Webinar: Avoiding Lost Revenue and Penalties by Ensuring Full Compliance with Hospital Price Transparency

Date: December 8, 2020

Time: 2:00 PM CT


Per a recent ruling, as of January 1, 2021, every hospital must make viewable in a searchable, machine-readable format, 300 “standard charges for all items and services” for their patient consumers. If not in compliance, you could be facing:

  • A monetary penalty of $300 a day per facility.
  • Potential denial of Medicare Payments.
  • Possible damage to reputation by being listed publicly, as con-compliant by CMS.
  • Losing business to competitor hospitals that have complied with the mandate.

This session will explain the details of the current rules and offer easily implementable strategies and tactics to make sure that your organization is in compliance. Specifically, we will examine:

  • The Regulatory Law – What is it, what is required for compliance, what is the consequence of non-compliance?
  • How will this impact your hospital’s relationship with the community you serve?
  • Financial impact to your organization.

Permanent Expansion of Medicare Telehealth Services and Improved Payment for Time Doctors Spend with Patients

On December 1, the Centers for Medicare and Medicaid Services (CMS) released the annual Physician Fee Schedule (PFS) final rule, prioritizing CMS’ investment in primary care and chronic disease management by increasing payments to physicians and other practitioners for the additional time they spend with patients, especially those with chronic conditions. The rule allows non-physician practitioners to provide the care they were trained and licensed to give, cutting red tape so health care professionals can practice at the top of their license and spend more time with patients instead of on unnecessary paperwork. This final rule takes steps to further implement President Trump’s Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors including prioritizing the expansion of proven alternatives like telehealth.

“During the COVID-19 pandemic, actions by the Trump Administration have unleashed an explosion in telehealth innovation, and we’re now moving to make many of these changes permanent,” said HHS Secretary Alex Azar. “Medicare beneficiaries will now be able to receive dozens of new services via telehealth, and we’ll keep exploring ways to deliver Americans access to health care in the setting that they and their doctor decide makes sense for them.”

“Telehealth has long been a priority for the Trump Administration, which is why we started paying for short virtual visits in rural areas long before the pandemic struck,” said CMS Administrator Seema Verma. “But the pandemic accentuated just how transformative it could be, and several months in, it’s clear that the health care system has adapted seamlessly to a historic telehealth expansion that inaugurates a new era in health care delivery.”

Finalizing Telehealth Expansion and Improving Rural Health

Before the COVID-19 Public Health Emergency (PHE), only 15,000 Fee-for-Service beneficiaries each week received a Medicare telemedicine service. Since the beginning of the PHE, CMS has added 144 telehealth services, such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services, that are covered by Medicare through the end of the PHE. These services were added to allow for safe access to important health care services during the PHE. As a result, preliminary data show that between mid-March and mid-October 2020, over 24.5 million out of 63 million beneficiaries and enrollees have received a Medicare telemedicine service during the PHE.

This final rule delivers on the President’s recent Executive Order on Improving Rural Health and Telehealth Access by adding more than 60 services to the Medicare telehealth list that will continue to be covered beyond the end of the PHE, and we will continue to gather more data and evaluate whether more services should be added in the future. These additions allow beneficiaries in rural areas who are in a medical facility (like a nursing home) to continue to have access to telehealth services such as certain types of emergency department visits, therapy services, and critical care services. Medicare does not have the statutory authority to pay for telehealth to beneficiaries outside of rural areas or, with certain exceptions, allow beneficiaries to receive telehealth in their home. However, this is an important step, and as a result, Medicare beneficiaries in rural areas will have more convenient access to health care.

Additionally, CMS is announcing a commissioned study of its telehealth flexibilities provided during the COVID-19 PHE. The study will explore new opportunities for services where telehealth and virtual care supervision, and remote monitoring can be used to more efficiently bring care to patients and to enhance program integrity, whether they are being treated in the hospital or at home.

Payment for Office/Outpatient Evaluation and Management (E/M) and Comparable Visits

Last year, CMS finalized a historic increase in payment rates for office/outpatient face-to-face E/M visits that goes into effect in 2021. The Medicare population is increasing, with over 10,000 beneficiaries joining the program every day. Along with this growth in enrollment is increasing complexity of beneficiary health care needs, with more than two-thirds of Medicare beneficiaries having two or more chronic conditions. Increasing the payment rate of E/M office visits recognizes this demand and ensures clinicians are paid appropriately for the time they spend on coordinating care for patients, especially those with chronic conditions. These payment increases, informed by recommendations from the American Medical Association (AMA), support clinicians who provide crucial care for patients with dementia or manage transitions between the hospital, nursing facilities, and home. 

