Implementing the American

Recovery & Reinvestment Act of 2009

Office of E-Health Standards and Services

Centers for Medicare & Medicaid Services
 HITECH Legislation: Purpose
Improve outcomes, facilitate access, simplify care and
reduce costs by providing:

• Major financial support to providers and States

• Learning opportunities created and leveraged through TA
from CMS and others
• Far-reaching frameworks are being established that will
orchestrate federal, State and local, public and private
health care resources for generations to come

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• American Recovery & Reinvestment Act
(Recovery Act) – February 2009
• Electronic Health Record (EHR) Incentive
Notice of Proposed Rulemaking (NPRM) on
Display – December 30, 2009; published
January 13, 2010
• NPRM Comment Period Closes – March 15,
2010

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• Definition of Meaningful Use (MU)
• Definition of Eligible Professional (EP) and Eligible
Hospital/Critical Access Hospital (CAH)
• Definition of Hospital-Based Eligible Professional
• Medicare Fee-for-service (FFS) EHR Incentive
Program
• Medicare Advantage (MA) EHR Incentive Program
• Medicaid EHR Incentive Program
• Collection of Information Analysis (Paperwork
Reduction Act)
• Regulatory Impact Analysis

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• Information about applying for grants
• Changes to HIPAA
• Office of the National Coordinator (ONC)
Interim Final Rule (IFR) – Health Information
Technology (HIT): Initial Set of Standards,
Implementation Specifications, and
Certification Criteria for EHR Technology
• EHR certification requirements
• ONC NPRM - Establishment of Certification
Programs for Health Information Technology
• Procedures to become a certifying body

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• Harmonizes MU criteria across CMS programs
as much as possible
• Closely links with the ONC certification and
standards IFR
• Builds on the recommendations of the HIT
Policy Committee and external stakeholders
• Coordinates with the existing CMS quality
initiatives
• Provides a platform that allows for a staged
implementation over time

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• Medicare FFS
◦ Eligible professionals (EPs)
◦ Eligible hospitals and critical access hospitals
(CAHs)
• Medicare Advantage (MA)
◦ MA EPs
◦ MA-affiliated eligible hospital
• Medicaid
◦ EPs
◦ Eligible hospitals

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 Eligible Providers in Medicare
Eligible Professionals (EPs)
Doctor of Medicine or Osteopathy
Doctor of Dental Surgery or Dental Medicine
Doctor of Podiatric Medicine
Doctor of Optometry
Chiropractor
Eligible Hospitals*
Acute Care Hospitals
Critical Access Hospitals (CAHs)

*Subsection (d) hospitals that are paid under the PPS and are located in the 50 States
or DC (including Maryland hospitals)

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 Eligible Providers in Medicare Advantage (MA)
MA Eligible Professionals (EPs)
Must furnish, on average, at least 20 hours/week of patient-care
services and be employed by the qualifying MA organization
-or-
Must be employed by, or be a partner of, an entity that through
contract with the qualifying MA organization furnishes at least 80
percent of the entity’s Medicare patient care services to enrollees
of the qualifying MA organization
Qualifying MA-Affiliated Eligible Hospitals
Will be paid under the Medicare Fee-for-service EHR incentive
program

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 Eligible Providers in Medicaid
Eligible Professionals (EPs)
Physicians (Pediatricians have special eligibility &
payment rules)
Nurse Practitioners (NPs)
Certified Nurse-Midwives (CNMs)
Dentists
Physician Assistants (PAs) who lead a Federally
Qualified Health Center (FQHC) or rural health clinic
(RHC) that is directed by a PA
Eligible Hospitals
Acute Care Hospitals
Children’s Hospitals

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• Hospital-based EPs do not qualify for
Medicare EHR incentive payments
• Most hospital-based EPs will not qualify for
Medicaid EHR incentive payments
• Defined as an EP who furnishes 90% or more
of their services in a hospital setting
(inpatient, outpatient, or emergency room)

