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Medicare reform in 2001--potential impact on home care
Washington Watch
Thomas A. Connaughton
Medicare Reform in 2001— Potential Impact on Home Care
Thomas A. Connaughton is president and CEO of the American Association for Homecare. Address for correspondence: AAH, 625 Slaters Lane, Suite 200, Alexandria, VA 22314; (703) 836-6263; www.aahomecare.org Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 69/1/115192 doi:10.1067/mhc.2001.115192
56 ■
Both Congress and the White House have signaled their seriousness about reforming Medicare this year. Although Congress is earnest about enacting reform to the system, the main question is whether the president and Congress have enough bipartisan support to make sweeping changes. From what the Senate Finance, House Energy and Commerce, and House Ways and Means committees have articulated, whatever reform emerges will closely resemble one of the Breaux-Frist proposals rereleased last month. The home care industry needs to examine these proposals and advocate the core principles that should be included in any legislation to guarantee beneficiaries access to quality health care services at home. One approach to modernizing Medicare is the Breaux-Frist I legislation or the Competitive Medicare Premium System that would create a seven-member Medicare Board, an agency of the executive branch, to administer the competitive environment for health care. The board would be responsible for determining beneficiary eligibility, coordinating enrollment, and negotiating contracts with entities that offer Medicare plans, including the Health Care Financing Administration (HCFA). Although all beneficiaries would be entitled to the same benefits as today, they would have the added ability to choose from a variety of plans and providers, including private plans. Breaux-Frist I would mandate that all entities offering Medicare plans must offer both the standard core benefit plan along with a highoption plan providing outpatient prescription drug coverage. Under this proposal, HCFA would be responsible for administering its own standard and high-option plans. Breaux-Frist I also would create a unified Medicare Trust Fund combining Parts A and B effective January 1, 2004.
Home Care Provider
“The Breaux-Frist bill introduced last year will be the starting point for Medicare legislation in the Finance Committee,” said Sen. Charles Grassley (RIA), chairman of that committee, at a hearing February 15.“It incorporates the principles that are critical to saving Medicare.” Unclear, however, is whether Sen. Grassley will be able to address these issues in the context of Breaux-Frist I. Many observers believe the other and less ambitious proposal put forth by Sens. Breaux and Frist—Breaux-Frist II—has a significantly better chance of enactment. This proposal establishes a new executive branch agency, the Competitive Medicare Agency, separate from the Department of Health and Human Services, which oversees Medicare+Choice plans and outpatient prescription drug coverage. Breaux-Frist II allows all Medicare beneficiaries entitled to Part A benefits and enrolled under Part B to elect outpatient prescription drug coverage beginning in 2004. A beneficiary could receive drug coverage through either a Medicare Prescription Plus Plan (for traditional Medicare enrollees) or a Medicare+Choice plan. Both plans would offer drug coverage with a $250 deductible, $2100 in initial coverage, and 50% cost-sharing. As an added benefit, the proposal would include a stop-loss prevention of $6000 so beneficiaries would never pay for drugs out of their own pockets beyond this amount. Although the narrower Breaux-Frist II has a better chance of being enacted this year, President Bush already has introduced his “Immediate Helping Hand” proposal, the fate of which is still to be determined, offering states $48 billion to help the nation’s neediest seniors pay for prescription drugs. Although the “Helping Hand” is meant only as a temporary stop-gap measure, Bush has indicated his willingness to consider moving forward
on broader health care legislation, including the BreauxFrist proposals. No matter which proposal Congress enacts, it is crucial for the home care industry to ensure that the following principles are included. Access. Medicare beneficiaries should have timely access to medically necessary home care items and services. Medicare coverage policies (national and local) should aim to provide access to appropriate technology and therapies to beneficiaries in their homes rather than control utilization. Funding for home care should be sufficient to ensure adequate access to medically necessary home care for all beneficiaries. Regulatory oversight of home care should be reasonable to beneficiaries or providers and suppliers. Choice. Medicare beneficiaries should be guaranteed the freedom to choose their home care provider or supplier. The American Association for Homecare believes that the ability to freely choose a health care provider or supplier will guarantee access to high-quality items and services. Moreover, Medicare beneficiaries should retain the right to choose upgraded items and services when they are willing to pay more than the Medicare allowable.
Fairness. Medicare beneficiaries and the providers and suppliers who serve them should receive timely notice and an opportunity to comment on changes in Medicare policy that will affect coverage and reimbursement. Medicare beneficiaries should be able to seek and obtain timely prior authorization for home care items and services and should receive timely decisions on appeals of Medicare coverage decisions and claim denials. Accessibility. Information about Medicare coverage criteria and payment policies should be comprehensive, readily available, and easy to understand. Beneficiaries and the home care providers and suppliers who serve them should not be burdened with unwieldy documentation requirements for determining eligibility, coverage, or payment requests. Although what Congress will be able to accomplish this year remains to be seen, the home care industry needs to make certain that legislators understand that the “givebacks” afforded in the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 did not go far enough to ensure the solvency of home care organizations across the country. Providers must continue to push for additional relief.
