Preparing For The New PERM Eligibility Review And Other .
Preparing for the New PERM Eligibility Review andOther Proposed PERM & MEQC ChangesCenters for Medicare & Medicaid ServicesOffice of Financial ManagementPayment Accuracy & Reporting GroupThe PERM Eligibility TeamAugust 30, 20161
Background The Affordable Care Act (ACA) included significant changes to Medicaidand CHIP eligibility processes that impacted the PERM program. CMS implemented the Medicaid and CHIP Eligibility Review Pilots whichtook the place of the PERM and MEQC eligibility reviews for four years. These pilots enabled CMS to update the eligibility componentmeasurement methodology in order to accurately measure improperpayments based on the new provisions implemented under the ACA. CMS issued the proposed rule outlining the changes to the PERM andMEQC programs in response to the new requirements under the ACA.– Public Commenting period closed August 222
Proposed Changes:PERM Review PeriodItemReviewPeriodComponentImpactedAllCurrent RegulationProposed RegulationPERM reviews paymentsPERM reviews paymentsmade in a Federal Fiscal Year made July through June(October throughSeptember)Rationale Alignmentwith statefiscal years Additionaltime tocomplete cyclebeforereporting3
Review Period ShiftOctober 2017September 2018Report ErrorRatesNovember 2019Current Review PeriodJuly 2017June 2018Report ErrorRatesNovember 2019Proposed Review Period4
Proposed Changes:PERM Eligibility ImpactedEligibilityCurrent RegulationStates are required toconduct their owneligibility reviews andreport results to CMSProposed RegulationA federal contractor performs the PERMeligibility reviews withsupport from the state RationaleReduce stateburdenDecrease reviewinconsistenciesacross states5
Proposed Changes:PERM Eligibility )Proposed RegulationA federal contractorperforms the PERMeligibility reviews withsupport from the stateNotesPilot testing: Confirmed experienced contractor canreview consistently across states whilecontinuing to recognize state-specific factors Developed processes to ensure effective andcollaborative communication with statesthat minimizes burden6
Proposed Changes:PERM Eligibility Reviews – State InvolvementItemEligibility ionA federal contractor State Involvement:performs the PERMeligibility reviews Provide policy information and casewith support fromdocumentation to contractor as requestedthe state Provide access to eligibility system Monitor findings and request differenceresolution/CMS appeal as necessary Develop corrective action plans to addressfindings7
Proposed Changes:PERM Eligibility Review- igibilityCurrent RegulationStates submit universesof Fee-for-Service (FFS)and managed carepayments which aresampled for dataprocessing and medicalreviewStates create universesof eligible individualswhich are sampled foreligibility reviewProposed RegulationUse sampled FFS and managed care paymentsfor eligibility review inaddition to medical and data processing reviewsEligibility reviewconducted on thebeneficiary associatedwith the sampled claimRationaleReduce stateburdenReduce programcosts byeliminatingfederal dollarsspent onreviewingeligibility casesfor which nopayments weremade8
Proposed Changes:PERM Eligibility Review-Universe (con’t)ItemEligibilityUniverseProposed RegulationNotesUse sampled FFS and managed care paymentsfor eligibility review inaddition to medical anddata processing reviews Eligibility reviewconducted on thebeneficiary associatedwith the sampled claim CMS did not propose to require states to develop aseparate negative case universe for review as part ofPERMIt is possible for negative cases to be reviewed throughPERM if relevant denied claims are sampledMaintain important oversight of negative cases throughproposed MEQC pilots9
Proposed Changes:PERM Eligibility Reviews- FFMItemInclusion nCasesComponent CurrentProposed RegulationImpacted RegulationEligibilityN/AErrors that result solely from anincorrect determination of eligibilityby the FFM will be included in thenational improper payment rate, butnot in state improper payment ratesStates are only required to submitcorrective actions for errors includedin state improper payment ratesRationaleStates that delegateauthority to theFFM are required toaccept FFMeligibilitydeterminations withno further actionConversely, errors resulting from incorrect state action taken on cases determined andtransferred from the FFM or from the state’s annual redetermination of cases initiallydetermined by the FFM will be included in state and national improper payment rates10
Proposed Changes:PERM Payment System AccessItemComponent CurrentProposed RegulationImpacted RegulationPaymentAllN/AStates grant access to federalSystemcontractors to facilitate reviewsAccessto eligibility systems, and allRequirementssystems that authorizepayments, contain beneficiarydemographics and providerenrollment informationRationaleDecrease delaysand burdenassociated withthe reviewprocess11
