FY2017 CMS Congressional Justification of Estimates for Appropriations Committees

393 Pages·2016·9.13 MB·English

DEPARTMENT OF
HEALTH
AND HUMAN
SERVICES
FISCAL YEAR
201
7
Centers for Medicare &
Medicaid Services
Justification of
Estimates for
Appropriations Committees
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

Page
Table of Contents
Organization Chart

Executive Summary
Introduction and Mission 1

FY 2017 Budget Overview 6

FY 2017 Performance Budget Overview 9

All-Purpose Table 10

Discretionary Appropriations
CMS Program Management

Budget Exhibits

Appropriations Language 13

Language Analysis 14

Amounts Available for Obligation 16

Summary of Changes 17

Budget Authority by Activity 18

Authorizing Legislation 19

Appropriations History Table 20

Appropriations Not Authorized by Law 23

Summary of the Request 25

Proposed Law Appropriation Table 29

Proposed Law Summary 31

Narrative by Activity

Program Operations 33

Federal Administration 115

Medicare Survey and Certification Program 123

Mandatory Appropriations
Medicaid 143

Payments to the Health Care Trust Funds 173

Other Accounts
HCFAC 185

CLIA 223

Quality Improvement Organizations 229

Medicare Benefits 237

Children’s Health Insurance Program 243

State Grants and Demonstrations 255

Center for Consumer Information and Insurance Oversight (CCIIO)

Affordable Insurance Exchange Grants 271

Early Retiree Reinsurance Program 275

Consumer Operated and Oriented Plan (CO-OP) Program and 277

Contingency Fund

Health Insurance Rate Review Grants 281
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

