Affordable Care Act,care coordination,Centers for Medicare & Medicaid Services,CMS,Cognosante,Enrollment Broker,managed care organizations,Medicaid

Effective Medicaid consumer engagement: Thinking outside the box

Rebecca Bruno, MPM, Director of Policy and Regulatory Affairs, Cognosante

Person-centered approach

Many individuals enrolled in Medicaid also access services from other state human services agencies and community-based providers. Deploying a “whole person” approach for enrollees – supported by modern tools and one-to-one support – can increase beneficiary engagement while lowering a state’s overall costs and administrative burden.

The Medicaid landscape is changing

Since implementation of the Affordable Care Act (ACA) in January 2014, Medicaid enrollment has been steadily increasing. As of August 2016, the latest period for which data is available, more than 73 million Americans were covered by Medicaid.[i] This is approximately a 28 percent increase from the enrollment period just prior to the first Marketplace Open Enrollment period in October 2013.[ii] In addition to Medicaid’s traditional coverage of low-income families, low-income elderly individuals, and individuals with disabilities, in many states Medicaid now covers adults without dependent children. Also, more Medicaid beneficiaries in need of long-term services and supports (LTSS) are being served in home and community-based settings rather than nursing homes and institutions.

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(HR 6404),American Occupational Therapy Association,AOTA,Government Perspectives,Medicare Home Heath Flexibility Act

Medicare Home Health Flexibility Act introduced in House

On Thursday, Dec. 1, U.S. Con. Charles Boustany (R-LA) and Lloyd Doggett (D-TX) introduced the Medicare Home Heath Flexibility Act, (HR 6404), a bill that would allow occupational therapists to open cases and conduct the initial assessment for rehabilitation cases in the home health setting.

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Cognosante,electronic health record,Health Information Exchange,HIEs,interoperability,MARCA,Medicaid,Medicare,Medicare Access and CHIP Reauthorization Act,Office of the National Coordinator for Health IT,ONC,quality payment program,SIM,State Innovation Model

Advancing payment reform with effective state health information exchange

Megan Renfrew, Director of Health Policy and Regulatory Affairs and Policy Team Lead, Cognosante


Sunaina Menawat, Director of Business Development for State Solutions, Cognosante

Throughout the healthcare system, payers are shifting away from payment models that incentivize volume of services to models that incentivize quality, outcomes, and savings. Efforts to transform healthcare through value-based payment reform can be seen in state Medicaid managed care contracts that incentivize outcomes, delivery system reform efforts under Medicaid demonstration projects, State Innovation Model (SIM) efforts that seek to implement reforms across public and commercial markets, and Medicare’s new quality payment program established by the Medicare Access and CHIP Reauthorization Act (MACRA).

The ability to exchange health information is foundational to these efforts. For value-based reform to be effective, all parties must be able to access relevant, useable, and timely data. Policy makers need clinical and claims data to identify areas for improvement, and providers and payers need data to understand their performance relative to peers and competitors. All stakeholders need access to data to evaluate progress towards defined goals, a common one being a reduction in hospital readmissions.

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Department of Health and Human Services,ePHI,Government Perspectives,HHS,HIPAA,UMass,University of Massachusetts Amherst

UMass settles potential HIPAA violations following malware infection

The University of Massachusetts Amherst (UMass) has agreed to settle potential violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules. The settlement includes a corrective action plan and a monetary payment of $650,000, which is reflective of the fact that the University operated at a financial loss in 2015.   

On June 18, 2013, UMass reported to the U.S. Department of Health and Human Services, Office for Civil Rights (OCR) that a workstation in its Center for Language, Speech, and Hearing (the “Center”) was infected with a malware program, which resulted in the impermissible disclosure of electronic protected health information (ePHI) of 1,670 individuals, including names, addresses, social security numbers, dates of birth, health insurance information, diagnoses and procedure codes. The University determined that the malware was a generic remote access Trojan that infiltrated their system, providing impermissible access to ePHI, because UMass did not have a firewall in place.

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Centers for Medicare & Medicaid Services,CMS,Government Perspectives,quality payment program

CMS launches new online tool to make Quality Payment Program easier for clinicians

Today, the Centers for Medicare & Medicaid Services (CMS) released a tool to share automatically electronic data for the Medicare Quality Payment Program. This new release is the first in a series that will be part of CMS’s ongoing efforts to spur the creation of innovative, customizable tools to reduce burden for clinicians, while also supporting high-quality care for patients.

In October, CMS released the Quality Payment Program website, an interactive site to help clinicians understand the program and successfully participate. Today’s release, commonly referred to as an Application Program Interface (API), builds on that site by making it easier for other organizations to retrieve and maintain the Quality Payment Program’s measures and enable them to build applications for clinicians and their practices. The API, available at, will allow developers to write software using the information described on the Explore Measures section of Based on interviews with clinicians, CMS created the Explores Measures tool, which enables clinicians and practice managers to select measures that likely fit their practice, assemble them into a group, and print or save them for reference. Already, tens of thousands of people are using this tool.

Dr. Kate Goodrich, Director of the CMS Centers for Clinical Standards and Quality said, “The API released today will continue CMS’s focus on user-driven design by providing developers and our partners the opportunity to turn our data into powerful applications. CMS is committed to collaborating with the organizations that doctors trust to make their lives easier, while supporting their efforts to improve the quality of care across America.”