Proposed Changes:PERM Federal Improper PaymentsItemFederalImproperPaymentsComponent Current RegulationImpactedAllImproper paymentsonly cited on totalcomputableamount (i.e.,federal share state share)Proposed RegulationImproper paymentscited if the federal orstate share is incorrect(even if totalcomputable amountcorrect)Rationale An incorrect eligibilitycategory assignment canresult in the incorrectfederal medical assistancepercentage (FMAP) beingclaimed by the state Size of the newly eligibleadult category makes thischange necessary toaccurately identify federalimproper payments12
Proposed Changes:PERM Sample SizesItemSampleSizesComponent Current RegulationImpactedAllState-specific samplesizes calculated basedon the state’sprevious error rateand state-levelprecisionrequirementProposed RegulationEstablish a nationalannual sample size,which would then bedistributed acrossstatesRationale More stablesample sizes foreach state Increase controlover the PERMprogram’sbudget13
Proposed Changes:PERM Corrective Action PlansItemComponent Current RegulationImpactedCorrectiveEligibilityStates implementAction PlansCAPs for all errors(CAPs)and deficienciesidentified in the FFS,managed care andeligibility reviewsProposed RegulationRationaleStates continue to implement AllowableCAPs for all errors andthreshold fordeficiencieseligibility errorrates is set byMore stringent requirements section 1903(u) ofadded for eligibility should a the Actstate have consecutive PERMeligibility improper paymentrates over the 3% nationalstandard set per 1903(u) ofthe Act14
Proposed Changes:PERM CAPsItemCorrectiveAction Plans(CAPs)Proposed RegulationNotesMore stringentAdditional requirements include:requirements added foreligibility should a state More frequent status updates on corrective actionshave consecutive PERMeligibility improper More details surrounding state implementation andpayment rates over theevaluation of corrective actions3% national standard set Information about setbacks with alternativeper 1903(u) of the Actcorrective actions or workarounds Examples demonstrating that corrective actionsled to improvements that will reduce errors Summary that demonstrates how the planned andimplemented corrective actions will enable thestate to meet the 3% threshold15
Proposed Changes:PERM Eligibility Payment tionN/AProposed RegulationRationalePayment reductions/disallowances Complies withunder 1903(u) of the Act would1903(u)only be applicable for eligibilityrequirementsreviews conducted during PERMyearsStates have the ability todemonstrate a good faith effort ifunable to meet the nationalstandard; A good faith effort isdefined as meeting PERM CAP andMEQC pilot requirements16
Proposed Changes:PERM Eligibility Payment Reduction/Disallowancescon’tItemProposed llowancesDisallowances under 1903(u) of the Actwould only be applicablefor eligibility reviewsconducted during PERMyearsNotes Eligibility error rates only calculated in a state’s PERMyear CMS would only pursue disallowances if a state doesnot demonstrate a good faith effort to meet thenational standard Not effective until a state’s second PERM eligibilitymeasurement under the new final ruleStates have the ability todemonstrate a good faitheffort if unable to meet the national standard; Agood faith effort is definedas meeting PERM CAP andMEQC pilot requirementsDisallowance amount is the percentage by which thelower limit of the state’s eligibility improper paymentrate exceeds 3%17
Proposed Changes:MEQCThe NPRM restructures the MEQC program into a pilot program that states would be required toconduct during their off-years from the PERM program. States would conduct an MEQC pilot during the 2 off-years between PERM cycles MEQC pilots would focus on areas not addressed through PERM reviews (e.g. negative cases) andpermit states to conduct focused reviews areas identified as error prone through PERM The calculated PERM eligibility improper payment rate would remain frozen at that level duringeach state’s 2 off-years when it conducts its MEQC pilot. Error rates would not be calculatedthrough MEQC, allowing states time to work on corrective actions before their next PERMeligibility improper payment rate would be measuredRATIONALE: PERM/MEQC rotations would be operationally complementary, and treated in a mannerthat allows for states to review identified issues, develop corrective actions, and effectivelyimplement prospective improvements to their eligibility determinations.18
