6 things doctors need to know about the MACRA final rule

By Todd Shryock, Medical Economics
October 14, 2016

The Centers for Medicare & Medicaid Services (CMS) released its final rule for the Medicare Access and CHIP Reauthorization Act (MACRA) on October 14. Here’s what physicians need to know…

6. Who has to participate in MACRA? If you bill Medicare more than $30,000 annually or provide care for more than 100 Medicare patients each year, you are affected by MACRA. If you do not meet those benchmarks, you are exempt from its requirements.

5. When does MACRA take effect? The program begins Jan. 1, 2017, but if you are not ready by then, you can choose to start collecting performance data as late as Oct. 2, 2017. Whenever you start, performance data is due by March 31, 2018.

4. Why are there different starting dates? To make it easier for practices to comply with MACRA, CMS created four options, each with its own requirements.

  • Option 1: Test the quality payment program. As long as you submit some data—for example, one quality measure or one improvement activity—you can avoid a downward payment adjustment. You need to start collecting data no later than Oct. 2, 2017.
  • Option 2: Participate for part of the year. If you submit 90 days of 2017 data to Medicare, you may earn a neutral or small payment adjustment. You must start no later than Oct. 2, 2017.
  • Option 3: Participate for the full year. If you submit a full year of 2017 data to Medicare, you may earn a moderate positive payment adjustment. You must start collecting data Jan. 1, 2017.
  • Option 4: Participate in an Advanced Alternative Payment Models in 2017. Instead of reporting quality data and other information, the law allows physicians to join an Advanced Alternative Payment Model, such as a Medical Home Model. This can result in a 5% incentive payment in 2019.

Regardless of which option you choose, to earn the possible positive payment adjustment that starts Jan. 1, 2019, all 2017 data must be submitted by March 31, 2018.

3. What happens if I ignore MACRA? If you don’t send in any data, you will receive a negative 4% payment adjustment in 2019. This penalty increases each year thereafter: 5% in 2020, 7% in 2021 and 9% in 2022.

2. Is this the last of the changes to MACRA? No. CMS indicated it will continue to listen to feedback and adjust rules as necessary and is already working on additional APM options to get more physicians involved.

1.  Is there any help available to help me with implementation? The Transforming Clinical Practices Initiative (TCPI) program offers assistance to transform your practice. Clink on the following link to find organizations in your area that can help: http://www.healthcarecommunities.org/CommunityNews/TCPI/PTNMap.aspx


Message From The PDA Benefits Desk

Some small companies driven by a tightening labor market and rising costs and fewer choices for individual coverage are reversing the practice of providing no health insurance. Workers are looking for healthcare. Job candidates are seeking employment that offers health benefits. That fact is also driven by major carriers ceasing to offer individual coverage. Individual policies seemed like a good option when the Affordable Care Act took effect. But, group plans have more value now.

Unlike large employers, small businesses –those with the equivalent of fewer than 50 full-time employees– aren’t required to offer health benefits under the ACA. Many do so anyway to remain competitive in the job market or because they think it’s the right thing to do.

The world for small businesses is quite dynamic. Companies in the current small group market are also accepting that benefit plan financial contribution is a creative variable. For example, 50 percent of premium cost can be a positive position for a less-than-50 full-time employee group. Also, the small group self-insured market, when joined with wellness and population health services, is an attractive cost-benefit option.

Questions about the merits of individual-versus-group coverage are intensifying as changes continue to roil the insurance market.  There are two sides to this issue. Agencies that work with small businesses across the country say most small businesses making changes continue to shift to individual coverage because their workers are eligible for significant government subsidies. But the trajectory of that is slowing, as there is a reverse migration back from individual to group.

Timely Statistics and Facts

Conflicting forces are buffeting small companies. Transitional rules that allowed certain companies to continue offering existing plans that don’t meet certain ACA requirements expire at the end of 2017. In North Carolina, some companies could face cost increases of as much as 40 percent for ACA-compliant plans.

At the same time, prices for individual coverage are climbing and insurance companies are dropping out of the state and federal marketplaces that sell individual coverage. Last week, Aetna Inc. said it would withdraw from 11 of the 15 state exchanges on which it currently offers coverage, making it the latest major insurer to pull back from that business. Estimates of how many small businesses offer group coverage vary. 54 percent of companies with three to 49 workers offered health benefits last year, about the same as in 2014 but down from 66 percent in 2000, according to a 2015 Kaiser Family Foundation survey.

Companies with three to 50 employees paid an average of $15,602 annually for each worker who elects family coverage, according to Kaiser, up from an average of $12,809 in 2010. Government subsidies can make individual coverage attractive to small firms employing workers earning as much as four times the poverty rate. For 2016, the ceiling generally was $97,200 for a family of four. Employers, however, generally can deduct the cost of group healthcare premiums.

Before the ACA, insurers often denied coverage to individuals with existing conditions; one reason costs were often higher for small groups. But the price gap has narrowed significantly. Individual coverage, meanwhile, has grown less attractive as insurers narrow options for physicians, hospitals and prescription drugs in an effort to cut costs.  There are also a lot of bad surprises, like showing up at a hospital with a doctor and being out of network. Finding affordable coverage is hard. The Broker/Agent is an invaluable asset, if educated with facts and aggressive in working with the market.

Sources: Wall Street Journal, CNBC and other wire reports.