Medicare Administrative Contracting

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Medicare Administrative Contracting

• Bureau of Primary Health Care Grantee Meeting
• June 24, 2008
• Mark Zobel, CMS

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LEGACY ENVIRONMENT circa 2005 FISCAL
INTERMEDIARIES
Noridian (BCBS ND)
Anthem NH
Noridian (BCBS ND)
BCBS MT
Regence (OR)
Anthem ME
UGS
BCBS AL (Cahaba)
Empire
BCBS WY
AR BCBS
Highmark
BCBS TN (Riverbend)
BCBS NE
UGS
Anthem/ AdminaStar
Empire
UGS
BCBS KS
CareFirst
BCBS SC (Palmetto)
BCBS TN (Riverbend)
BCBS AZ
AR BCBS
BCBS AL (Cahaba)
BCBS MS
BCBS GA
TrailBlazer
BCBS FL (FIRST COAST)
Noridian (BCBS ND)
Guam
Group Health (BCBS OK)
Cooperativa
UGS
Hawaii
Puerto Rico and Virgin Islands
Mutual of Omaha serves as a Fiscal Intermediary
to providers in all states except NY and PR.
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LEGACY ENVIRONMENT circa 2005 CARRIERS
Noridian (BCBS ND)
Noridian (BCBS ND)
Empire
BCBS MT
NHIC
WPS
HealthNow
CIGNA
BS WNY
AR BCBS
Highmark
BCBS FL (First Coast)
BCBS KS
Regence (UT)
Palmetto
Noridian (BCBS ND)
GHI
NHIC
TrailBlazer
Anthem/ AdminaStar
Noridian (BCBS ND)
CIGNA
AR BCBS
AR BCBS
BCBS AL (Cahaba)
BCBS SC (Palmetto)
TrailBlazer
BCBS FL (First Coast)
Noridian (BCBS ND)
Guam
Triple S, Inc.
Hawaii
Puerto Rico and Virgin Islands
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15 A/B MAC Jurisdictions
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Contracting Reform Schedule

• MAC Acquisition Plan
• Start-up Cycle
• 4 Durable Medical Equipment MACs
• 1 Part A/Part B MAC
• Cycle One
• 7 A/B MACs
• Cycle Two
• 7 A/B MACs
• Home Health/Hospice workload

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Start-Up Cycle - DME MAC Awards

• Durable Medical Equipment (DME) MAC awards
• Jurisdiction A National Heritage Insurance
  Company
• Jurisdiction B AdminaStar Federal, Inc.
• Jurisdiction C CIGNA
• Protest
• Jurisdiction D Noridian
• Awards January 2006
• Implementation Complete June 2007

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Start-Up Cycle (continued)

• First A/B MAC award
• Jurisdiction 3 A/B MAC award made July 31, 2006
  to Noridian
• Fully implemented March 1, 2007
• Pilot FQHCs and RHCs located in Jurisdiction 3
  states moved to Jurisdiction 3 workload

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Cycle One 7 A/B MAC Acquisitions

• Two Requests for Proposal
• RFP 1 - September 29, 2006
• Jurisdiction 4 TrailBlazer August 2, 2007
• Jurisdiction 5 Wisconsin Physicians Service
  September 5, 2007
• Jurisdiction 12 Highmark October 24, 2007
• Protest

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Cycle One (continued)

• RFP 2 - December 15, 2006
• Jurisdiction 1- Palmetto October 25, 2007
• Protest
• Jurisdiction 13 National Government Services
  March 18, 2008
• Jurisdiction 2 NHIC May 7, 2008
• Protest
• On track to award Jurisdiction 7 soon.

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A/B MAC Acquisition Cycle Two

• Two Requests for Proposal August 31, 2007
• RFP 1 includes J8, J9, J10
• RFP 2 includes J6, J11, J14 J15
• Each of these contracts will contain one home
  health hospice workload region
• Contract awards are anticipated
• September December 2008

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Where Will Grantees be Assigned in the MAC
Environment ?
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Provider Assignment Overview

• Provider Nomination Repealed
• Replaced with the Geographic Assignment Rule
• MMA 911, Dec. 8, 2003
• 42 CFR 421.404, Nov. 24, 2006
• CR 5979, Apr. 18, 2008

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Exceptions to the Geographic Assignment Rule

• HHH, DMEPOS, RRB, Specialty
• Demos
• Provider-based relationships
• Qualified Chain Providers
• a subset within the Medicare
• chain universe

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Sequence of Events for FQHCs

• Initial Enrollment
• Non-IHS, Non-Tribal
• Geographic Assignment
• IHS/Tribal
• Jurisdiction 4 MAC

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FQHCs (continued)

• Existing FQHC
• For now, stay in current assignment
• NGS Wisconsins workload will be absorbed by the
  Jurisdiction 6 MAC
• During the Out-of-Jurisdiction Provider
  Migration FQHCs will be moved to their
  destination MACs

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Out-of-Jurisdiction Provider Migration

• Two Prerequisite Events
• All 15 A/B MAC are awarded
• and implemented
• System compatibility
• Claims processing
• Provider enrollment
• Cost report audit/accounting

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FQHCs in the Settled MAC Environment
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Sequence of Events for RHCs

• Initial Enrollment Geographic Assignment
• Existing RHC
• For now, stay in current assignment
• Current FIs workload will be absorbed by the
  incoming MAC
• During the Out-of-Jurisdiction Provider
  Migration RHCs will be moved to their
  destination MACs

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RHCs in the Settled MAC Environment
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Moving Forward from Here

• Our primary objective is to ensure continuity in
  Medicare FFS operations
• Essential throughout the procurements and
  contract implementations
• We are adjusting our approaches based on lessons
  learned in each stage of this initiative
• Flexibility is key
• For instance, contract award protests are
  possible with each acquisition
• Can result in implementation delays

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Information and Comments

• Look for updates and additional information on
  Medicare Contracting Reform on the Medicare
  Contracting Reform Website
• www.cms.hhs.gov/medicarecontractingreform/
• Formal procurement documents are posted on the
  federal acquisitions website
• www.fedbizopps.gov
• Submit comments and questions to
  Section911_at_cms.hhs.gov