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 Entity Minimum Medicaid Or the Medicaid EP
patient volume practices
threshold predominantly in an
Physicians 30% FQHC or RHC—30%
needy individual
- Pediatricians 20% patient volume
Dentists 30% threshold
CNMs 30%
PAs when practicing 30%
at an FQHC/RHC that
is so led by a PA
NPs 30%
Acute care hospitals 10% Not an option for
Children’s hospitals No requirement hospitals

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 EP is also eligible when practicing predominantly
in FQHC/RHC providing care to needy individuals
 Proposes practicing predominantly is when
FQHC/RHC is the clinical location for over 50% of
total encounters over a period of 6 months in the
most recent calendar year
 Needy individuals (specified in statute) include:
◦ Medicaid or CHIP enrollees;
◦ Patients furnished uncompensated care by the provider;
or
◦ furnished services at either no cost or on a sliding scale.

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• The Recovery Act specifies the following 3
components of Meaningful Use:
1. Use of certified EHR in a meaningful manner (ex:
e-prescribing)
2. Use of certified EHR technology for electronic
exchange of health information to improve quality
of health care
3. Use of certified EHR technology to submit clinical
quality and other measures

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• Definition
o To be determined by Secretary
o Must include quality reporting, electronic
prescribing, information exchange
• Process of defining
o NCVHS hearings
o HIT Policy Committee (HITPC) recommendations
o Listening Sessions with providers/organizations
o Public comments on HITPC recommendations
o Comments received from the Department and the
Office of Management and Budget (OMB)

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 Improved
outcomes
Advanced
clinical
Data processes
capture and
sharing

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• Meaningful Use will be defined in 3 stages
through rulemaking
◦ Stage 1 – 2011
◦ Stage 2 – 2013*
◦ Stage 3 – 2015*

*Stages 2 and 3 will be defined in future CMS rulemaking.

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• Improving quality, safety, efficiency, and
reducing health disparities
• Engage patients and families in their health
care
• Improve care coordination
• Improve population and public health
• Ensure adequate privacy and security
protections for personal health information
*Adapted from National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts
to Transform America’s Healthcare. Washington, DC: National Quality Forum; 2008.

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• EPs
◦ 25 Objectives and Measures
◦ 8 Measures require ‘Yes’ or ‘No’ as structured data
◦ 17 Measures require numerator and denominator
• Eligible Hospitals and CAHs
◦ 23 Objectives and Measures
◦ 10 Measures require ‘Yes’ or ‘No’ as structured data
◦ 13 Measures require numerator and denominator
• Reporting Period – 90 days for first year; one
year subsequently

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1. Use CPOE
2. Implement drug-drug, drug-allergy, drug-
formulary checks
3. Maintain an up-to-date problem list of
current and active diagnoses based on ICD-
9-CM or SNOMED CT®
4. Maintain active medication list
5. Maintain active medication allergy list
6. Record demographics
7. Record and chart changes in vital signs

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8. Record smoking status for patients 13 years and older
9. Incorporate clinical lab-test results into EHR as structured
data
10. Generate lists of patients by specific conditions to use for
quality improvement, reduction of disparities, and outreach
11. Report ambulatory quality measures to CMS or the States
12. Implement 5 clinical decision support rules relevant to
specialty or high clinical priority, including diagnostic test
ordering, along with the ability to track compliance with
those rules
13. Check insurance eligibility electronically from public and
private payers
14. Submit claims electronically to public and private payers

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15. Provide patients with an electronic copy of their health information
upon request
16. Capability to electronically exchange key clinical information among
providers of care and patient-authorized entities
17. Perform medication reconciliation at relevant encounters and each
transition of care
18. Provide summary care record for each transition of care and referral
19. Capability to submit electronic data to immunization registries and
actual submission where required and accepted
20. Capability to provide electronic syndromic surveillance data to public
health agencies and actual transmission according to applicable law
and practice
21. Protect electronic health information created or maintained by the
certified EHR technology through the implementation of appropriate
technical capabilities

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1. Generate and transmit permissible
prescriptions electronically
2. Send reminders to patients per patient
preference for preventive/follow-up care
3. Provide patients with timely electronic access
to their health information within 96 hours
of information being available to the EP
4. Provide clinical summaries for patients for
each office visit

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1. Provide patients with an electronic copy of
their discharge instructions and procedures
at time of discharge, upon request
2. Capability to provide electronic submission
of reportable lab results, as required by state
or local law, to public health agencies and
actual submission where it can be received.

