Nebraska Medicaid Electronic Health Record (EHR) Incentive Program

1. Nebraska Medicaid Electronic Health Record (EHR) Incentive Program Sarah Briggs Administrator, Medicaid IT Initiatives Division of Medicaid & Long-Term Care

2. Topics • Overview of the Program • Legislation • Medicare/Medicaid comparison • Eligibility • Payments • Program requirements • Patient Volume • Enrollment Process • (Meaningful Use) • Next Steps and Contact Information

3. Medicaid Electronic Health Record (EHR) Incentive Payment Program Background • Section 4201 of the American Recovery and Reinvestment Act of 2009 (ARRA) authorized funding for Medicaid programs to run incentive payment programs for the adoption and meaningful use of health information technology (HIT). • Planning, implementation, and operation of the Electronic Health Record (EHR) incentive program is funded 90% by the federal government, 10% by state general funds.

4. Medicaid EHR Incentive Payment Program Background • Incentive payments to providers who participate in the program will be funded 100% by the federal government. • The final rule governing the EHR incentive program was published to the Federal Register July 28, 2010, with a clarifying amendment added December 28, 2010. http://www.gpo.gov/fdsys/pkg/FR-2010-07-28/pdf/2010-17207.pdf http://www.gpo.gov/fdsys/pkg/FR-2010-12-29/pdf/2010-32861.pdf

5. Medicaid EHR Incentive Program Overview • The purpose of the incentive program is to encourage eligible Medicaid providers to adopt and subsequently meaningfully use certified EHR technology. • Incentive payments are NOT intended to cover all of the costs involved in EHR adoption and implementation, and practice re-organization. • The incentive payment is issued after a provider demonstrates program compliance.

6. Medicaid EHR Incentive Program Overview • The incentive payment program runs from 2011 through 2021. • Program participation for Nebraska’s program can start on May 7, 2012, or as late as 2016. • For any given provider, payments may be made for no more than 6 years. • Payments are not required to be consecutive years prior to 2016.

7. EHR Incentive Payment Program– Notable Differences between Medicare and Medicaid Programs

8. Medicaid EHR Incentive Program Eligibility

9. Medicaid EHR Incentive Program Eligibility – Patient Volume Calculation Total Medicaid (or Needy Individual, if an FQHC/RHC) patient encounters in any 90-day period (for EPs-in the preceding calendar year, for EHs in the preceding Federal Fiscal Year) Total patient encounters in same 90-day period X 100

10. Medicaid EHR Incentive Program Payment Overview – EPs

11. Medicaid EHR Incentive Program Payment Overview – Eligible Hospitals • Total incentive payment amount is a one time calculation: • Based on cost report data from the current and 3 previous years. • Medicaid percentage of patients • Calculated for each CCN regardless of the number of campuses. • Payout of the total incentive payment amount will be: • Year 1 – 50% of the total amount • Year 2 – 40% of the total amount • Year 3 – 10% of the total amount • Note: Years do not have to be consecutive. • Base amount is $2 Million which can be adjusted up or down

12. Payments for EHs are based on Medicare Cost Reports

13. Medicaid EHR Incentive Program Payment Overview – Eligible Hospitals • The hospital fiscal year which ended in the Federal Fiscal Year preceding the Payment Year is considered the base year in the payment calculation. • A Payment Year is the year for which payment is requested. Individual providers have 60 days after the end of the calendar year to apply for a payment for the previous year. For example, to request a payment for Payment Year 2012, Registration and Attestation must occur before February 28, 2013. Hospitals have 60 days after the end of the Federal Fiscal Year which ends September 30.

14. Medicaid EHR Incentive Program Payment Overview – Eligible Hospitals • https://www.cms.gov/MLNProducts/downloads/Medicaid_Hosp_Incentive_Payments_Tip_Sheets.pdf CMS tip sheet on Hospital Payment Calculation:

15. USE THE PAYMENT CALCULATION TOOL ON OUR WEBSITE TO CALCULATE THE AMOUNT OF THE PAYMENT Medicaid EHR Incentive Program Payment Overview – Eligible Hospitals

17. Total Charity Charges need to be calculated from the amount of uncompensated charges minus the bad debt.

18. Medicaid EHR Incentive Program Requirements • Key points: • Must be in the list of eligible professionals or eligible hospital types • Must meet the minimum Medicaid patient volume specified in the table • Must adopt, implement or upgrade to a certified EHR system or demonstrate meaningful use • Clinics cannot receive a payment unless it is voluntarily assigned to them by the individual provider • An individual provider can only receive one payment per *Payment Year • *A Payment Year is the year for which payment is requested. Individual providers have 60 days after the end of the calendar year to apply for a payment for the previous year. For example, to request a payment for Payment Year 2012, Registration and Attestation must occur before February 28, 2013. Hospitals have 60 days after the end of the Federal Fiscal Year which ends September 30.

