Medicare Watch

Comprehensive Primary Care Initiative Seeks to Support Primary Care

Yesterday, the Centers for Medicare & Medicaid Services (CMS) announced a new, four-year initiative to improve primary care for Medicare and Medicaid beneficiaries. Made possible by the Affordable Care Act, the initiative seeks to support primary care’s role in promoting patients’ health, strengthening care coordination and reducing overall health care system costs.

Under this Comprehensive Primary Care initiative, administered by the Center for Medicare & Medicaid Innovation (CMMI), CMS will collaborate with commercial and state health insurance plans; so far, insurers operating across eight different states have agreed to participate. Together, these agencies will offer bonus payments to primary care providers to help them provide enhanced, comprehensive primary care services. Enhanced services include longer, more flexible hours of provider availability, use of electronic medical records, delivery of preventive services, improved care coordination and individualized treatments for patients living with chronic conditions and other high medical needs.

According to CMS, the initiative’s multi-payer system will build on previous efforts to improve primary care delivery. The collaboration will pool the resources of independent health insurers and collectively invest them in transforming primary care practices and making a broader array of services available to patients. CMS will choose approximately 75 primary care practices in the areas served by the participating insurers. Applications for the Comprehensive Primary Care Initiative will be accepted until July 20.

Read more about the Comprehensive Primary Care Initiative.

Apply to participate in the initiative as a primary care provider.

Study Shows Experience with Integrated Plans for Duals is Limited

Many states are currently developing models to improve care coordination for dual-eligibles, or people with both Medicare and Medicaid—a population that accounts for a disproportionate amount of spending in both programs. But states and health insurance plans have little experience coordinating Medicare and Medicaid benefits for dual-eligibles within a single integrated plan, reports a study published in this month’s issue of Health Affairs (“There is Little Experience and Limited Data to Support Policy Making on Integrated Care for Dual-Eligibles”). Additionally, very few duals are currently enrolled in fully integrated plans, which are meant to coordinate care across Medicare and Medicaid. Most people receive benefits for each of these programs separately.

The study utilizes data from Medicare and Medicaid managed care plans, including Special Needs Plans for dual-eligibles (D-SNPs), the Program of All-Inclusive Care for the Elderly (PACE) and Medicaid managed care, to examine dual-eligible enrollment. PACE is a fully integrated program that provides all services covered by Medicare and those offered under a state’s Medicaid program. The study found that less than 1 percent of duals were enrolled in a PACE program in almost every state. Nationally, only 12 percent of dual-eligibles were enrolled in a D-SNP. And in most states, there is no or little enrollment of duals in comprehensive Medicaid managed care plans.

According to the study, there exists a need for better and more comprehensive information about current enrollment in integrated plans. Analysis of available enrollment data shows that states have very limited experience with integrating Medicare and Medicaid for dual-eligibles. The authors contend that as a result, policymakers should exercise caution when considering policies that would rapidly require states to coordinate integrated care for these individuals.

Read the Health Affairs article.

Medicare Reminder

Medicare will cover outpatient physical and occupational therapy, as well as speech therapy services, if:

• They are medically necessary;
• Your doctor or therapist sets up the plan of treatment; and
• Your doctor periodically reviews the plan to determine how long you will need therapy.

Generally, Medicare will only cover therapy services if your condition can improve or if your condition would deteriorate without therapy.

You can access therapy services as an outpatient of a participating hospital, rehabilitation agency, comprehensive outpatient rehabilitation facility (CORF) or public health agency. If you qualify for home health benefits, you can access therapy services from your home health care agency, and if you qualify for skilled nursing facility (SNF) benefits, you can access therapy services from your SNF. You may also be able to receive services from a privately-practicing and Medicare-approved physical, speech or occupational therapist in his or her office or in your home.

In 2012, Medicare will cover up to $1,880 for physical and speech therapy combined, and an additional $1,880 for occupational therapy. If you are approaching the limit and need more therapy, your doctor can request additional therapy. If Medicare denies the claim, you can appeal.

Learn more about Medicare coverage of outpatient therapy services at www.medicareinteractive.org, or call our helpline at 800-333-4114.

Spotlight

What will happen if the Supreme Court repeals the Affordable Care Act? The number of uninsured Americans will continue to increase, and there will be “chaos” in the health care delivery system, said Bruce Vladeck in a recent interview with Kaiser Health News. Vladeck, who is chairman of the Medicare Rights Center’s board of directors, also stated that implications for the future of health care—including that of the Medicare program—remain uncertain at this time, absent a decision from the court.

Watch the interview.