Page

Transitional Reinsurance Program 285

Risk Adjustment Program Payments 287

CMMI 289

Information Technology 307

Office of National Drug Control Policy
Resource Summary 319

Supplementary Materials

Budget Authority by Object Class 325

Salaries and Expenses 327

Detail of Positions 329

Programs Proposed for Elimination 331

Federal Employment Funded by the PPACA 333

Physicians’ Comparability Allowance (PCA) Worksheet 335

Summary of Proposed Changes in Performance Measures 339

Discontinued Performance Measures 343

Significant Items in Appropriations Committee Reports
Significant Items 357
APPROVED LEADERSHIP
DEPARTMENT OF HEALTH AND HUMAN SERVICES
As of February 1, 2016
* Acting
CENTERS FOR MEDICARE & MEDICAID SERVICES
**Reports to Deputy Admin. for Innovation and Quality
OFFICE OF EQUAL OPPORTUNITY
AND CIVIL RIGHTS OFFICE OF ENTERPRISE DATA
Anita Pinder, Director Andrew Slavitt AND ANALYTICS
Alaina Jenkins, Dep. Dir. ADMINISTRATOR* Niall Brennan, Director & CMS Chief Data Officer
Christine Cox, Dep. Dir.
Patrick Conway, M.D.
PRINCIPAL DEPUTY ADMINISTRATOR*
OFFICE OF COMMUNICATIONS
Lori Lodes, Director OFFICE OF HUMAN CAPITAL
Mary Wallace, Dep. Dir. Mandy Cohen Elisabeth Handley, Director
Vacant, Dep. Dir. CHIEF OPERATING OFFICER Vacant, Dep. Dir.
Mandy Cohen
CHIEF OF STAFF
OFFICE OF LEGISLATION
Megan O’Reilly, Director Patrick Conway, M.D. OPERATIONS
Jennifer Boulanger, Dep. Dir. DEPUTY ADMINISTRATOR FOR INNOVATION AND QUALITY AND
CMS CHIEF MEDICAL OFFICER Karen Jackson, Deputy Chief Operating Officer*
EPPS—Bridget Berardino, Director
FEDERAL COORDINATED HEALTH OAGM—Daniel Kane, Director
CARE OFFICE
Tim Engelhardt, Director OTS—Janet Vogel, Director & Dep. CIO
Sara Vitolo, Dep. Dir.
OSSO—James Weber, Director
CENTER FOR CLINICAL STANDARDS CFMFFSO--Nanette Foster Reilly, Consortium Administrator
**CENTER FOR MEDICARE AND
AND QUALITY
MEDICAID INNOVATION
OFFICE OF MINORITY HEALTH CMCHO—Jackie Garner, Consortium Administrator
Cara V. James, Director Kate Goodrich, M.D., Director Rahul Rajkumar, M.D., Dep. Dir.
Madeleine Shea, Dep. Dir. Jean Moody-Williams, Dep. Dir. Karen Jackson, Dep. Dir. CMHPO—James T. Kerr, Consortium Administrator
Debbie Hattery, Dep. Dir.
Shari Ling, M.D., Dep. Chief Medical Officer CQISCO—Renard Murray, Consortium Administrator
OHI—Randy Brauer, Director
OFFICE OF THE ACTUARY OEI—David Nelson, Director & Chief Information Officer
Paul Spitalnic, Chief Actuary
OFFICE OF STRATEGIC OPERATIONS
AND REGULATORY AFFAIRS
Kathleen Cantwell, Director
Olen Clybourn, Dep. Dir.
OFFICE OF FINANCIAL MANAGEMENT
Megan Worstell, Director & Chief Financial
Officer* CENTER FOR CONSUMER
Maria Montilla, Dep. Dir.* CENTER FOR MEDICARE CENTER FOR PROGRAM INFORMATION AND
CENTER FOR MEDICAID
INTEGRITY INSURANCE OVERSIGHT
AND CHIP SERVICES
Kevin Counihan
Sean Cavanaugh Shantanu Agrawal, M.D. Deputy Administrator and Director
Vikki Wachino
Deputy Administrator and Director Deputy Administrator and Director
Deputy Administrator and Director
Christen Young
Liz Richter Jonathan Morse Deputy Center & Policy Director
Vacant
Deputy Center Director Deputy Director
Deputy Center Director
Karen Shields*
Cynthia Tudor George Mills, Jr. Deputy Center & Operations Director
Tim Hill
Deputy Center Director Deputy Director
Deputy Center Director
Jeff Wu*
Associate Deputy Director for Policy
Executive Summary Page
Introduction and Mission 1

FY 2017 Budget Overview 6

FY 2017 Performance Budget Overview 9

All-Purpose Table 10
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EXECUTIVE SUMMARY