Under this final rule, CMS continues to prioritize this investment in primary care and chronic disease management by similarly increasing the value of many services that are similar to E/M office visits, such as maternity care bundles, emergency department visits, end-stage renal disease capitated payment bundles, and physical and occupational therapy evaluation services. These adjustments ensure CMS is appropriately recognizing the kind of care where clinicians need to spend more face-to-face time with patients.

“This finalized policy marks the most significant updates to E/M codes in 30 years, reducing burden on doctors imposed by the coding system and rewarding time spent evaluating and managing their patients’ care,” Administrator Verma added. “In the past, the system has rewarded interventions and procedures over time spent with patients – time taken preventing disease and managing chronic illnesses.”

In addition to the increase in payment for E/M office visits, simplified coding and documentation changes for Medicare billing for these visits will go into effect beginning January 1, 2021. The changes modernize documentation and coding guidelines developed in the 1990s, and come after extensive stakeholder collaboration with the AMA and others. These changes will significantly reduce the burden of documentation for all clinicians, giving them greater discretion to choose the visit level based on either guidelines for medical decision-making (the process by which a clinician formulates a course of treatment based on a patient’s information, i.e., through performing a physical exam, reviewing history, conducting tests, etc.) or time dedicated with patients. These changes are expected to save clinicians 2.3 million hours per year in administrative burden so that clinicians can spend more time with their patients.

Professional Scope of Practice and Supervision

As part of the Patients Over Paperwork Initiative, the Trump Administration is cutting red tape so that health care professionals can practice at the top of their license and spend more time with patients instead of on unnecessary paperwork. The PFS final rule makes permanent several workforce flexibilities provided during the COVID-19 PHE that allow non-physician practitioners to provide the care they were trained and licensed to give, without imposing additional restrictions by the Medicare program.

Specifically, CMS is finalizing the following changes:

  • Certain non-physician practitioners, such as nurse practitioners and physician assistants, can supervise the performance of diagnostic tests within their scope of practice and state law, as they maintain required statutory relationships with supervising or collaborating physicians.
  • Physical and occupational therapists will be able to delegate “maintenance therapy” – the ongoing care after a therapy program is established – to a therapy assistant.
  • Physical and occupational therapists, speech-language pathologists, and other clinicians who directly bill Medicare can review and verify, rather than re-document, information already entered by other members of the clinical team into a patient’s medical record. As a result, practitioners have the flexibility to delegate certain types of care, reduce duplicative documentation, and supervise certain services they could not before, increasing access to care for Medicare beneficiaries.

For More Information:

CMS Announces Comprehensive Strategy to Enhance Hospital Capacity Amid COVID-19 Surge

November 25, 2020

The Centers for Medicare & Medicaid Services (CMS) outlined unprecedented comprehensive steps to increase the capacity of the American health care system to provide care to patients outside a traditional hospital setting amid a rising number of coronavirus disease 2019 (COVID-19) hospitalizations across the country. These flexibilities include allowances for safe hospital care for eligible patients in their homes and updated staffing flexibility designed to allow ambulatory surgical centers (ASCs) to provide greater inpatient care when needed. Building on CMS’s previous actions to expand the availability of telehealth across the nation, these actions are aimed at allowing health care services to be provided outside a hospital setting while maintaining capacity to continue critical non-COVID-19 care, allowing hospitals to focus on the increased need for care stemming from public health emergency (PHE).

“We’re at a new level of crisis response with COVID-19 and CMS is leveraging the latest innovations and technology to help health care systems that are facing significant challenges to increase their capacity to make sure patients get the care they need,” said CMS Administrator Seema Verma. “With new areas across the country experiencing significant challenges to the capacity of their health care systems, our job is to make sure that CMS regulations are not standing in the way of patient care for COVID-19 and beyond.”

Acute Hospital Care at Home

In March 2020, CMS announced the Hospitals Without Walls program, which provides broad regulatory flexibility that allowed hospitals to provide services in locations beyond their existing walls. CMS is expanding on this effort by executing an innovative Acute Hospital Care At Home program, providing eligible hospitals with unprecedented regulatory flexibilities to treat eligible patients in their homes. This program was developed to support models of at-home hospital care throughout the country that have seen prior success in several leading hospital institutions and networks, and reported in academic journals, including a major study funded by a Healthcare Innovation Award from the Center for Medicare and Medicaid Innovation (CMMI).

