Medicare's Free Preventive Services Provisions Take
Effect January 1 in Proposed New Rule
CMS issues rule to drop 20% cost sharing for hospital
outpatient serves as part of health care reform legislation
July 6, 2010 - Senior citizens and others enrolled
in Medicare will see a decline in their out-of-pocket costs for hospital
outpatients services in next year if a role proposed by the Centers for
Medicare & Medicaid Services as part of the implementation of the
Affordable Care Act of 2010 (health care reform).
Patient cost-sharing is waived for most
Medicare-covered preventive services, including the Initial Preventive
Physical Examination (IPPE or what is often referred to as the “Welcome
to Medicare Visit”) by the Affordable Care Act – which was enacted as
the Patient Protection and Affordable Care Act, as amended by the Health
Care and Education Reconciliation Act of 2010
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This waiver applies not only to the 20 percent
coinsurance for the physician’s service, but also to any cost-sharing
relating to the separate payment to the facility when the service is
furnished in an hospital outpatient department (HOPD), as well as those
preventive services, such as colonoscopies, that may be furnished in a
ambulatory surgical centers (ASC).
“Preventing diseases that can be prevented, and
detecting others at earlier, more treatable stages, are among the
keystones for transforming Medicare,” said Jonathan Blum, CMS deputy
administrator and director of the Center for Medicare.
“By eliminating the beneficiary’s out-of-pocket
costs for most preventive services, we are removing a barrier to access
and paving the way for improved health for seniors and people with
disabilities who rely on Medicare for their health coverage.”
The proposed rule was presented July 2 and
implements changes required by the Affordable Care Act of 2010 for
services furnished on or after Jan. 1, 2011, by HOPDs in more than 4,000
hospitals that are paid under the Outpatient Prospective Payment System
(OPPS).
The proposed rule would also update policies and
payment rates for services in approximately 5,000 Medicare-participating
ASCs, under a payment system that aligns ASC payments with payments for
the corresponding services in HOPDs. CY 2011 is the first year the
revised ASC payment system rates will be fully implemented.
CMS projects total Medicare payments of
approximately $40 billion to HOPDs and $4 billion to ASCs for CY 2011.
While the Affordable Care Act imposes a 0.25
percentage point reduction to the HOPD fee schedule increase factor (an
update for inflation) for services furnished under the OPPS in CY 2011
that will affect all hospitals, it includes several provisions that will
boost payments to certain groups of hospitals, according to CMS.
For example, the Affordable Care Act requires
Medicare to adjust payments under the OPPS to a small number of cancer
hospitals that meet the classification criteria set forth in the statute
if the Secretary determines that costs incurred by those hospitals with
respect to ambulatory payment groups are higher than the costs incurred
by other hospitals under the OPPS as determined appropriate by the
Secretary.
Medicare is proposing an adjustment to OPPS
payments for those cancer hospitals with some reductions in payments to
other hospitals to make to meet the budget neutrality requirement for
these changes.
Increasing Primary Care Physicians
The proposed rule also includes proposals to
implement the graduate medical education (GME) provisions of the
Affordable Care Act. The law requires CMS to identify unused residency
slots and redistribute them to certain hospitals with qualified
residency programs, with a special emphasis on increasing the number of
primary care physicians.
The law also requires CMS to redistribute residency
slots from hospitals that close down to other teaching hospitals, giving
preference to hospitals in the same or a contiguous area as the closed
hospital. In addition, the law specifies how CMS is to count hours
spent by a resident in certain training and research activities, as well
as how to count hours spent by a resident in patient care activities in
a non-hospital setting, such as a physician’s office.
Other changes in the rule
The proposed rule would make several significant
changes to the OPPS in addition to those required by the Affordable Care
Act. These proposals include:
● Modifying the supervision requirements for
outpatient therapeutic services to require direct supervision of the
initiation of a service followed by general supervision for a limited
set of non-surgical extended duration services, including observation
services.
● Establishing separate APCs for partial
hospitalization programs in community mental health centers (CMHCs) and
for hospital-based programs, while continuing the policy of paying a
separate APC per diem payment rate for partial hospitalization services
depending on the number of services provided; that is, one APC for three
services and a separate one for four or more services.
● Paying for the acquisition and pharmacy
overhead costs of separately payable drugs and biologicals without
pass-through status furnished in HOPDs at 106 percent of the
manufacturers’ average sales prices.
● Expanding the set of measures that must be
reported by HOPDs to qualify for the full payment update in the
succeeding year. The proposed rule includes proposals for additions to
the set for reporting in CYs 2011, 2012, and 2013 to make it easier for
hospitals and the agency to prepare for the changing reporting
requirements.
CMS will accept public comments on the proposed
rule through Aug. 31, 2010, and will respond to them in a final rule to
be issued by Nov. 1, 2010.
For more information on the CY 2011 proposals for
the OPPS and ASC payment system, see
July 6, 2010 - Senior citizens and others enrolled
in Medicare will see a decline in their out-of-pocket costs for hospital
outpatients services in next year if a role proposed by the Centers for
Medicare & Medicaid Services as part of the implementation of the
Affordable Care Act of 2010 (health care reform).
Seniors don't need to give personal info to anyone,
checks being mailed automatically to eligible Medicare recipients - June
11, 2010