19. Medicaid EHR Incentive Program Requirements • In order to receive incentive payments, EPs and EHs must: • First year • Adopt, implement, or upgrade a certified EHR • Subsequent years • Achieve and demonstrate ‘meaningful use’ (MU) • MU criteria defined in final rule • Meeting MU criteria is graduated and increasingly more challenging over the course of the incentive program.

20. Patient volume How do I count them and who gets counted?

21. For Eligible Providers • For Nebraska’s program, we are allowing the following to be included in the patient volume: • A claim where Medicaid paid an amount greater than zero. This can be for any type of service (lab work, immunization, office visit, nursing home visit, ER visit, etc.) • For any one provider, only one visit per day per patient can be counted. For example if the same physician saw a patient for an office visit and also gave an allergy shot on that same day, this is considered one encounter. If the patient came in on Monday for an office visit and then back on Tuesday for an allergy shot, this is two encounters. • Only Medicaid payments paid through funding under Title XIX of the Social Security Act can be included in the encounters. Medicaid payments for the Kids Connection program, state-only funded programs and Federal grant-funded programs cannot be included. Since Nebraska pays all of these under the Medicaid program and there is no distinction of the funding source on the Medicaid card or claim, DHHS will need to help separate these. • Both Medicaid as primary and secondary insurer can be counted toward the encounters; however, if Medicaid is secondary and the primary insurance paid more than the Medicaid allowable share (so Medicaid paid zero), then it would not be counted as an encounter.

22. Patient Volume at the Clinic/Practice Level PATIENT VOLUME CAN ALSO BE DETERMINED AS A GROUP AT THE CLINIC/PRACTICE LEVEL AS LONG AS: • The group practice/clinic patient volume is appropriate as a patient volume methodology calculation for the EP (for example, if an EP only sees Medicare, commercial or self-pay patients, this is not an appropriate calculation). • There is an auditable data source to support the group practice/clinic patient volume determination. • All EPs in the group practice/clinic must use the same methodology for the payment year. If one uses clinic volume, then all providers in that clinic must use clinic patient volume. • The group practice/clinic uses the entire practice or clinic’s patient volume and does not limit patient volume in any way. • If an EP works inside and outside of the clinic or practice, then the patient volume calculation includes only those encounters associated with the clinic or group practice.

23. Group Patient VolumeEXAMPLE CLINIC A • EP #1 (physician): individually had 40% Medicaid encounters (80/200 encounters) • EP# 2 (nurse practitioner): individually had 50% Medicaid encounters (50/100 encounters) • Practitioner at the clinic, but not an EP (registered nurse): individually had 75% Medicaid encounters (150/200) • Practitioner at the clinic, but not an EP (pharmacist): individually had 80% Medicaid encounters (80/100) • EP #3 (physician): individually had 10% Medicaid encounters (30/300) • EP #4 (dentist): individually had 5% Medicaid encounters (5/100) • EP #5 (dentist): individually had 10% Medicaid encounters (20/200) In this scenario, there are 1200 encounters in the selected 90-day period for Clinic A. There are 415 encounters attributable to Medicaid, which is 35% of the clinic’s volume. This means that 5 of the 7 professionals would meet the Medicaid patient volume criteria under the rules for the EHR Incentive Program. (Two of the professionals are not eligible for the program on their own, but their clinical encounters at Clinic A should be included.)

24. Group Patient VolumeEXAMPLE-CONTINUED CLINIC A • EP #1 (physician): individually had 40% Medicaid encounters (80/200 encounters) • EP# 2 (nurse practitioner): individually had 50% Medicaid encounters (50/100 encounters) • Practitioner at the clinic, but not an EP (registered nurse): individually had 75% Medicaid encounters (150/200) • Practitioner at the clinic, but not an EP (pharmacist): individually had 80% Medicaid encounters (80/100) • EP #3 (physician): individually had 10% Medicaid encounters (30/300) • EP #4 (dentist): individually had 5% Medicaid encounters (5/100) • EP #5 (dentist): individually had 10% Medicaid encounters (20/200) If EP #2 is practicing part-time at both Clinic A, and another clinic, Clinic B, and both Clinics are using the clinic-level option, each clinic would use the encounters associated with the respective clinics when developing a proxy value for the entire clinic. EP #2 could then apply for an incentive using data from one clinic or the other. Similarly, if EP #4 is practicing both at Clinic A, and has her own practice, EP # 4 could choose to use the proxy-level Clinic A patient volume data, or the patient volume associated with her individual practice. She could not, however, include the Clinic A patient encounters in determining her individual practice’s Medicaid patient volume. In addition, her Clinic A patient encounters would be included in determining such clinic’s overall Medicaid patient volume.

