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WASHINGTON, June 10 — Matt Cook, admiral of Riley Children’s Health, Indianapolis, Indiana, and arch action administrator of the Indiana University Health, Indianapolis, has issued a accessible animadversion on the Centers for Medicare and Medicaid Services’ proposed aphorism advantaged “Coordinating Affliction from Out-of-State Providers for Medicaid Acceptable Accouchement with Medically Circuitous Conditions”. The animadversion was accounting and acquaint on June 3, 2020:

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On account of Indiana University Bloom (“IU Health”), we acknowledge the befalling to animadversion on the appeal for advice for CMS-2324-NC, Appeal for Advice on Analogous Affliction from Out-of-State Providers (“RFI”). We acknowledge CMS’ efforts to aggregate added advice and your advancing chat on this important issue.

IU Bloom is Indiana’s bigger and best absolute bloom arrangement and one of the busiest hospital systems in the United States. Based in Indianapolis, IU Bloom is comprised of 16 hospitals, including Riley Hospital for Accouchement at IU Bloom (“Riley”). Riley is Indiana’s bigger and best accomplished pediatric system, with over 50 affliction locations beyond the state. As one of the nation’s arch healthcare networks accurately for children, Riley’s multidisciplinary aggregation of pediatric primary affliction and specialists acquire adeptness in all areas of pediatric health. Riley is additionally the alone pediatric analysis hospital in the accompaniment of Indiana and is ranked amid the top hospitals in the nation in ten categories of specialized healthcare for children.

The aggregation at Riley cares not alone for some of the best medically circuitous cases in Indiana, but we are generally alleged to affliction for patients alfresco of our accompaniment who are in charge of specialized affliction and adeptness whether on an emergency or non-emergency basis. Unfortunately, in contempo years, Riley has been affected to accomplish the difficult accommodation to not acquire for analysis accouchement with out-of-state Medicaid due to the disability to defended a reliable antecedent of acceding from these states’ Medicaid programs. (EMTALA scenarios actuality the accessible exclusion to this practice.) This has been a difficult accommodation for our affliction aggregation as we acquire acerb in actuality able to accommodate affliction to all accouchement behindhand of geographic arena accustomed the different and specialized casework Riley has to offer.

Issues Faced with Out-of-State Care

An estimated two-thirds of accouchement with circuitous medical altitude acquire bloom allowance through Medicaid. There are common challenges in accepting acquittal from Medicaid and clandestine payers that providers face aback alleviative a adolescent that has catholic out-of-state for care. This unnecessarily burdens the already circuitous affliction that is actuality provided to pediatric cases. Approval for affliction involves allocation with the patient’s out-of-state Medicaid office, and states generally acquire assorted processes for analysis and, if denied, appeals of the denial. Delays can additionally appear aback gluttonous allotment of advantage beneath the alone bloom plans. Some states acquire accustomed the providers’ home accompaniment acceptance or acceptance in Medicare as an adequate process, but this is not universal. These challenges in the adeptness to admission affliction add accent on families already adverse abounding challenges in their circadian lives. This accent is added affronted aback accident to bloom cachet is escalated due to admission delays.

Families face abounding abroad costs aback traveling alfresco their home accompaniment for care–including abode and added biking costs, daycare costs for accouchement who abide at home, absent accomplishment for absent work, and are additionally afar from their archetypal association abutment systems. These issues can be financially and emotionally demanding for families and add to the cogent accent created by caring for a adolescent with specialized healthcare needs. Furthermore, there can be admission and barometer issues aback children, who acknowledgment home, crave chase up casework and abutment bare post-discharge whether because these casework and supports are either not accessible aback home or actual difficult for an out-of-state provider to adjustment for the child. Ordering abiding medical equipment, prescriptions from alfresco the state, accepting bare acquittal affliction for families, or accepting clandestine assignment nursing or added home affliction can all be complicated aback accouterment out of accompaniment care. Some states crave in-state providers to adjustment prescriptions or abiding medical equipment, but the in-state provider is generally not the provider best accustomed with the child’s action or care.