The program clearly differentiates the delivery of acute hospital care at home from more traditional home health services. While home health care provides important skilled nursing and other skilled care services, Acute Hospital Care at Home is for beneficiaries who require acute inpatient admission to a hospital and who require at least daily rounding by a physician and a medical team monitoring their care needs on an ongoing basis.

To support these efforts, CMS has launched an online portal https://qualitynet.cms.gov/acute-hospital-care-at-home to streamline the waiver request process and allow hospitals and healthcare systems to submit the necessary information to ensure they meet the program’s criteria to participate. CMS will also closely monitor the program to safeguard beneficiaries by requiring hospitals to report quality and safety data to CMS on a frequency that is based on their prior experience with the Hospital At Home model.

Ambulatory Surgical Center (ASC) Flexibility

As part of Hospital Without Walls, CMS also previously announced regulatory flexibility that allowed ASCs – facilities that normally provide same-day surgical care – the ability to be temporarily certified as hospitals and provide inpatient care for longer periods than normally allowed, with the appropriate staffing in place. ASCs are normally subject to a requirement that patients only remain in their care for less than 24 hours or require admission to a regular hospital.

CMS is announcing an update to that regulatory flexibility, clarifying that participating ASCs need only provide 24-hour nursing services when there is actually one or more patient receiving care onsite. The program change provides ASCs enrolled as hospitals the ability to flex up their staffing when needed and provide an important relief valve in communities experiencing hospital capacity constraints, while not mandating nurses be present when no patients are in the ASC. The flexibility is available to any of the 5,732 ASCs throughout the country seeking to participate and will be immediately effective for the 85 ASCs currently participating in the Hospital Without Walls initiative. CMS expects this flexibility will allow these and additional ASCs enrolled as hospitals to serve as an added access point that will allow communities to maintain surgical capacity and other life-saving non-COVID-19, like cancer surgeries. Allowing these types of treatments to occur in designated ASCs enrolled as hospitals while hospitals are managing any surges of COVID-19 would allow vulnerable patients to receive this needed care in settings without known COVID-19 cases.

The announcement builds upon the critical work by CMS to expand telehealth coverage to keep beneficiaries safe and prevent the spread of COVID-19. CMS has expanded the scope of Medicare telehealth to allow Medicare beneficiaries across the country to receive telehealth services from any location, including their homes. CMS also added over 135 services such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services, that could be paid when delivered by telehealth. The flexibilities announced today, and the aggressive action taken by CMS to remove barriers to telehealth, ensure patients and providers have options when receiving and providing care given the challenges and additional stress placed on hospitals and the health care system during the COVID-19 PHE.

To view the Acute Hospital Care At Home initiative and application, please visit: CMS’: https://qualitynet.cms.gov/acute-hospital-care-at-home  

For more on the ambulatory surgical center flexibilities, please see: https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/guidance-processing-attestation-statements-ambulatory-surgical-centers-ascs-temporarily-enrolling

To view comments from health systems participating in the Acute Hospital Care at Home, please visit: https://www.cms.gov/files/document/what-are-they-saying-hospital-capacity.pdf

Link to FAQs:


CMS Announces Historic Changes to Physician Self-Referral Regulations

November 22, 2020

The Centers for Medicare & Medicaid Services (CMS) finalized changes to outdated federal regulations that have burdened health care providers with added administrative costs and impeded the health care system’s move toward value-based reimbursement. The Physician Self-Referral Law, also known as the “Stark Law,” generally prohibits a physician from sending a patient for many types of services to a provider that the physician owns, is employed by, or otherwise receives payment from—regardless of what that payment is for.  The old federal regulations that interpret and implement this law were designed for a health care system that reimburses providers on a fee-for-service basis, where the financial incentives are to deliver more services. However, the 21st century American health care system is increasingly moving toward financial arrangements that reward providers who are successful at keeping patients healthy and out of the hospital, where payment is tied to value rather than volume.

Full press release

CMS Proposes to Allow APM Entities to Submit Applications for the Extreme and Uncontrollable Circumstances Exception; Applications are Due December 31

In the 2021 Medicare Physician Fee Schedule (PFS) Notice of Proposed Rulemaking (NPRM), the Centers for Medicare & Medicaid Services (CMS) proposed to allow APM Entities to submit an application to reweight Merit-based Incentive Payment System (MIPS) performance categories as a result of extreme and uncontrollable circumstances. We intend to allow APM Entities to submit applications now, but CMS will not be able to make final determinations on applications until and unless the policy proposal is finalized.

