10 points
• 90 total points for groups >10
• 80 total points for smaller groups (all-cause hospital readmission measure not
applied)
• Distribution of points for each measure based on performance benchmarks
(80% for claims reporting, 90% for registry reporting)
Scoring
• Up to 4 bonus points may be added for reporting on outcome and high priority
measures
• 1 bonus point possible for each measure captured and reported through
CEHRT
• Total bonus points capped at 5% of those used to calculate the quality score
Bonus points

18. MACRA - COMPLIANCE (MEANINGFUL USE)
 50 point base score threshold still 100%
 Security attestation required
 Measures reduced
 Exclusions eliminated
 Full year reporting

19. MACRA - TIMELINE
19
201
6
201
7
201
8
201
9
202
0
202
1
202
2
202
3
202
4
20
25
20
26
on
Fee
Schedu
le
Update
s
MIPS
QPs in
Adv.
APMs
0.5% annual baseline updates No annual baseline updates
4% 5% 7% 9%
Max Adjustment
(additional bonuses
possible)
0.25%
or
0.75%
9% 9% 9%
5% bonus

20. MACRA – ICD 10

21. MACRA - ICD 10
 October 1st Significance
 Trends
 Recommendations

22. SUMMARY
Affordable Care Act (ACA)
Medicare Access and CHIP
Reauthorization Act (MACRA)

23. RESOURCES
 Taino Consultants Inc.
 www.tainoconsultants.com
 Drdelgado@tainoconsultants.com
 Diabetic Centers for excellence
 Lavern Dowell
 People Helping People
 josedelgado@tainoconsultants.com
 Stat Medical
 Telephone 904-824-4990
 www.statmos.com
 Vassallo Health Center
 Telephone 904-797-7722