If you ever wonder where CMS is heading, or what their priorities are, follow the money. This article details one of this author’s favorite annual 300+ page documents, the Centers for Medicare and Medicaid Services (CMS) Justification of Estimates for Appropriations Committees, or as she affectionately refers to it, JoE.

As reported by FedHealthIT, the CMS Justification of Estimates (JoE) for the Appropriations Committees is out for Fiscal Year (FY) 2019. Compared to previous years, this is definitely a slimmed down version, even more so than FY 2018 was. Traditionally, this document is between 350 and 400 pages. This version is succinct at a mere 304 pages.

One of the greatest areas to gain insight into CMS’ future plans was in the “Other Accounts” sections. The table below shows the accounts discussed in detail in the FY 2017 JoE, under Andy Slavitt, and those in the FY 2019 JoE, under Administrator Verma.

Throughout the document there are a few indications, which are not a surprise, as to the future CMS has planned. For example, on page 23, discussing the budget request for Program Operations, the JoE states, “This request will allow CMS to efficiently operate Medicare, Medicaid, CHIP, and other CMS support programs while allowing Federal Exchange operations to wind down in an orderly fashion under the proposal to repeal and replace Obamacare.” The FY 2019 Program Operations budget request is $2,402,089,000, $403.6M below the FY 2018 Annualized Continuing Resolution (CR) level.

In order to make the intent perfectly clear, page 43 states, “In FY 2019, CMS proposes to further empower stakeholders by providing greater flexibility and recognizing the traditional regulatory role of States. States will be able to assume more control of their markets and expand enrollment options to include private partners to promote innovation and provide a better consumer experience. This includes a proposal to repeal and replace Obamacare, which would phase down Federal Exchange operations in plan year 2020.”

Just in case you were wondering if I am picking a side, I am not. There is one piece of information in the JoE which is shocking – how much the Exchanges cost us every year (page 194). All years are the actual costs except for 2018 and 2019. Altogether, that is a grand total of $13,349,503,000.

I have told this story many times, and I will tell it again. There was a time in my life, only 10 years ago, when I was in graduate school, with a 2-year-old son, and newly divorced. I had no way to get health insurance; it wasn’t even a possibility. If I had broken a leg, I can’t imagine how my life could have turned out, with no way to work and deeply in debt with medical bills. I am sure I wouldn’t be writing this article you are reading. Had the Exchanges been around then, I could have gotten some type of insurance through them; at least there would have been a venue.

But the time for having a venue is passed. And it is time to move to the next phase. I started my own company a few, short months ago. I went on the Exchange to find a health plan but ended up going through a private broker instead ($1,700 a month for my family for inquiring minds). I ask you, for $13 BILLION, do you think you got value for your money? Because it is your money. I am not sure because I still can’t find quality, affordable Healthcare.

Now that I have waxed philosophical on you, let’s move on to what priorities are in the JoE. I suggest you read the Significant Items and Reports section beginning on page 193. This section describes requests from the Committee and actions CMS has taken or plans to take to address those requests.

For example, in the rural health section, the Committee states that the majority of rural residents are older, poorer, and less likely to have employer sponsored health plans. It directs CMS to provide an update in the FY2019 JoE on action taken to alleviate the disproportionate impact of regulation, reimbursement cuts, and workforce issues on rural hospitals. CMS’ actions taken include the launch of the “Patients over Paperwork” Initiative which will include additional rural listening sessions in 2018 to help CMS find ways to make it easier for rural providers to focus on their patients’ and families’ needs without excessive regulatory and administrative burden. Also, CMS launched go.cms.gov/ruralhealth in 2017.

Another example is the Committee’s request for CMS to enhance the Medicare Plan Finder website. CMS plans to display an icon or some other icon on Plan Finder to alert beneficiaries when a plan has received a Civil Money Penalty (CMP), and general information about the CMP. This likely means if you are the Plan Finder contractor, you’re probably getting a mod for additional work within scope.

Another great section to review to understand potential upcoming changes is the Program Management Proposed Law Summary. This section includes instituting a Survey and Certification Re-Visit and Complaint Investigation Fee for Healthcare facilities that have a deficiency for which it must be resurveyed, or for substantiated complaint investigations; public reporting of Medicare Survey and Certification Reports; adjusting the survey frequency for top-performing nursing homes; and gaining efficiencies in the Medicare & You Education Program.

So, what’s the bottom line? The million-dollar question. Actually, in this case, it’s the billion-dollar question, as in $793,741,700,000 requested. The Program Management account is the only loser in that it’s budget is lower than last year’s by $403 million. The Health Care Fraud and Abuse Control account (+$45M) and Grant to States for Medicaid (+$1B) are the winners. However, if we continue to improve Healthcare, which is really a basic human right, we are all winners.

Desirea is not stranger to JoE. She shared her insights on the previous iteration here.

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