PERM-MEQC Operational Relationship Improper Payment Ratecalculated for Eligibility andfrozen until next PERMCycle States complete CAPsPERMMEQC Pilot review performed byStates No error rate calculated States complete CAPs Next Improper PaymentRate calculated forEligibility and frozen untilnext PERM Cycle States complete CAPsPERM19
Proposed Changes:MEQCCMS will provide states detailed guidance for conducting MEQC pilots. Statesmust submit MEQC pilot planning documents for CMS approval.Review Requirements Includes both Medicaid & CHIP eligibility determinations Includes both active and negative case reviews– State flexibility for active case reviews A state may conduct a comprehensive review or focus active case reviews on– Recent changes to eligibility policies and processes– Areas where the state suspects vulnerabilities– Proven error prone areas If a state’s PERM eligibility improper payment rate is above 3% for two consecutivePERM cycles, CMS will provide direction for active case reviews– Pilots must include comprehensive review of negative cases to ensure continuingoversight of the accuracy of state determinations to deny or terminate eligibility20
Proposed Changes:MEQC Sample SizeMinimum Sample Sizes Active cases: 400 total minimum (Medicaid and CHIP); at least 200 Medicaidcases Negative cases: 400 total minimum; 200 Medicaid minimum & 200 CHIPminimumTimeline PERM review period: July – June MEQC pilot planning document due: November 1 MEQC pilot review period: January – December MEQC pilot findings and corrective actions due: August 121
MEQC TimelineEnd of PERMReview PeriodJune 30 PERM Review PeriodMEQC PilotPlanningDocumentDueNovember 1 JanuaryDecemberMEQC Findings& CAPs DueAugust 1MEQC Review Period22
Proposed Changes:MEQC Cycle TimelineTimelineFollowing final rule publication, states will not all be at the same point in theirMEQC/PERM timelineCycle 1 StatesCycle 2 States First PERM review period:July 2017 – June 2018 MEQC planning documentdue: November 1, 2018CMS will provide guidanceregarding a modified MEQCpilot that will occur prior tothe beginning of your firstPERM cycleMEQC review period: January 1 – December 31, 2019First PERM review period:July 2018 – June 2019 Cycle 3 States First MEQC planningdocument due: November1, 2017 MEQC review period:January 1 – December 31,2018 MEQC findings and CAPdue: August 1, 2019 First PERM review period:July 2019 – June 2020MEQC findings and CAP due:August 1, 202023
Preparing for the NewPERM Eligibility Review
PERM Eligibility Where are we now in the pilot process? What should states be doing to prepare for PERMeligibility?25
Where we are now States are finalizing results for Round 4 case reviewpilots CMS is preparing Round 5 case review pilot guidance26
Round 5 PilotsFinal Roundof Eligibility Pilots Goal: Preparing for PERM Eligibility– Cycle 3 States: Round 5 pilot reviews conducted by federalcontractor as a “dry run” of PERM– Cycle 1 & 2 States: Round 5 pilot guidance will include changesthat will assist states in preparing for PERM reviews States should use Round 5 pilots to:– Focus on fixing problems now before PERM resumes and errorrates are reported– Be sure the action associated with an eligibility determinationincludes an audit trail and that records are maintained, asrequired– Improve collaboration with state staff
Plan for PERM Readiness Webinars States are at various stages in preparing for thefuture of PERM eligibility To assist states in this preparation, CMS will host aPERM Readiness Webinar with each state The goal of these state webinars is to focus on statespecific questions and readiness for the restart ofPERM eligibility28
PERM Readiness Webinars Who should participate on the call?––––Systems/IT staffEligibility Policy staff (Medicaid and CHIP)QC staff working with PERMAdditional staff - state should include other staff, asappropriate, including staff representing caseworkers Topics for discussion– What corrective actions are working and what correctiveactions have not been effective? What is your progress onfixing identified errors?– Where is your state now and are you ready for PERM?– What type of audit trail will we see in your state whenconducting PERM eligibility reviews?29
Preparing for PERM Eligibility1. Fix all issues/vulnerabilities identified through thefirst 4 rounds of pilots2. Ensure your state is reviewing against all federalregulation eligibility requirements to fully assesscompliance before resumption of PERM3. Ensure your state is maintaining an audit trail tosupport the eligibility determinations30
Preparing for PERM EligibilityStep 1Step 1: Fix all issues/vulnerabilities identified throughthe first 4 rounds of pilots31
