Volumne 12, Issue No. 1
February 4, 2014

What’s Happening on Health Care Reform?

We recently celebrated the one-year anniversary of the Affordable Care Act (ACA), which became law on March 23, 2010.  Although the Act is very long and complex, like many federal laws, the details are left up to federal agencies and departments – as well as the States – which must issue rules and other decisions to actually carry out its policies and create its programs.  In addition, many ACA provisions build upon, change, or add to federal programs that are already in existence — especially Medicare, Medicaid, and CHIP (the Children’s Health Insurance Program).  Here is an update on what has been happening in federal agencies and departments, in recent actions to carry out the goals and provisions of ACA.  View ANA comments on these and other regulatory issues.

Face-to-Face encounters required for Medicare home health, hospice

The Affordable Care Act now requires “face-to-face encounters” with patients who receive Medicare home health or hospice services, to ensure these services are appropriate.  For home health, the certifying physician or a “non-physician practitioner” working with the physician must see the patient within 90 days before, or 30 days after, the start of care.  For hospice, a hospice physician or nurse practitioner must see the patient prior to the 180th-day recertification, and any additional recertifications.  (Hospice encounters must be within 30 days before the third benefit period.)  These requirements were scheduled to take effect on January 1, 2011.  However, CMS (the Centers for Medicare & Medicaid Services), decided to delay their enforcement until the start of the second quarter of 2011 – or April 1, 2011 – to provide additional time to establish operational protocols to adopt the new requirements.  “Beginning in the second quarter, CMS will expect home health agencies and hospices to have fully established such internal processes and have appropriate documentation of required encounters.”  CMS plans to update information and answer questions on these web pages: www.cms.gov/center/hha.asp and www.cms.gov/center/hospice.asp.

New “Physician Compare” website includes information on APRNs

On December 30, 2010, CMS launched the new “Physician Compare” website as required under section 10331 of ACA.  Physician Compare is designed to help all patients, including Medicare beneficiaries, locate providers within their communities.  It contains information about – Medicare providers, including nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse-midwives.  Consumers can use the site to search for providers by specialty, type of profession, location, gender, education, languages spoken, group practice and hospital affiliations, and whether the provider accepts Medicare as payment in full.  CMS is scheduled to include information on performance – from the Physician Quality Reporting System – by January 2013.  CMS has recently made available a “Physician Compare Initiative” web page specifically for physicians and other health care providers, to provide links and information about CMS forums and resources.   For more information on the Physician Compare website, visit here

Medicare begins free annual “wellness” and preventive health visits

The Department of Health and Human Services (HHS) recently reported that over 150,000 Medicare beneficiaries received annual wellness visits in January and February 2011, or about 2,800 per day.  Under ACA, this visit and certain other prevention services are now provided free of charge, without a copayment or deductible, for seniors and persons with disabilities enrolled in Medicare Part B.  These include cancer screenings such as mammograms and colonoscopies, tobacco cessation counseling, some immunizations, and other services recommended by the U.S. Preventive Services Task Force.  Previously, Medicare only paid for the initial “Welcome to Medicare” visit.  A full report is available here.

Medicaid “Preventable Conditions” proposal stirs controversy

The Centers for Medicare & Medicaid Services issued a proposed rule on February 17 that would disallow federal funding to state Medicaid program spending to treat certain preventable health conditions.  This rule implements section 2702 of the Affordable Care Act, to bring Medicaid more in line with Medicare’s payment prohibitions for certain hospital-acquired conditions not present on admission.  In March, leading hospital and provider groups objected to the proposal in public comments calling for better alignment between Medicare and Medicaid policies, consistent standards across all states, and delayed implementation of the rule.  The American Medical Association comments supported “encouraging compliance with evidence-based guidelines” rather than non-payment policies for Medicare or Medicaid, which “will place Medicaid patients at further risk of reduced access to care and increased financial costs, with unproven benefits, on an already over-stretched Medicaid program.”

Help for the Medicare Part D “doughnut hole”

CMS recently reported that 3.75 million Medicare beneficiaries received $250 rebate checks during 2010, as part of the ACA provisions to help patients facing the gap in prescription drug coverage known as the “doughnut hole.”  Another 250,000 were estimated to receive the $250 one-time rebates.  About 48,000 Medicare Part D beneficiaries who reached the gap received 50 percent manufacturers’ discounts on covered brand-name drugs in the first two months of a new program established under ACA, with average savings around $800 each.  The discount program is for enrollees who don’t qualify for low-income subsidy assistance, and 29 percent are disabled persons under 65.

“MLR” & limits on insurance premium increases

Beginning in 2012, ACA will require individual and small group health insurance plans to spend at least 80 percent of premiums on medical claims or quality improvements.  Large group plans must devote 85 percent of their premiums on substantive care.  Otherwise, insurers must refund the difference to policyholders.  This is known as the “Medical Loss Ratio Rule” or “MLR.”  The Department of Health and Human Services can provide waivers for individual plans that would be “destabilized” by meeting the requirement.  As of late March 2011, seven such requests had been received, with the latest coming from North Dakota, where the MLR for individual plans is 55 percent.  On March 8, Maine became the first state to receive an adjustment to the rule, with the new CMS Center for Consumer Information and Insurance Oversight (CCIIO) approving a lower standard of 65 percent.

In December 2010, HHS issued a proposed rule that would require review of health insurance premium increases above 10 percent, which is expected to be finalized this summer.  The rule is designed to lower rates for consumers and provide more information for consumers and insurance regulators.  On March 7, CMS proposed requiring insurers to file a disclosure notice when they planned to increase rates more than 10 percent. CCIIO director Steve Larsen believes this “will turn out to be one of the key parts of the Affordable Care Act because for the first time it’s going to give people some visibility not only into proposed increases, but also into the components of the premium and [what] in particular is going to be driving rate increases in the future.”

Small businesses getting tax credits for offering health insurance

Democratic members of the House Small Business Committee issued a report on March 23, reflecting that 650,000 new small businesses have begun to offer health insurance coverage since 2009 – thus earning a 35 percent tax credit under the Affordable Care Act.  They said the tax credit – which increases to 50 percent of costs in 2014 – will provide as much as $40 billion in tax relief to as many as 6.7 million small businesses.

Eileen Shannon Carlson, RN, JD

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