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• 2011 – Providers required to submit summary
quality measure data to CMS or States by
attestation
• 2012 – Providers required to electronically
submit summary quality measure data to CMS or
States
• EPs are required to submit clinical data on the 2
measure groups: core measures and a subset of
clinical measures most appropriate to the EP’s
specialty
• Eligible hospitals are required to report summary
quality measures for applicable cases

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• Preventive care and screening: Inquiry
regarding tobacco use
• Blood pressure management
• Drugs to be avoided by the elderly:
o Patients who receive at least one drug to be avoided
o Patients who receive at least two different drugs to
be avoided

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 EPs will need to select one of the following specialties
Cardiology Obstetrics and Gynecology
Pulmonology Neurology
Endocrinology Psychiatry
Oncology Ophthalmology
Proceduralist/Surgery Podiatry
Primary Care Radiology
Pediatrics Gastroenterology
Nephrology

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• Hospitals are required to report summary
data to CMS or States on 35 clinical quality
measures
• For the Medicaid program incentive, hospitals
have the option to select 8 alternative
Medicaid clinical quality measures to meet
the requirements for reporting if the 35
measures do not apply to their patient
population
• Hospitals only eligible for Medicaid will report
directly to the States

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 Adopt, implement, upgrade (AIU)
◦ First participation year only
 Meaningful use (MU)
◦ Successive participation years; and
◦ Proposed option for early adopters in year 1
 States may propose to CMS for approval
limited additional criteria for MU, beyond the
NPRM
◦ NPRM is the MU base-level requirement
 Prioritizing coordination between:
◦ CHIPRA and HITECH

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Adopt: Acquired and installed
- e.g., evidence of acquisition, installation etc.
Implement: Commenced utilization
- e.g., staff training, data entry of patient
demographic information into EHR, data use
agreements
Upgrade: Version 2.0; expanded functionality
- e.g., ONC EHR certification (short-term) or
additional functionality such as clinical support or
HIE capacity (longer-term)

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 Eligible hospitals, unlike EPs, may receive
incentives from Medicare and Medicaid
◦ Subsection(d) hospitals, also acute care

 Hospitals meeting Medicare MU requirements

may be deemed for Medicaid , even if the
State has an expanded (approved) definition
of meaningful use

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 There is a deliberate overlap between the
CHIPRA core measures and the Stage 1
measures for MU.
◦ BMI 2-18 yrs old
◦ Annual hemoglobin A1C testing (all children and
adolescents diagnosed with diabetes)
◦ Pharyngitis - appropriate testing 2-18 yrs old
◦ Follow-up care for children prescribed attention-
deficit/hyperactivity disorder (ADHD) medication

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 The Medicaid EHR Incentive Program starts in
2011 and ends in 2021
 The latest that a Medicaid provider can
initiate the program is 2016
 A Medicaid provider can initiate the program
under the Adopt, Implement and Upgrade bar
but in their 2nd and subsequent years, they
must meet MU at the stage that is in place,
per rule-making (Stage 3 by 2015).