Agency Overview

The Centers for Medicare & Medicaid Services (CMS) is an Operating Division within the
Department of Health and Human Services (HHS). The creation of CMS (previously the
Health Care Financing Administration) in 1977 brought together, under unified leadership,
the two largest Federal health care programs at that time—Medicare and Medicaid. In
1997, the Children’s Health Insurance Program (CHIP) was established to address the
health care needs of uninsured children. CMS’ programs will touch the lives of more than
125 million Medicare, Medicaid, and Children’s Health Insurance Program (CHIP)
beneficiaries in FY 2017. CMS takes its role very seriously, as CMS’ oversight
responsibilities impact millions of citizens and continue to grow dramatically.
In the past decade, legislation has significantly expanded CMS’ responsibilities. The
American Recovery and Reinvestment Act of 2009 (ARRA or “Recovery Act”) provided
investment funding for technological advances including health information technology and
the use of electronic health records, along with prevention and wellness activities. In March
2010, the President signed into law the Affordable Care Act. The law contains numerous
provisions that impact CMS’ traditional role as the overseer of Medicare, Medicaid, and
CHIP, including: a major expansion of the Medicaid program; a two-year extension of CHIP;
the establishment of a new Federal Coordinated Health Care Office in CMS to improve care
for beneficiaries who are eligible for both Medicare and Medicaid; the gradual elimination of
the Medicare prescription drug “donut hole”; and the creation of a CMS Innovation Center to
explore different care delivery and payment models in Medicare, Medicaid, and CHIP. In
January 2011, CMS became responsible for the implementation of the Affordable Care
Act’s consumer protections and private health insurance market regulations. These
provisions include: new coverage options for previously uninsured Americans with pre-
existing conditions; reimbursement for employers to help pay part of the cost of providing
health benefits for early retirees, their spouses and dependents; new requirements
regarding the market conduct of private health care insurers; and new consumer outreach
and education efforts to help consumers assess their options and determine their eligibility
for public health programs. In 2014, CMS worked with states to create new competitive
health insurance markets that will operate through Health Insurance Marketplaces and
provide millions of Americans with access to affordable health coverage.
More recently, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
includes a number of provisions focused on transforming the Medicare program to a system
based on quality and healthy outcomes. MACRA also extended CHIP funding, ensuring
comprehensive coverage for low-income children through FY 2017. CMS is building a
better Medicare payment system for physicians and beneficiaries alike. This includes large-
scale healthcare delivery system reform efforts such as implementing the new Merit-based
Incentive Payment System (MIPS) to help reward providers for high quality, efficient care
and removing Social Security Numbers from Medicare cards to reduce both the Agency’s
and beneficiaries’ exposure to fraudulent activity. The successful and timely
implementation of MACRA is a CMS priority, as this aligns with the broader Department
effort to move the Medicare program to a health care system focused on the delivery of
safe, quality care, and value.
1
The performance budget proposes improvements to CMS’ programs that directly contribute
to significant savings and deficit reduction. CMS uses performance measures to track our
progress toward meeting our goals.
Through better care for individuals, better health for the population, and lower cost through
improvements, CMS remains committed to strengthening and modernizing the nation’s
health care system. This budget request reflects CMS’ commitment to the Medicare,
Medicaid and CHIP programs, while highlighting progress in the continued implementation
of the Health Insurance Marketplace and consumer protection programs. Building on CMS’
success in transforming America’s health care system and making quality, affordable health
insurance available to millions of Americans continues to be the priority in FY 2017.
Mission
As an effective steward of public funds, CMS is committed to strengthening and
modernizing the nation’s health care system to provide access to high quality care and
improved health at a lower cost.
Overview of Budget Request
CMS requests funding for four annually-appropriated accounts including Program
Management (PM), discretionary Health Care Fraud and Abuse Control (HCFAC), Grants
to States for Medicaid, and Payments to the Health Care Trust Funds. The table on the
next page displays CMS’ FY 2015 Final, FY 2016 Enacted, and FY 2017 President’s
Budget request for these accounts.
CMS’ resource needs are principally driven by workloads that grow annually and by its role
in leading national efforts to improve efficiency, health care quality and access to
care. CMS’ FY 2017 Program Management request reflects a level of funding that is
consistent with the magnitude and complexity of the new programs and provisions CMS is
tasked with implementing. Wherever possible, CMS will leverage its experience and
existing systems and programs to achieve efficiencies and avoid duplication of effort.
2
CMS Annually-Appropriated Accounts

(Dollars in Millions)

FY 2017 FY 2017
FY 2015 FY 2016 President’s +/-
Accounts Final Enacted Budget FY 2016
Program
Management $3,974.7 $3,974.7 $4,109.5 $134.8
HCFAC –
Discretionary $672.0 $681.0 $725.0 $44.0
Grants to States
for Medicaid 1/ $354,916.8 $356,817.5 $377,586.5 $20,769.0
Payments to
Health Care Trust
Funds 1/ $268,212.0 $283,171.8 $299,187.7 $16,015.9
Grand Total 1/ $627,775.5 $644,645.0 $681,608.7 $36,963.7
1/ Totals may not add, due to rounding. The FY 2016 enacted amount excludes
indefinite authority.
Key Initiatives
Health Insurance Marketplace
CMS is responsible for operating the Health Insurance Marketplace in states that elect not
to set up their own Marketplace, as well as for operating many other functions that support
Marketplaces in all states. The Marketplace gives millions of Americans and small
businesses access to affordable coverage. Administration of the Federally-facilitated
Marketplace continues to be an Agency priority. CMS’ FY 2017 Program Management
request includes $535.0 million in appropriated funding for the Marketplaces, along with
$1.6 billion in projected user fee collections from all sources to fund the Marketplaces at a
program level totaling $2.1 billion.
CMS Workforce
CMS is seeking to invest in enterprise workforce management and planning tools which
provide the strategy to attract talented and qualified candidates, as well as manage the
existing workforce. The tools automate the Human Resources (HR) administrative
processes through workflow capabilities, increasing the efficiency of HR operations, and
3