Medicare Watch

Final Rule Promotes Prevention

This week, the Centers for Medicare & Medicaid Services (CMS) released the final rule for physician payments under Part B of Medicare. The rule not only sets payment rates for doctors and other providers who participate in Medicare, but also implements important provisions of the Affordable Care Act (ACA) that eliminate Medicare consumers’ out-of-pocket costs for certain preventive services.

Specifically, the rule implements the new annual wellness visit under Medicare. At the annual wellness visit, which must be in the form of a face-to-face consultation, doctors will update the patient’s care plan and history. They will also measure vital statistics, such as their blood pressure and body weight, and other items the doctor feels should be monitored, based on the patient’s medical history. In addition, providers will test for cognitive impairments, as well as set and update testing schedules for other conditions as needed, based on the patient’s condition for the next five to ten years. Other preventive services covered at no cost to consumers who qualify include mammographies, screenings for colon and cervical cancer, osteoporosis and heart disease, as well as tobacco cessation counseling.

In an effort to emphasize and improve access to primary care, the rule also implements a provision of the ACA that provides incentive payments for primary care physicians. However, the rule also includes the 25 percent cut in reimbursement rates for Medicare physicians under the Sustainable Growth Rate formula (SGR), which was included in the Balanced Budget Act of 1997. Congress has taken action to avert the cuts in the past, and must do so again by December 1, 2010, in order to avoid the cuts taking effect.

Read Medicare Rights Center’s preventive services fact sheet.

Read Medicare Rights Center’s press release on the final rule.

Read the final rule on payments for physicians under Part B.

Read the CMS fact sheet on the final rule.

Improvement Not Required for Coverage of Skilled Therapy

The Centers for Medicare & Medicaid Services (CMS) has incorrectly denied coverage for skilled nursing facility (SNF) and home health care to individuals, according to two recent federal court decisions. CMS had denied coverage because, in the Medicare program’s view, the plaintiffs’ conditions had not improved. The courts found, however, that under the law, individuals could obtain coverage for qualified therapy in SNF and home care settings if the services were needed to prevent deterioration of their condition, and that improvement is not required for coverage of such services. The Center for Medicare Advocacy (CMA) is leading an education and advocacy campaign about the improper use of the improvement standard in Medicare. The focus of the campaign is to raise awareness about the issue, and to eliminate the improper use of the standard by Medicare and Medicare contractors.

CMS also released this week the final rule on prospective payments for home health care in 2011, which includes regulations implementing coverage for skilled therapy services in a home health care setting. Some stakeholders who had earlier provided comments on the proposed rule, including CMA and the Medicare Rights Center, had expressed concern about the clarity of CMS’s current coverage requirements, and cautioned that regulatory language improperly emphasized improvement as a requirement for coverage. CMS provided a response to comments, stating that the new rule neither limits nor expands available coverage, and that maintenance therapy may be covered, as it always has been, if the condition of the patient requires complex services that only a qualified therapist can provide.

Read about the federal court decisions.

Learn more about the improvement standard issue and CMA’s campaign.

Read the rule and CMS’s response to comments.

Medicare Reminder

You are limited in when you can change your Medicare health plan during the year.

1. You can switch Medicare private plans during Fall Open Enrollment (sometimes referred to as the Annual Coordinated Election Period), which runs from November 15 through December 31 in 2010.
2. You can switch from your Medicare private health plan (except MSA plan) to Original Medicare during the Medicare Advantage Disenrollment Period (MADP). The MADP will occur every year starting in 2011, from January 1 to February 14.
3. Under certain circumstances, you may be eligible for a Special Enrollment Period (SEP) to change your health and/or drug plan outside of the usual enrollment or disenrollment periods.

Learn more about when you can change your Medicare health plan.

Find answers to your Medicare questions at www.MedicareInteractive.org.

Spotlight

Earlier today, the Kaiser Family Foundation released the latest version of its Medicare Chartbook. This resource provides a current snapshot of the Medicare program, and places it in the context of historical data and trends.

View the Medicare Chartbook.