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• EPs
◦ Medicare FFS
◦ Medicare Advantage
◦ Medicaid
• Eligible Hospitals and CAHs
◦ Medicare FFS
◦ Medicare Advantage (paid under Medicare FFS)
◦ Medicaid

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• Eligible professionals (EPs)
o Calendar Year
o 2011-2016 (Medicare) – Up to $44,000 over 5 years
if “meaningful EHR user”
o 2011-2021 (Medicaid) – Up to $63,750 over 6 years
– Adopt/Implement/Upgrade or meaningful use in
Year 1, MU Years 2-6
o 2015 and later – If not “meaningful EHR user” up to
3% payment adjustment in Medicare reimbursement
o We propose that after the initial designation, EPs be
allowed to change their program selection only
once during payment years 2012 through 2014

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 First Calendar Year in which the EP receives an Incentive
Payment
Calendar CY 2011 CY 2012 CY 2013 CY 2014 CY 2015
Year and later
2011 $18,000
2012 $12,000 $18,000
2013 $8,000 $12,000 $15,000
2014 $4,000 $8,000 $12,000 $12,000
2015 $2,000 $4,000 $8,000 $8,000 $0
2016 $2,000 $4,000 $4,000 $0
TOTAL $44,000 $44,000 $39,000 $24,000 $0

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 First Calendar Year in which the EP receives an Incentive
Payment
Calendar CY 2011 CY 2012 CY 2013 CY 2014 CY 2015
Year and later
2011 $1,800
2012 $1,200 $1,800
2013 $800 $1,200 $1,500
2014 $400 $800 $1,200 $1,200
2015 $200 $400 $800 $800 $0
2016 $200 $400 $400 $0
TOTAL $4,400 $4,400 $3,900 $2,400 $0

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 First Calendar Year in which the EP receives an Incentive
Payment
Calendar CY 2011 CY 2012 CY 2013 CY 2014 CY 2015 CY 2016
Year
2011 $21,250
2012 $8,500 $21,250
2013 $8,500 $8,500 $21,250
2014 $8,500 $8,500 $8,500 $21,250
2015 $8,500 $8,500 $8,500 $8,500 $21,250
2016 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250
2017 $8,500 $8,500 $8,500 $8,500 $8,500
2018 $8,500 $8,500 $8,500 $8,500
2019 $8,500 $8,500 $8,500
2020 $8,500 $8,500
2021 $8,500
TOTAL $63,750 $63,750 $63,750 $63,750 $63,750 $63,750
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• Eligible hospitals
◦ Federal Fiscal Year
◦ $2M base + per discharge amount (based on
Medicare/Medicaid share)
◦ Hospitals meeting Medicare MU requirements may
be deemed eligible for Medicaid payments
◦ Payment adjustments for Medicare after 2015
◦ Medicare hospitals cannot receive payments after
2016. For Medicaid, hospitals cannot initiate
payments after 2016 but can receive payments if
they initiated the program before 2016
◦ No penalties for Medicaid
◦ NPRM has narrative and sample calculation

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• Medicare can pay incentives to EPs no sooner
than January 2011
• Medicare can pay eligible hospitals and CAHs
no sooner than October 2010
• Medicaid EPs can potentially receive payments
as early as 2010 for adopting, implementing
or upgrading

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 Prior approval for reasonable administrative
expenses (P-APD, I-APD)
 Establish a State Medicaid HIT Plan (SMHP)
 State may receive 90% FFP and 100% FFP for
the payments themselves
 NPRM defines numerous previously undefined
terms in CFR
◦ Medicaid Management Information Systems (MMIS)
◦ Medicaid IT Architecture (MITA)

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 Statutory Conditions of Use of the HITECH Admin
Funds:

1. Administration of incentives, including tracking of

meaningful use by Medicaid EPs and eligible
hospitals;
2. Oversight, including routine tracking of meaningful
use attestations and reporting mechanisms; and
3. Pursuing initiatives to encourage the adoption of
certified EHR technology for the promotion of
health care quality and the exchange of health care
information.

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 3 Key Elements: What is the current HIT landscape?
What is the State’s Vision for the next 5 years? How
will they implement and oversee a successful EHR
Incentive Program?
 NPRM proposes States uses MITA principles in
developing SMHP
 SMHP will include State’s methodologies for
verifying eligibility; disbursing payments;
coordinating with stakeholders; contracting; privacy
& security; curtailing fraud & abuse; and other
activities

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 States and CMS must assure there is no
duplication of payments to providers (between
States and between States and Medicare)
 States are required to seek recoupment of
erroneous payments and have an appeals
process
 CMS/Medicaid has oversight/auditing role
including how States implement the EHR
Incentive Program (90% FFP) and how they
make correct payments to the right providers
for the right criteria (100% FFP).