Areas of Befalling to Improve Admission to Care

We do believe, however, there are opportunities to actualize a added seamless arrangement of affliction for this citizenry of accouchement by creating constant behavior and abutment beyond states. Abutment for change from CMS and federal policymakers can advice advance bigger accommodating affliction beyond states for this citizenry of accouchement enrolled in Medicaid.

Support and Strengthen Basal Medicaid Behavior Analytical for All Children. Ensuring connected advantage for all children, but chiefly those accouchement with medically circuitous conditions, is important to their adeptness to acquire the affliction they charge to alive their best affection of life. Acceptance them admission to the abounding arrangement of medically all-important allowances that reflect the child’s different needs, and attached their out-ofpocket costs is additionally important to their care, behindhand of whether the affliction is provided in their home accompaniment or beyond accompaniment lines. Altering the accommodation processes and procedures as new behavior and regulations are allowable should be minimized to the greatest admeasurement accessible to anticipate accident of coverage. This is accurate whether the affliction is provided in their home accompaniment or beyond accompaniment lines. We ask CMS to advocate these important protections and ensure they are not aback beneath and assure Medicaid affairs allotment as new behavior are proposed or implemented to ensure children’s bloom and adeptness to acquire bare bloom affliction casework alfresco their home accompaniment continue.

Further Apparatus the ACE Kids Act. Another befalling to bigger alike out-of-state affliction for accouchement with medically circuitous altitude is accomplishing of the Advancing Affliction for Exceptional Kids Act (“ACE Kids Act”). The ACE Kids Act establishes added bendability beyond states for this baby accumulation of accouchement with actual circuitous medical needs to activate to abode the challenges they face accessing affliction alfresco their home states. For states that opt in, we apprehend the bloom homes tailored to this citizenry will accommodate bigger accommodating affliction beyond accompaniment lines, bigger acknowledging families as they accord with authoritative and added burdens associated with traveling for care. In addition, accepting a constant framework for accomplishing to abutment states, providers and accouchement who participate in ACE Kids– including advice on how best to operationalize the ACE Kid acceptable adolescent analogue and constant affection metrics tailored to this population–will be important to carrying on the aldermanic absorbed to accumulate and bigger abutment affliction beyond accompaniment lines. A constant way of operationalizing beyond states will additionally accredit bigger civic abstracts to analyze affliction patterns, gaps, costs and affection advance opportunities for this citizenry of children. Added bendability for accessing and analogous affliction beyond accompaniment curve and bigger abstracts on children’s needs will best accredit states and providers aback accouterment the best affection affliction for accouchement with circuitous medical conditions, no amount area bare affliction is provided.

Encourage constant approaches that assignment beyond states. As discussed above, the inconsistent approaches amid states creates authoritative burdens and puts paperwork advanced of accommodating care. Although we acquire that, as a collective federal/state program, Medicaid programs will acquire some airheadedness amid states, affliction could be bigger with acclimation for this small, but actual circuitous (and accordingly actual expensive) citizenry that charge cantankerous accompaniment curve for care. Added bendability in behavior like credentialing, acquittal and telehealth rules would abundantly advice both in Medicaid managed affliction and in fee-for-service Medicaid.

Specific Action Recommendations

Building on the basal concepts categorical above, we acclaim the afterward specific behavior that CMS could apparatus to admission bendability amid states and abate challenges for accouchement acute out-of-state care:

* Undertake an assay of this citizenry of children, their affliction patterns, acceding and affection of affliction to do a bigger job of acknowledging affliction beyond states and fast tracking accommodating admission to out-of-state affliction aback needed. This is a accepted citizenry of accouchement and through such an assay we should be able to analyze area we can do a bigger job of acknowledging this affliction and streamlining behavior and procedures. There should be bright guidelines and processes beyond states to bigger abutment affliction for this actual medically accessible citizenry of children.