April 2001 ■ 57
Thomas A. Connaughton
Medicare Reform in 2001— Potential Impact on Home Care
Thomas A. Connaughton is president and CEO of the American Association for Homecare. Address for correspondence: AAH, 625 Slaters Lane, Suite 200, Alexandria, VA 22314; (703) 836-6263; www.aahomecare.org Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 69/1/115192 doi:10.1067/mhc.2001.115192
56 ■
Both Congress and the White House have signaled their seriousness about reforming Medicare this year. Although Congress is earnest about enacting reform to the system, the main question is whether the president and Congress have enough bipartisan support to make sweeping changes. From what the Senate Finance, House Energy and Commerce, and House Ways and Means committees have articulated, whatever reform emerges will closely resemble one of the Breaux-Frist proposals rereleased last month. The home care industry needs to examine these proposals and advocate the core principles that should be included in any legislation to guarantee beneficiaries access to quality health care services at home. One approach to modernizing Medicare is the Breaux-Frist I legislation or the Competitive Medicare Premium System that would create a seven-member Medicare Board, an agency of the executive branch, to administer the competitive environment for health care. The board would be responsible for determining beneficiary eligibility, coordinating enrollment, and negotiating contracts with entities that offer Medicare plans, including the Health Care Financing Administration (HCFA). Although all beneficiaries would be entitled to the same benefits as today, they would have the added ability to choose from a variety of plans and providers, including private plans. Breaux-Frist I would mandate that all entities offering Medicare plans must offer both the standard core benefit plan along with a highoption plan providing outpatient prescription drug coverage. Under this proposal, HCFA would be responsible for administering its own standard and high-option plans. Breaux-Frist I also would create a unified Medicare Trust Fund combining Parts A and B effective January 1, 2004.
Home Care Provider
“The Breaux-Frist bill introduced last year will be the starting point for Medicare legislation in the Finance Committee,” said Sen. Charles Grassley (RIA), chairman of that committee, at a hearing February 15.“It incorporates the principles that are critical to saving Medicare.” Unclear, however, is whether Sen. Grassley will be able to address these issues in the context of Breaux-Frist I. Many observers believe the other and less ambitious proposal put forth by Sens. Breaux and Frist—Breaux-Frist II—has a significantly better chance of enactment. This proposal establishes a new executive branch agency, the Competitive Medicare Agency, separate from the Department of Health and Human Services, which oversees Medicare+Choice plans and outpatient prescription drug coverage. Breaux-Frist II allows all Medicare beneficiaries entitled to Part A benefits and enrolled under Part B to elect outpatient prescription drug coverage beginning in 2004. A beneficiary could receive drug coverage through either a Medicare Prescription Plus Plan (for traditional Medicare enrollees) or a Medicare+Choice plan. Both plans would offer drug coverage with a $250 deductible, $2100 in initial coverage, and 50% cost-sharing. As an added benefit, the proposal would include a stop-loss prevention of $6000 so beneficiaries would never pay for drugs out of their own pockets beyond this amount. Although the narrower Breaux-Frist II has a better chance of being enacted this year, President Bush already has introduced his “Immediate Helping Hand” proposal, the fate of which is still to be determined, offering states $48 billion to help the nation’s neediest seniors pay for prescription drugs. Although the “Helping Hand” is meant only as a temporary stop-gap measure, Bush has indicated his willingness to consider moving forward
on broader health care legislation, including the BreauxFrist proposals. No matter which proposal Congress enacts, it is crucial for the home care industry to ensure that the following principles are included. Access. Medicare beneficiaries should have timely access to medically necessary home care items and services. Medicare coverage policies (national and local) should aim to provide access to appropriate technology and therapies to beneficiaries in their homes rather than control utilization. Funding for home care should be sufficient to ensure adequate access to medically necessary home care for all beneficiaries. Regulatory oversight of home care should be reasonable to beneficiaries or providers and suppliers. Choice. Medicare beneficiaries should be guaranteed the freedom to choose their home care provider or supplier. The American Association for Homecare believes that the ability to freely choose a health care provider or supplier will guarantee access to high-quality items and services. Moreover, Medicare beneficiaries should retain the right to choose upgraded items and services when they are willing to pay more than the Medicare allowable.
Fairness. Medicare beneficiaries and the providers and suppliers who serve them should receive timely notice and an opportunity to comment on changes in Medicare policy that will affect coverage and reimbursement. Medicare beneficiaries should be able to seek and obtain timely prior authorization for home care items and services and should receive timely decisions on appeals of Medicare coverage decisions and claim denials. Accessibility. Information about Medicare coverage criteria and payment policies should be comprehensive, readily available, and easy to understand. Beneficiaries and the home care providers and suppliers who serve them should not be burdened with unwieldy documentation requirements for determining eligibility, coverage, or payment requests. Although what Congress will be able to accomplish this year remains to be seen, the home care industry needs to make certain that legislators understand that the “givebacks” afforded in the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 did not go far enough to ensure the solvency of home care organizations across the country. Providers must continue to push for additional relief.
April 2001 ■ 57