Welcome to Medicare Heads Up, a regular feature intended to deliver state and national Medicare-related headlines that will keep consumers abreast of developments that affect their coverage and costs. This week:
Medicare hospice choice model extended for additional year
The Center for Medicare and Medicaid Innovation (CMMI) has announced it will extend the Medicare Care Choices Model (MCCM) through the end of 2021. Medicare and Medicaid beneficiaries normally aren’t covered by Medicare for curative treatment for a terminal illness once they enter hospice, but under the MCCM program, they are allowed to continue receiving curative treatment with their palliative care services.
A total of 82 hospice providers currently participate in the program, which had been scheduled to end this year. MCCM is intended to reduce Medicare spending during hospice while allowing beneficiaries to be more satisfied with their care. Beneficiaries interested in this option should speak with their hospice provider or the physician who ordered the hospice. (Here is a list of the participating providers.)
(Medicare always covers curative treatment for illnesses unrelated to a beneficiary’s terminal condition. For example, if a diabetic beneficiary dying of congestive heart failure elects hospice, Medicare will still cover physician visits and medications for diabetes. And while that beneficiary could normally only receive palliative treatment for the heart condition, under the MCCM program, the beneficiary could receive both palliative and curative care.)
Black Medicare beneficiaries nearly four times as likely to be hospitalized with coronavirus
The Centers for Medicare and Medicaid Services (CMS) released claims data showing that Black Medicare beneficiaries were nearly four times as likely to be hospitalized for coronavirus as white beneficiaries.
More than 325,000 Medicare beneficiaries were diagnosed with COVID-19 during the period from January 1 through May 16, 2020 – equivalent to about 518 coronavirus cases per 100,000 beneficiaries. Of those beneficiaries, 110,000 were hospitalized for COVID-19 – which equals about 175 hospitalizations for every 100,000 beneficiaries.
COVID-19 patients with pre-existing medical conditions are likely to have longer illnesses and poorer outcomes. The Medicare data showed that among Original Medicare beneficiaries who were hospitalized, the most common comorbid conditions were hypertension (79%), high cholesterol (60%), chronic kidney disease (50%), anemia (50%), and diabetes (50%). Medicare paid $1.9 billion in hospitalization costs, which averaged $23,094 per beneficiary treated.
The data also showed beneficiaries were more likely to need extensive treatment if they were poor. This category includes dual eligibles insured by Medicare and Medicaid – who were hospitalized at a rate of 473 per 100,000 beneficiaries (and this was significantly higher than the rate of 112 per 100,000 for beneficiaries who only had Medicare).
CMS said the data show why the agency must continue efforts to tie Medicare’s payments to patient outcomes rather than the amount of care provided – which will improve access to services for lower income beneficiaries.
Home health providers can use telehealth in 2021, but won’t be reimbursed
In 2021, Original Medicare intends to continue its current policy of not reimbursing home health providers for services provided by telehealth. CMS has proposed to permanently extend rules it issued to address the COVID-19 pandemic, which allow home health providers to care for patients using telehealth under certain conditions – even though Medicare will not reimburse them for those services. Telehealth services have to be specified in the beneficiary’s home health plan of care in order to be eligible for coverage, be related to the skilled services provided, and tied to a specific treatment goal.
Congress must change the Medicare law in order for CMS to directly reimburse home health agencies for services provided through telehealth. Lobbyists for home health agencies told Home Health Care News in May that they were continuing to advocate for legislation that would allow Medicare reimbursement for telehealth-based home health.
The CMS regulation would mean beneficiaries’ access to telehealth-based home healthcare will remain the same as it is now in 2021 – unless Congress passes legislation to expand Medicare’s home health coverage.
Dialysis patient group sues HHS over dialysis facility coverage in Medicare Advantage
A nonprofit organization representing dialysis patients has sued CMS over a rule that will allow Medicare Advantage plans to drop dialysis facilities from their networks. Dialysis Patient Citizens is suing to block a CMS policy under which Medicare Advantage insurers will no longer have to ensure outpatient dialysis facilities are located within a specific time and distance from enrollees’ homes. Beginning August 3, 2020, insurers will instead attest to having an adequate number of facilities in-network – which the organization says is insufficient to ensure beneficiary access.
The 21st Century CURES Act permitted End-Stage Renal Disease (ESRD) beneficiaries to enroll in most Medicare Advantage plans for the first time beginning in 2021. When CMS implemented this provision of the CURES Act, it allowed insurers to exclude dialysis facilities from their networks, undercutting Congress’s intent of expanding the insurance options for ESRD patients when it passed the CURES Act. The organization says that Medicare Advantage will not be a realistic option for ESRD patients if insurers have few in-network dialysis facilities – as this could mean that many enrollees will have to remain in Original Medicare if they wish to continue care at a nearby dialysis facility (and with Original Medicare, dialysis is covered under Medicare Part B, which means the enrollee pays 20 percent of the cost unless they have supplemental coverage; in many states, Medigap plans are unavailable or prohibitively expensive for enrollees under age 65 with ESRD).
CMS issued the regulation at the same time that the Trump Administration isworking to encourage more ESRD beneficiaries to receive home-based dialysis, which costs less than hemodialysis in a facility and occurs at home (although beneficiaries who receive this type of treatment may still visit a dialysis facility periodically). In its lawsuit, the organization said that most home-based dialysis patients are higher income and white, while lower-income, Black and Hispanic patients rely more heavily on access to outpatient dialysis facilities impacted by the rule.
American Medical Association urges Congress to pass legislation changing Medicare Advantage prior-authorization
The American Medical Association (AMA) is asking Congress to pass legislation to standardize prior-authorization processes used by Medicare Advantage insurers. In a 2018 consensus statement, America’s Health Insurance Plans, the Blue Cross Blue Shield Association, AMA, and other provider groups agreed to insurers making several changes to prior-authorization processes in Medicare Advantage and commercial insurance, including reviewing the services and medications requiring prior-authorization each year and communicating prior-authorization rule changes with providers.
The insurers also agreed to ease prior-authorization rules to promote continuity of care for patients when beneficiaries enroll in a plan for the first time.
But the AMA says that insurers are not making progress toward these goals, which is why it is encouraging Congress to pass The Improving Seniors’ Timely Access to Care Act (H.R. 3107), which would require Medicare Advantage insurers to do these things. The legislation has been referred to the House Committee on Energy and Commerce – although the committee hasn’t scheduled a hearing.
Medicare Advantage beneficiaries could ultimately expect fewer delays in care under the legislation.
Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated a Medicare ombudsman contract at the Medicare Rights Center in New York City, and represented clients in extensive Medicare claims and appeals. In addition to advocacy work, Josh helped implement federal and state health insurance exchanges at the technology firm hCentive. He also has held consulting roles, including as an associate at Sachs Policy Group, where he worked with insurer, hospital and technology clients on Medicare and Medicaid issues.
Tags: coronavirus, dialysis, hospice, Medicare Heads Up, prior authorization, telehealth