* Accumulate out-of-state Medicaid provider acceptance and screening. CMS should acerb animate states to accumulate their acceptance and screening requirements for out-of-state Medicaid providers. Several states already acquire the home accompaniment acceptance of the provider and/or providers’ Medicare enrollment. If added states acclimated this approach, it would cut aback decidedly on the authoritative accountability on providers and aftereffect in added adapted affliction for children. We abutment legislation alien in the House–Accelerating Kids’ Admission to Affliction Act (H.R. 5900)– that would acquiesce a automated alleyway to acceptance and screening agnate to some states’ accepted behavior to ensure this admission is adopted added consistently beyond states.

* Accommodate abutment and advice on telehealth. We ask CMS to accommodate advice on the use of telehealth, analogue accepted ascendancy and rules about use and acquittal beneath Medicaid– decidedly for this citizenry of children. Robust telehealth networks with adapted acceding for provider-to-provider (primary affliction to circuitous dispensary care) advice while a adolescent is in an assay allowance or afterwards a adolescent allotment to their home accompaniment would advice significantly. Acknowledging this analytical advice amid the specialty provider and association providers will advice ensure accouchement break as abutting to home as accessible and alone biking aback all-important to specialty clinics or children’s hospitals.

* Abutment added bendability in the out-of-state affliction authoritative processes, including the following:

– Develop a arrangement for a distinct case acceding and animate state/health plan use.

– Accommodate advice and best practices to states on acknowledging out-of-state affliction to accumulate the process, accomplish the action added cellophane for accouchement and families and authorize adapted timelines/criteria for decisions.

– Animate states to acquire constant behavior on out-of-state affliction for all their Medicaid managed affliction plans, including constant accoutrement in Medicaid managed affliction affairs on out-of-state care.

– Animate states to ensure that, if bloom affairs accommodate providers in children’s affliction plans, afresh the provider should be included in their provider arrangement or acquire an acceding in abode for that care.

– Analyze how best to analyze the specific pediatric casework accouchement aural a accompaniment will charge to admission out-of-state affliction in their Medicaid accompaniment plan amendments.

* Added abutment for families. The administration of best practices on how to abutment families acute out- of-state affliction should be a key aspect of advice to states. There is a charge for added support/training provided to ancestors organizations to advice abutment accouchement and families as they admission affliction alfresco the accompaniment and for identification of assets accessible to advice with added costs accompanying to out-of-state biking for care. In addition, auspicious states to pay for ancestors navigators to bigger abutment families who charge to admission affliction alfresco of their home accompaniment should be included in CMS’ advice to states.

* Analyze and abode the accepted accompaniment of Medicaid acquittal for out-of-state care. We ask CMS to conduct a analysis of Medicaid out-of-state payment, accompanying opportunities and accompanying challenges, including the actuality that out-of-state costs are generally not reflected in in-state abject ante or added payments. We additionally ask CMS to analyze a CMMI affirmation activity to analysis new and artistic approaches to payment, including acceptance Medicaid funds to added acutely and seamlessly chase the adolescent beyond accompaniment lines.

* Use of non-face-to-face encounters and abiding action administration codes. States that acquire reimbursed for non-face-to-face encounters and acclimated abiding affliction administration codes for acquittal acquire added finer accurate out-of-state care. CMS should analyze how best to allotment these best practices and animate added states to accept this approach.

* Abutment added administration of advice beyond affliction settings. As interoperability is formed out, CMS should accumulate advanced of apperception the charge for consistent, reliable breeze of dispensary addendum to out-of-state primary affliction providers and defended e-communications amid accompaniment agencies and artery providers.

Once again, we acknowledge you for the befalling to accommodate animadversion on this RFI. If you acquire any questions apropos the aforementioned, amuse feel chargeless to acquaintance me via email at [email protected].


Matt Cook

President, Riley Children’s Health

Chief Action Officer, Indiana University Health

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The proposed aphorism can be beheld at: https://beta.regulations.gov/document/CMS-2020-0006-0001

TARGETED NEWS SERVICE (founded 2004) appearance non-partisan ‘edited journalism’ account briefs and advice for account organizations, accessible action groups and individuals; as able-bodied as ‘gathered’ accessible action information, including account releases, reports, speeches. For added advice acquaintance MYRON STRUCK, editor, [email protected], Springfield, Virginia; 703/304-1897; https://targetednews.com

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