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 Other Medicare Incentive
Program
Medicare Physician Quality
Reporting Initiative (PQRI)
Medicare Electronic Health
Records Demonstration
(EHR Demo)
Medicare Care
Management Performance
Demonstration (MCMP)
Electronic Prescribing
Incentive Program (eRx)
Eligible for HITECH?
Yes, if the PQRI incentive is extended in its current
format beyond 2010, EPs can participate in both if they
are eligible
Yes, if the EP is eligible
Yes, if the practice is eligible. The MCMP demo will end
before EHR incentive payments are available
If the EP chooses to participate in the Medicare EHR
Incentive Program, they cannot participate in the
Medicare eRx Incentive Program simultaneously. If the
EP chooses to participate in the Medicaid EHR Incentive
Program, they can participate in the Medicare eRx
Incentive Program simultaneously
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 Medicare
Feds will implement (will be an option
nationally)
Fee schedule reductions begin in 2015
for providers that are not Meaningful
Users
Must be a meaningful user in Year 1
Maximum incentive is $44,000 for EPs
MU definition will be common for
Medicare
Medicare Advantage EPs have special
eligibility accommodations
Last year an EP may initiate program is
2014; Last payment in program is 2016;
Payment adjustments begin in 2015
Only physicians, subsection (d) hospitals
and CAHs
Medicaid
Voluntary for States to implement (may
not be an option in every State)
No Medicaid fee schedule reductions
A/I/U option for 1st participation year
Maximum incentive is $63,750 for EPs
States can adopt a more rigorous
definition (based on common definition)
Medicaid managed care providers must
meet regular eligibility requirements
Last year an EP may initiate program is
2016; Last payment in program is 2021
5 types of EPs, 3 types of hospitals
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• Public comment period ends March 15, 2010
• CMS review of comments
• Draft final regulation
• CMS/HHS/OMB clearance
• Final rule publication - Spring 2010
• CMS On-going review of States’ Planning
APDs
• CMS to issue additional guidance on Medicaid
90/10 Implementation funding
• On-Going Federal HIT Coordination (ONC,
AHRQ, HRSA, IHS, FCC, etc)

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• Visit http://www.regulations.gov
o Document type: Proposed Rule
o Keyword or ID: CMS-2009-0117-0002
• Comments are due March 15, 2010 at 5 p.m.

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• A/I/U – Adopt, implement or upgrade
• CAH – Critical Access Hospital
• CCN – CMS Certification Number
• CDS – Clinical Decision Support
• CMS – Centers for Medicare & Medicaid
Services
• CY – Calendar Year
• EHR – Electronic Health Record
• EP – Eligible Professional
eRx – E-Prescribing
•
FFS – Fee-for-service
•
FY – Federal Fiscal Year
•
HHS – U.S. Department of Health and
•
Human Services
• HIT – Health Information Technology
HITECH Act – Health Information
•
Technology for Electronic and Clinical
Health Act
• HITPC – Health Information Technology
Policy Committee
• HIPAA – Health Insurance Portability and
Accountability Act of 1996
• HPSA – Health Professional Shortage
Area
• IFR – Interim Final Rule
• MA – Medicare Advantage
• MCMP – Medicare Care Management
Performance Demonstration
• MITA- Medicaid Information Technology
Architecture
MU – Meaningful Use
•
NPI – National Provider Identifier
•
NPRM – Notice of Proposed Rulemaking
•
OMB – Office of Management and Budget
•
• ONC – Office of the National Coordinator
of Health Information Technology
PQRI – Medicare Physician Quality
•
Reporting Initiative
• Recovery Act – American Reinvestment &
Recovery Act of 2009
• TIN – Taxpayer Identification Number
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