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Department of Health and Human Services,Government Perspectives,HHS,Move Health Data Forward Challenge

HHS announces Phase 1 winners of the Move Health Data Forward Challenge

The Department of Health and Humans Services’ Office of the National Coordinator for Health Information Technology (ONC) today announced the Phase 1 winners of the Move Health Data Forward Challenge. Winners were selected based on their proposals for using application programming interfaces (API) to enable consumers to share their personal health information safely and securely with their health care providers, family members or other caregivers.

“As health information technology becomes more accessible, consumers are playing an even greater role in how and when their health information is exchanged or shared,” said Dr. Vindell Washington, national coordinator for health information technology. “The Move Health Data Forward Challenge will help consumers unleash their health data and put it to work.”

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Department of Health and Human Services,electronic protected health information,ePHI,Government Perspectives,HHS,HIPAA,OCR,Office for Civil Rights,St. Joseph Health

$2.14 million HIPAA settlement underscores importance of managing security risk

St. Joseph Health (SJH) has agreed to settle potential violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules following the report that files containing electronic protected health information (ePHI) were publicly accessible through internet search engines from 2011 until 2012. SJH, a nonprofit integrated Catholic health care delivery system sponsored by the St. Joseph Health Ministry, will pay a settlement amount of $2,140,500 and adopt a comprehensive corrective action plan. SJH’s range of services includes 14 acute care hospitals, home health agencies, hospice care, outpatient services, skilled nursing facilities, community clinics and physician organizations throughout California and in parts of Texas and New Mexico.

On February 14, 2012, SJH reported to the U.S. Department of Health and Human Services, Office for Civil Rights (OCR) that certain files it created for its participation in the meaningful use program, which contained ePHI, were publicly accessible on the internet from February 1, 2011, until February 13, 2012, via Google and possibly other internet search engines. The server SJH purchased to store the files included a file sharing application whose default settings allowed anyone with an internet connection to access them. Upon implementation of this server and the file sharing application, SJH did not examine or modify it. As a result, the public had unrestricted access to PDF files containing the ePHI of 31,800 individuals, including patient names, health statuses, diagnoses, and demographic information.

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beneficiaries,Centers for Medicare and Medicaid Services,Children’s Health Insurance Program,CMS,Medicaid,Medicaid managed care

Modernizing Medicaid managed care

Megan Renfrew, Director of Health Policy and Regulatory Affairs and Policy Team Lead, Cognosante

The “mega” Medicaid managed care rule released this spring by the Centers for Medicare and Medicaid Services (CMS) set in motion a long-overdue overhaul of managed care programs in Medicaid and the Children’s Health Insurance Program. As managed care plans oversee larger percentages of enrollees and benefits, the pressure on state Medicaid agencies to ensure that those plans are providing quality services for a good value increases, as does the need to ensure program integrity is maintained.

The Medicaid managed care rule improves beneficiary protections, increases the focus on quality of care, strengthens financial management and program integrity efforts, and provides states with support for delivery and payment system reform efforts within managed care (e.g. value-based purchasing). In addition, this rule strengthens data submission and reporting requirements to support program oversight, program integrity, and increased transparency.

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Department of Health and Human Services,Government Perspectives,HHS,ONC Health IT Certification Program: Enhanced Oversight and Accountability,transparency

HHS issues final rule to enhance the reliability, transparency, accountability, and safety of certified health information technology

Today, the U.S. Department of Health and Human Services’ (HHS) Office of the National Coordinator for Health Information Technology (ONC) issued a final rule that emphasizes the importance of protecting public health and safety while also strengthening transparency and accountability in the ONC Health IT Certification Program (“Program”).

The “ONC Health IT Certification Program: Enhanced Oversight and Accountability” final rule will enable the ONC Health IT Certification Program to better support physicians and hospitals – the vast majority of whom use certified electronic health records (EHRs) –  and the rapid pace of innovation in the health information technology (health IT) market.

“More transparency and accountability in health IT is good for consumers, physicians, and hospitals,” said Vindell Washington, M.D., M.H.C.M., national coordinator for health IT. “Today’s final rule strengthens the program by ensuring that certified health IT helps clinicians and individuals use and exchange electronic health information safely and reliably.” 

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Clearwater Compliance,HIPAA,Information Risk Management,IRM,National Institute of Standards and Technology Cybersecurity Framework,NIST,NIST IRM,OCR,OCR investigation,Office for Civil Rights

OCR getting tougher about information security


Bob Chaput, Chief Executive Officer and Founder, Clearwater Compliance

In the healthcare field, the word “audit” is about as welcome as the word “Zika.” But it’s inevitable that there will be more audits this year, in addition to investigations, related to information security shortcomings.

That’s because the Office for Civil Rights (OCR) has moved from the concept of performance audits in 2012, focused on efforts to comply, to compliance audits in 2017, focused on evidence of practice. And this year and beyond, an audit can result in a full-blown OCR investigation based on the severity of identified weaknesses or gaps.

What happened? Last September, the Office of the Inspector General issued a report scolding the OCR for its weak enforcement of HIPAA regulations based on evidence of incomplete investigations, lack of follow-up, inadequate documentation, a lousy tracking system for identifying repeat offenders, and the absence of a permanent audit program. Now OCR has decided to play “No More Mister Nice Guy” with healthcare organizations. The office’s new Phase 2 Audit Protocol is significantly tougher and more comprehensive than the 2012 version.

These Phase 2 audits will “evaluate auditees against a comprehensive set of HIPAA compliance controls.” For example, the Security Rule controls to be audited are those addressing Security Management Process requirements for Risk Analysis and Risk Management. Here’s what we know about this year’s audit process:

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