If the policy is finalized and an APM Entity’s application is approved, that APM Entity would receive a final score equal to the performance threshold for the 2020 MIPS performance year, and the MIPS eligible clinicians in the APM Entity group would receive a neutral payment adjustment in 2022.

Who is Eligible to Submit an Application?

If the policy is finalized, then APM Entities affected by extreme and uncontrollable circumstances in the following models would be able to submit an application:

  • Medicare Shared Saving Program
  • Next Generation ACO Model
  • Vermont Medicare ACO Model
  • Comprehensive Primary Care Plus (CPC+)
  • Comprehensive ESRD Care (CEC)
  • Bundled Payments for Care Improvement (BPCI)
  • Oncology Care Model (OCM)
  • Maryland Primary Care Program
  • Independence at Home Demonstration

What are the Application Requirements?

Unlike those who choose to apply as individual clinicians, groups, or virtual groups, APM Entities must apply to reweight all MIPS performance categories to 0%. Additionally, 75% of the MIPS eligible clinicians in the APM Entity must qualify for reweighting in the MIPS Promoting Interoperability performance category. They may qualify automatically or through a MIPS Promoting Interoperability Hardship Exception Application.

CMS does not require APM Entities to submit documentation with their applications. However, APM Entities should retain documentation of the circumstances supporting their application for their own records in the event they are selected by CMS for data validation or an audit.

When are Applications Due?

Applications are due to CMS by Thursday, December 31, 2020, at 8:00 p.m. ET.

How do I Apply?

New for 2020: You must have a HCQIS Access Roles and Profile (HARP) account to complete and submit an exception application. For more information on HARP accounts, please refer to the Register for a HARP Account document in the QPP Access User Guide.

Once you register for a HARP account, sign in to qpp.cms.gov, select ‘Exceptions Applications’ on the left-hand navigation, select ‘Add New Exception,’ and select ‘Extreme and Uncontrollable Circumstances Exception.’

How do I Know if I’m Approved?

If you submit an application and this policy is finalized to allow APM Entities to apply, then you will be notified by email if your request was approved or denied. If approved, this will also be added to your eligibility profile on the QPP Participation Status Tool, but it may not appear in the tool until the submission window is open in 2021.

Will Submitting Data Void the Exception?

Data submitted for an APM Entity will not override performance category reweighting from an approved application. This differs from the policy for individual, group, and virtual group applications.

Will an Approved Application Affect Model-Specific Reporting Requirements?

If the policy is finalized and an APM Entity’s application is approved, the approval would only affect MIPS reporting, and that APM Entity would still be required to meet its model-specific reporting requirements.

For More Information


Contact the Quality Payment Program at 1-866-288-8292 or by e-mail at: QPP@cms.hhs.gov. To receive assistance more quickly, please consider calling during non-peak hours—before 10:00 a.m. and after 2:00 p.m. ET.

Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.

2020 Extreme and Uncontrollable Circumstances Exception and Promoting Interoperability Hardship Exception Applications are Due December 31

Extreme and Uncontrollable Circumstances Application & COVID-19

The COVID-19 pandemic has impacted all clinicians across the United States and territories. However, CMS recognizes that not all practices have been impacted by COVID-19 to the same extent. For the 2020 performance year, CMS will be using our Extreme and Uncontrollable Circumstances policy to allow MIPS eligible clinicians, groups, and virtual groups to submit an application requesting reweighting of one or more MIPS performance categories to 0% due to the current COVID-19 public health emergency.

If you have any concerns about the effect of the COVID-19 pandemic on your performance data, including cost measures, for the 2020 performance period, submit an application now and be sure to cite COVID-19 as the reason for your application.

If you have an approved application, you can still receive scores for the quality, improvement activities and Promoting Interoperability performance categories if you submit data. If the cost performance category is included in your approved application, you will not be scored on cost measures even if other data are submitted.

Learn more in the 2020 Exceptions Applications Fact Sheet.

Note: CMS has proposed to allow APM Entities to submit an application to reweight MIPS performance categories as a result of extreme and uncontrollable circumstances, such as the public health emergency resulting from the COVID-19 pandemic. Learn more in the 2021 Quality Payment Program Proposed Rule Overview Fact Sheet.