25. Patient Volume For Eligible Hospitals • Count inpatient discharges where Medicaid paid something on the service (Medicaid paid amount is greater than zero) • Count emergency room visits where the revenue code is 450-459 and Medicaid paid something on the bill. If the same patient was treated in the emergency room more than once on a given day, only count as one encounter. • Only Medicaid payments paid through funding with Title XIX of the Social Security Act can be included in the encounters. Medicaid payments for the Kids Connection program, state-only funded programs and Federal grant-funded programs cannot be included. Since Nebraska pays all of these under the Medicaid program and there is no distinction of the funding source on the Medicaid card, DHHS will need to help separate these. • Include managed care encounters • Include things like nursery bed days, psychiatric care, regular inpatient care, etc. • If your organization has more than one hospital, patient volume is considered by the NPI# regardless of the number of campuses/facilities

26. Eligible Providers in FQHC/RHC Settings • If you have practiced more than 50% of your time in an FQHC or RHC for at least six months in the year prior to the Payment Year, you can also claim needy patient volume in addition to the Medicaid patient volume. • Needy patients include all Medicaid (both Title XIX funded and funded from other sources), patients whom services were furnished at no cost and services paid for at a reduced cost based on a sliding scale determined by the individual’s ability to pay.

27. Medicaid EHR Incentive Program Oversight • The Medicaid agency is also tasked with oversight responsibilities for the incentive program, including: • Ensuring that there is no duplication of Medicare and Medicaid incentive payments to EPs. • Ensuring timely and accurate payments and that payments do not exceed allowable amounts. • Ensuring the integrity of the program through audit processes. • Developing and implementing appeal processes for the program.

28. Registration and Enrollment

29. Medicaid EHR Incentive Program Enrollment Process

30. Medicaid EHR Incentive Program Steps to Payment

31. Registration The first step in the process is to register with CMS. Registration cannot occur until on or after our launch date of May 7, 2012. There is a CMS user guide to help you with the registration process. This is the link for CMS’ registration page, which contains guides for EPs and EHs: https://www.cms.gov/EHRIncentivePrograms/20_RegistrationandAttestation.asp#TopOfPage

32. Enrollment After registering with CMS, wait 24 hours for the information to be electronically sent to Nebraska DHHS from CMS, then complete the enrollment form with DHHS. The enrollment form can be obtained from our website http://dhhs.ne.gov/medicaid/Pages/med_ehr.aspx. Registration is at the Federal (CMS) level, Enrollment is at the State Medicaid (DHHS) level

36. Accompanying Documentation • System generated report from the software system from which the patient volume calculations were made • Proof of A/I/U. An eligible professional working at an Indian Health Services (IHS) clinic will need to submit the official vendor letter issued from the U.S. Department of Health and Human Services containing information about the clinic’s electronic health record • For EPs, Methodology of how group Medicaid patient volume was calculated (NPI# of group, TIN of group, any other method used to define your group) • For EHs, break down of the uncompensated care amount from the Medicare Cost Report (amount that is charity care and amount that is bad debt)

37. When Will I Receive Payment? Payment will be made within 30 days from the date eligibility is determined.

38. Meaningful Use

39. What is meaningful use? • The Recovery Act requires that the definition of meaningful use include three specific elements: • Using a certified EHR in a meaningful manner (e.g. – e-prescribing) • The use of certified EHR technology for electronic exchange of health information to improve quality of health care • The use of certified EHR technology to submit clinical quality and other measures. • CMS was responsible for defining meaningful use as it applies to the EHR incentive programs • CMS solicited and received significant public comment as part of the meaningful use rulemaking

40. Achievement of Meaningful Use • Standard has both “core” and “menu” objectives with associated measures • EP or EH must meet the measures for every objective in the “core set” (15 objectives for EP; 14 for EH) • EP or EH must meet the measures for five of the 10 “menu” objectives (10 “menu” objectives for EP; 10 for EH) • EP or EH must choose at least one of the population and public health measures to demonstrate as part of the “menu” set • Not all MU objectives are applicable to all providers. These objectives are excluded from the “core” set for affected providers.

41. Achievement of Meaningful Use Core Set Measures

42. Achievement of Meaningful Use Menu Set Measures

43. Meaningful Use Stage 2 – Notice of Proposed Rule-Making http://www.healthit.gov/providers-professionals/video/meaningful-use-stage-2-nprm-overview New proposed rules from CMS and ONC announced February 24, 2012. Public comment on these is accepted for 60 days from publication in the federal register.

44. Medicaid EHR Incentive Program Information – How to Learn More • Subscribe to the EHR webpage to receive notification of every update www.hhs.state.ne.us/med/EHR.htm • Send questions to the EHR Incentive Program mailbox: DHHS.EHRIncentives@Nebraska.gov • See the Frequently Asked Questions document on the CMS webpage http://www.cms.gov/EHRIncentivePrograms/ or on the DHHS web page

45. We want to talk with you: LaRue Cole larue.cole@nebraska.gov Karen Cheloha karen.cheloha@nebraska.gov