Preparing for PERM EligibilityStep 2Step 2: Ensure your state is reviewing against all federal regulationeligibility requirements to fully assess compliance before resumptionof PERMNotes: PERM will review for all eligibility requirements. The following slidesare not a comprehensive list of eligibility requirements. The following slides highlight areas that all states may not haveconsistently reviewed for through the pilot reviews (areas wherefederal regulation specifies certain processes that states mustfollow when making an eligibility determination). States should assess their compliance in these areas (and otherareas) if they did not do so through the first 4 rounds of pilots.32
Assess Compliance with Federal RegulationCitizenshipFederal Regulations require:- Individuals to declare citizenship and states to document theindividual’s citizenship in the eligibility file- States to verify citizenship using certain acceptable evidenceExamples of questions to assess compliance:Note: States should check electronic data sources before asking for paper- What documents is the state accepting to verify citizenship?- Does the state ever accept a passport with limitations, asouvenir birth certificate, a voters registration card, or otherunacceptable forms of documentation?33
Assess Compliance with Federal RegulationDetermination of Disability/BlindnessFederal Regulations require:- States to obtain a medical report and other evidence forindividuals applying for Medicaid on the basis ofdisability/blindness- States to review the medical report and other evidence to makea determination of disability/blindness- States to determine whether and when reexaminations will benecessary for periodic redeterminations of eligibilityExamples of questions to assess compliance:- Does the state have medical documentation that confirms thedetermination of disability/blindness?- Are reexaminations occurring for periodic redeterminations ofeligibility as required?34
Assess Compliance with Federal RegulationRedeterminationsFederal Regulations require:- States to redetermine eligibility (for MAGI and non-MAGI) every12 monthsExamples of questions to assess compliance:- Are there any instances where the state is not completingredeterminations within 12 months? How often does thisoccur?35
Assess Compliance with Federal RegulationSignaturesFederal Regulations require:- All applications to be signed under penalty of perjuryExamples of questions to assess compliance:- Is the state requiring and maintaining signatures on allapplications?36
Assess Compliance with Federal RegulationSSN VerificationFederal Regulations require:- States to verify the SSN of each applicantExamples of questions to assess compliance:- Are there any instances where the state is not verifying theapplicant’s SSN?37
Assess Compliance with Federal RegulationFollow-Up on Inconsistent InformationFederal Regulations require:- States to seek additional information from individuals ifinformation provided is not reasonably compatible withinformation obtained through an electronic data matchExamples of questions to assess compliance:- Is the state appropriately following up on information that isnot reasonably compatible?38
Preparing for PERM Eligibility –Audit TrailStep 3: Ensure your state is maintaining an audit trail tosupport the eligibility determinations39
State Audit Trail Is your state ready for PERM based on what reviewers willneed to see for review of the eligibility criteria and all actionsunder review? If verifying electronically, does your state have a systemindicator to confirm element was appropriately verified at thetime of determination? Is your state maintaining all documents required in makingeligibility determinations?40
Electronic VerificationElectronic VerificationThere must be an indicator in the eligibility system associated with the action under reviewfor all eligibility elements where electronic verification is utilized.Examples of acceptable indicators within an eligibility system: The state’s eligibility system contains a check box where a check appears when a datamatch occurred.An example of a check box:41
Electronic Verification- ExamplesElectronic VerificationExamples of acceptable indicators within an eligibility system: The state’s eligibility system provides more detailed information related to the electronicdata match.Examples of indicators that contain detailed information about the electronic data match:42
Electronic Verification- Example IndicatorElectronic VerificationExamples of acceptable indicators within an eligibility system: The state’s eligibility system displays information that the electronic data matchoccurred.An example of a display:43