MIPS Promoting Interoperability Hardship Exceptions

MIPS eligible clinicians, groups, and virtual groups may qualify for a re-weighting of the Promoting Interoperability performance category to 0% if they:

  • Are a small practice;
  • Have decertified EHR technology;
  • Have insufficient Internet connectivity;
  • Face extreme and uncontrollable circumstances such as disaster, practice closure, severe financial distress, or vendor issues; or
  • Lack control over the availability of CEHRT.

Note: If you’re already exempt from reporting Promoting Interoperability data, you don’t need to apply.

How do I Apply?

New for 2020: You must have a HCQIS Access Roles and Profile (HARP) account to complete and submit an exception application on behalf of yourself, or another MIPS eligible clinician, group ,virtual group or APM Entity.  For more information on HARP accounts, please refer to the Register for a HARP Account document in the QPP Access User Guide.

Once you register for a HARP account, sign in to qpp.cms.gov, select ‘Exceptions Applications’ on the left-hand navigation, select ‘Add New Exception,’ and select ‘Extreme and Uncontrollable Circumstances Exception’ or ‘Promoting Interoperability Hardship Exception.’

How do I Know if I’m Approved?

If you submit an application for either of the exceptions, you will be notified by email if your request was approved or denied. If approved, this will also be added to your eligibility profile on the QPP Participation Status Tool, but may not appear in the tool until the submission window is open in 2021.

For More Information


Contact the Quality Payment Program at 1-866-288-8292 or by e-mail at: QPP@cms.hhs.gov. To receive assistance more quickly, please consider calling during non-peak hours—before 10:00 a.m. and after 2:00 p.m. ET.

  • Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.



Rural Health Clinics Increase Access to COVID-19 Testing

As COVID-19 swept across America, Congress and the Trump Administration quickly recognized that Rural Health Clinics (RHCs) would be an important source of testing for the new virus. In early May, Congress approved a $225 Million RHC COVID-19 Testing Program so all RHCs could assist with a national effort to increase COVID-19 testing.

The Federal Office of Rural Health Policy (FORHP) was charged with organizing the distribution of this money to RHCs. Through an unprecedented level of collaboration between FORHP, the National Association of Rural Health Clinics (NARHC) and the National Organization of State Offices of Rural Health (NOSORH), this money began flowing to virtually every RHC in the country in a matter of weeks.

Join the leaders of NARHC, NOSORH and FORHP as they discuss both the triumphs of RHCs during COVID-19 and the challenges ahead as we head into a winter resurgence in cases. After brief remarks from each of the rural health leaders, the lines will be opened for you to ask questions and share your experiences with the panelists and attendees. They want to hear about your success as well as what challenges you continue to face in meeting the healthcare needs of your communities in these challenging times.

This Town Hall will also serve as a kick-off to a week-long celebration of the Power of Rural culminating in National Rural Health Day on November 19th! 

Date of Webinar: Monday, November 16th, 2020
Time: 1:00 PM Central

Hosted by the leaders of NARHC, NOSORH, and FORHP


  • Tom Morris, MPA, Associate Administrator for Rural Health Policy, HRS, HHS
  • Lindsey Nienstedt, MPH, MSW, Public Health Analyst, FORHP, HHS
  • Bill Finerfrock, Executive Director of NARHC
  • Teryl Eisinger, Executive Director of NOSORH

This webinar is being provided free of charge. However, you must register in advance. If you have issues registering and are using Internet Explorer, try using another browser. If you continue to have issues, please contact us and we will assist you, 866.306.1961.  

To register, go to: https://attendee.gotowebinar.com/register/546882101207560208 or http://bit.ly/RHCs_Increase_COVID_Testing

When the webinar begins you will be connected to audio using your computer’s speakers.

A copy of the slides and a recording will be available within a few days after the webinar is complete at: https://www.narhc.org/narhc/TA_Webinars1.asp

If you have any questions about registering please email us at asst@narhc.org.

IFC-4 and COVID-19 Vaccine Toolkits Listening Session Invitation

On October 28, 2020, the Centers for Medicare & Medicaid Services (CMS) issued an Interim Final Rule with Comment Period (IFC) that removes administrative barriers to eliminate potential delays to patient access to a lifesaving vaccine. In addition, the rule:

  • Creates flexibilities for states maintaining Medicaid enrollment during the COVID19 PHE;
  • Establishes enhanced Medicare payments for new COVID-19 treatments;
  • Takes steps to ensure price transparency for COVID-19 tests, and
  • Provides an extension of Performance Year 5 for the Comprehensive Care for Joint Replacement (CJR) model; and
  • Creates flexibilities in the public notice requirements and post-award public participation requirements for a State Innovation Waiver under Section 1332 of the Patient Protection and Affordable Care Act during the COVID-19 PHE.

The CMS Kansas City office is hosting two 1-hours conversations with sessions CMS staff regarding IFC-4 and the COVID-19 Vaccine Toolkits. They will provide a brief overview of IFC-4 and look at the resources available in the COVID-19 Vaccine Toolkits. Following the overview, the lines will open up to answer questions and listen to feedback.  Information presented will be the same at both sessions; however, the listening portion will be unique to each session.

To register for the November 9 session from 10:00 – 11:00 AM CST, please click on the link here: https://www.eventbrite.com/e/registration-cms-kc-ifc-4-covid-19-vaccine-toolkits-listening-session-tickets-127913156695

To register for the November 10 session from 4:00 – 5:00 pm CST, please click on the link here: https://www.eventbrite.com/e/registration-cms-kc-ifc-4-covid-19-vaccine-toolkits-listening-session-tickets-127927874717

Register for the session that works best for you or both if you are interested in hearing questions and feedback during both sessions. After you register, you will be provided a link to access your session(s). It is strongly encouraged to review the IFC and toolkit prior to the conversation. The IFC can be found at https://www.cms.gov/files/document/covid-vax-ifc-4.pdf and the toolkits can be found at https://www.cms.gov/covidvax.

Webinar Recording: Negotiating the Requirements of Pricing Transparency

Exceeding Patient Expectations and How to Use Pricing as a Competitive Weapon 

Effective January 1st, 2021, every hospital must make available two files for public consumption. The first file must detail a listing of 300 shoppable services. The second file must be a comprehensive file that makes public all standard charge information for all hospital items and services. To ensure that your hospital has an effective and satisfactory platform to address January 2021 expectations, Warbird Revenue Cycle Optimization has created a complimentary educational webinar that reviews the 2020 Pricing Transparency Final Rule’s requirements and scope. Within the webinar, focus is placed upon steps and strategies that will allow you to make pricing transparency a competitive advantage and exceed patient expectations. 

Webinar addresses the following:  

  • Review the 2020 Pricing Transparency Final Rule, effective January 1, 2021 
  • Discuss the logic behind the requirements and expectations 
  • Review component definitions 
  • Detail file formats and requirements 
    • Comprehensive File 
    • Shoppable Services 
  • Provide “Tales from the Field” 
    • Issues 
    • Best Practices 
  • Review “Action Items to Optimize Results” 
  • Address Frequently Asked Questions

Click to view Webinar Recording.

CMS Provides Transparency on Cost and Quality in State Medicaid and CHIP Programs

November 2, 2020

The Centers for Medicare & Medicaid Services (CMS) released the third annual update to its Medicaid and Children’s Health Insurance Program (CHIP) Scorecard. The Scorecard is the signature Medicaid accountability initiative that highlights state and federal performance on the administration and health outcomes of the Medicaid and CHIP programs that collectively account for approximately $600 billion in annual spending and serve over 74 million Americans. For the first time, the Scorecard now provides identified per capita spending data across all states, highlighting variation in program costs alongside the quality and performance data. First released in 2018, the Medicaid and CHIP (MAC) Scorecard is a key part of President Trump’s efforts to ensure greater transparency and accountability of the nation’s largest health coverage programs.

“From the beginning of his administration, President Trump has made giving states more flexibility to provide high quality accessible care for our most vulnerable citizens on Medicaid and CHIP a priority,” said Administrator Seema Verma. “At the same time, we also recognize that with greater autonomy must come greater accountability. The Medicaid and CHIP Scorecard provides unprecedented transparency on cost and quality across state Medicaid and CHIP programs.”

This year’s release builds on the success of the previous Scorecards with a variety of updates and improvements for users, including the debut of a new way to view state-specific data on the Medicaid.gov State Profile “Quality of Care” section. CMS has also improved the overall design and navigation across the 2020 MAC Scorecard to enhance the user experience.