Electronic Verification- ExamplesElectronic VerificationExamples of acceptable indicators within an eligibility system: The state’s eligibility system contains a separate verification page for each eligibilitydecision. The verification page lists the verification element and the verification status.An example of a verification page with pass/fail status:Verification ElementVerification StatusCitizenshipPassSSNPassIncomeFailAn example of a verification page with verified/not verified status:Verification ElementVerification StatusCitizenshipVerifiedSSNVerifiedIncomeNot Verified44
State Audit Trail ExamplesCitizenship and Immigration Status, Social SecurityNumber If verified electronically, states will need to have anindicator in the eligibility system showing thatcitizenship/immigration status and/or social securityis verified. If verified in hard copy, states must have theacceptable documents available.45
State Audit Trail – Examples Con’tResidency, Age/Date of Birth, Household Size If state does not accept self-attestation, and if verifiedelectronically, there must be an indicator in the systemshowing that appropriate third party data sources wereverified. If verified via hard copy, appropriate documents mustbe available to reviewer.46
State Audit Trail- Additional ExamplesIncome and Resources/Assets If verified electronically, states will need to have anindicator in the eligibility system showing thatincome and resources/assets were verified (forapplicants for whom assets are a factor of eligibility). If verified in hard copy, states must have theacceptable documents available.47
State Audit Trail –More ExamplesBlindness and Disability Documentation is required in the record thatconfirms blindness/disability was appropriatelyverified at the time of determination. PERM reviewers will need to see supporting medicaldocumentation confirming disability/blindness.48
State Audit Trail - ApplicationsMaintaining Medicaid and CHIP Applications The original application or redetermination form must bemade available to the PERM reviewer. The original application or redetermination may beelectronic or hard copy, but should include a record of theinformation the applicant submitted and the applicant’ssignature. Applies to all application types including: online, inperson, and via phone, unless a passive renewal.49
State Audit Trail- SignaturesMaintaining Application SignaturesThe type of documentation that must be provided for PERM reviewers to verify thesignature varies by the channel of the application: Paper application/redetermination form: must be signed under penalty of perjurywith a handwritten signature. Fax application/redetermination form: must be signed under penalty of perjurywith a handwritten signature. Electronic application/redetermination form: must be signed under penalty ofperjury with an electronic signature.An example of an electronic signature:Person’s NameDate Phone application/redetermination: must be signed under penalty of perjury witha handwritten, electronic, or telephonically recorded signature. The audio file ofthe telephonically recorded signatures must be provided to PERM reviewers.50
State Audit Trail - Changes/NoticesChange in CircumstanceDocumentation should include when changes werereported to the state and how and when state acted onthe change, if required.NoticesRecord of notices is required, including proof thatappropriate notices were sent to applicants.51
State Audit Trail- Con’tSSI cases, Title IV-EReviewers will need to see electronic or hard copy documentshowing that individual was receiving SSI or Title IV-E benefits.Presumptive EligibilityReviewers will need to see appropriate presumptive eligibilityinformation submitted by qualified entity.Tax Filing StatusReviewers will need to see applicant reported tax filing status or, iftax filer information was missing, evidence the state followed upwith the applicant.52
Addressing State Audit Trails IssuesWhat are states doing to address audit trail issues?Example: State was missing a system indicator thatconfirmed electronic data sources were utilized inverifying income.Fix: State successfully implemented a system fix thatadded an indicator that shows income was verified andthe result of the verification.53
Collaboration and Communication Increase communication within your stateParticipate on the monthly All State Pilot callsPrepare for Readiness Webinars and follow upContact Technical Advisory Group (TAG) RepresentativesVisit the CMS PERM Websitewww.cms.gov/perm Contact your PERM Eligibility Liaison54
CMS PERM Eligibility ContactsPlease send questions to thePERM Eligibility mailbox @FY2014-2016EligibilityPilots@cms.hhs.gov55
Preparing for the New PERM Eligibility Review and . Payment Accuracy & Reporting Group The PERM Eligibility Team August 30, 2016 1 The Affordable Care Act (ACA) included significant changes to Medicaid and CHIP eligibility processes that impacted th
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