The Scorecard includes healthcare quality measures of asthma medication management for children and adults as well as a measure of follow-up care for adults after an emergency department visit for mental illness. It also contains new administrative accountability measures including CMS and state approval times for managed care contract reviews; and CMS approval times for enhanced federal funding to support states’ eligibility, enrollment and information technology systems.

The 2020 Scorecard provides per capita expenditure data across all states. For the 2018 T-MSIS based per capita expenditure data, seventeen states had a high level of data usability, and an additional eleven states showed a moderate level of data usability. The remaining states fell into the category of having a low level of data usability. The median per capita expenditures, based on CMS calculations, for all states in 2018 is $8,126, with a range of $1,807 in Puerto Rico to $14,387 in North Dakota.[1]  

This year, new data were added to the MAC Scorecard’s National Context page. For example, these new data show the percentage of each state’s population that is enrolled in Medicaid, which ranges from 9.0% to 36.3 % and that nationally, about half of those enrolled in Medicaid and CHIP are children. The National Context page also has new data on the national percentage of beneficiaries enrolled in Medicaid and CHIP by eligibility group and the national rate of improper payments in Medicaid and CHIP.

Further, the national context now provides information on the percentage of Medicaid beneficiaries currently enrolled in Medicare (i.e., dually eligible beneficiaries); the percentage of dually eligible beneficiaries in programs that integrate the delivery of Medicare and Medicaid benefits; and the approval status for states’ transition plans for home and community-based services. For example, nearly half of all states (23) have a Medicaid population where 11.8%-24.2% are dually eligible beneficiaries and 36 states now enroll dually eligible beneficiaries in integrated care programs. The addition of these new data in the Scorecard help to further underscore the importance of understanding the dually-eligible population’s role in the Medicaid program.

CMS continues to engage stakeholders in identifying enhancements to the MAC Scorecard, including receiving input from Medicaid agencies through a collaboration with the National Association of Medicaid Directors.

CMS analyzed trends in median state performance on a subset of Child and Adult Core Sets measures that are included in the MAC Scorecard’s State Health System Performance pillar. Under this pillar, five states reported all measures in Federal Fiscal Year (FFY) 19: Connecticut, Massachusetts, New Hampshire, Tennessee and Washington. Across all states that reportedperformance improved from FFY 2017 to FFY 2019 on several measures, suggesting progress in the quality of care provided to Medicaid and CHIP beneficiaries. These measures include:

  • Well-Child Visits in the First 15 Months of Life (performance improved from 60.2% to 65.1%)
  • Adolescent Well-Care Visits (performance improved from 44.9% to 50.7%)
  • Immunizations for Adolescents (performance improved from 74.5% to 79.2%)
  • Percentage of Eligibles Who Received Preventive Dental Services (performance improved from 48.2% to 49.0%)
  • Comprehensive Diabetes Care: Hemoglobin A1c Poor Control (performance improved from 40.9% to 38.3%). Lower rates are better for this measure.

Overall, under the State Health System Performance pillar, states that reported for FFY19 have opportunities to improve in measures such as: emergency department utilization rate for children and adolescents; the percentage of children ages 3 to 6 who had at least one well-child visit with a primary care provider; the percentage of women delivering a live birth who had a timely postpartum care visit; and inpatient hospital admission rates for short-term complications of diabetes (e.g., diabetic ketoacidosis, hyperosmolarity) in adults ages 18 and older.

The State and Federal Administrative Accountability pillar measures show, for example, that the percentage of State Plan Amendments and 1915 waivers approved in within the first 90 day review period has increased between 2016 and the second quarter of 2020.

When viewing data in the MAC Scorecard, CMS would caution against making direct state-to-state comparisons based solely on data presented. For example, for measures drawn from Child and Adult Core Set, reporting methods can vary among states. States have access to different data on populations covered under fee-for-service as compared to populations covered under managed care. This variation in data availability can impact measure performance. Users should review the state-specific measure notes to better understand states’ reported rates. CMS is committed to working with states to improve standardized measure calculation and reporting which will increase the ability to do direct state-to-state comparisons in the future.

CMS is committed to working with states to improve standardized measure calculation and reporting on measures across the Scorecard. As with other measurement-focused initiatives, CMS offers states technical assistance and quality improvement opportunities to assist states in collecting and reporting measures displayed in the Scorecard, as well as sharing best practices to support improved state performance.

To view the 2020 MAC Scorecard, please visit: https://www.medicaid.gov/state-overviews/scorecard/index.html  

For more information pertaining to the 2020 MAC Scorecard, please visit: