Today's Datapoint

26% ... of all Medicare beneficiaries were enrolled in Medicare Advantage plans in 2010, with 31% of seniors with incomes between $10,001 and $20,000 and 29% of those with incomes from $20,001 to $30,000 in MA, according to a new report from AHIP.

You CAN Leave the Nursing Home

Late spring is a time for myriad gatherings with family and friends: high school and college graduations, Memorial Day weekend, weddings and more.  Nursing home residents often want to join in family festivities and visit with children and grandchildren, but may be under the impression that they will lose Medicare coverage if they leave the facility to do so.  This is not true.

The Medicare Benefit Policy Manual recognizes that although most beneficiaries are unable to leave their facility,

an outside pass or short leave of absence for the purpose of attending a special religious service, holiday meal, family occasion, going on a car ride, or for a trial visit home, is not, by itself evidence that the individual no longer needs to be in a SNF for the receipt of required skilled care.[1]

A facility should NOT notify patients that leaving the facility will lead to loss of Medicare coverage. The Medicare Policy manual says that such a notice is "not appropriate."[2]

If the resident returns to the facility by midnight, the facility can bill Medicare for the day's stay.[3]

If the resident is gone overnight (i.e., past midnight) and returns to the facility the next day, the day the resident leaves is considered a leave of absence day.  Clarifying what seemed to be conflicting provisions in the Manuals, the Centers for Medicare & Medicaid Services has now confirmed that the facility can bill a beneficiary for bed-hold days during a SNF absence.[4]

As before, Chapter 6 of the Medicare Claims Processing Manual says that the facility cannot bill a beneficiary during a leave of absence.[5]  However, a revision to the Manual, issued June 16, 2011 and effective August 1, 2011, allows a SNF to bill a beneficiary for a leave of absence "as specified in Chapter 1 of this manual at §30.1.1.1."  That section authorizes skilled nursing facilities to bill a beneficiary for bed-hold during a temporary "SNF Absence" if the SNF informs the resident in advance of the option to make bed-hold payments and of the amount of the charge and if the resident "affirmatively elect[s]" to make bed-hold payments prior to being billed.[6]   CMS distinguishes bed-hold payments from payments for admission or readmission, which are "not allowed."[7]

Nursing home residents can leave for short periods to enjoy the holidays with family without losing Medicare coverage.  But their SNFs are allowed to bill residents to hold their beds under Medicare rules.

[1]Medicare Benefit Policy Manual, Pub. 100-02, Ch. 8, §30.7.3. (Example, second paragraph) (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08.pdf)
[2]Medicare Benefit Policy Manual, Pub. 100-02, Ch. 8, §30.7.3. (Example, third paragraph) (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08.pdf)
[3]Medicare Benefit Policy Manual, Pub. 100-02, Ch. 3, §20.1.2.  (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c03.pdf)
[4]Medicare Claims Processing Manual, Pub. 100-04, Ch. 6, §40.3.5.2.  (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf)
[5]Medicare Claims Processing Manual, Pub. 100-04, Ch. 6, §40.3.5.2.  (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf)
[6]Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §30.1.1.1 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf)   CMS cites, as authority for this payment option, the Nursing Home Reform Law, 42 U.S.C. §1395i-3(c)(1)(B)(iii), which requires that SNFs "inform each other resident, in writing before or at the time of admission and periodically during the resident’s stay, of services available in the facility and of related charges for such services, including any charges for services not covered under this subchapter or by the facility’s basic per diem charge."  CMS also cites 42 C.F.R. §483.10(b)(5)-(6).
[7]Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §30.1.1.1 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf)

More states work to implement health care law

Illinois, Nevada, Oregon, South Dakota, Tennessee and Washington receive grants to establish Affordable Insurance Exchanges

Health and Human Services (HHS) Secretary Kathleen Sebelius announced today that Illinois, Nevada, Oregon, South Dakota, Tennessee and Washington will receive more than $181 million in grants to help implement the new health care law. The grants will help states establish Affordable Insurance Exchanges. Starting in 2014, Affordable Insurance Exchanges will help consumers and small businesses in every state to choose a private health insurance plan. These comprehensive health plans will ensure consumers have the same kinds of insurance choices as members of Congress. Including today’s awards, 34 states and the District of Columbia have received Establishment grants to fund their progress toward building Exchanges.

HHS also issued two guidance documents today to help states build Affordable Insurance Exchanges. 

“States across the country are implementing the new health care law,” said Secretary Sebelius. “In 2014, consumers in every state will have access to a new marketplace where they will be able to easily purchase affordable insurance.”

Today, the Department released:

New resources for states: The six new Exchange Establishment grant awards to Illinois, Nevada, Oregon, South Dakota, Tennessee and Washington total more than $181 million. This round of awards brings the total of Exchange-related grants provided to states over the last two years to more than $1 billion. Illinois, Nevada, Oregon, South Dakota and Tennessee today have been awarded Level One Exchange Establishment grants, which provide one year of funding to states that have begun the process of building their Exchange. Washington is the second state to be awarded a Level Two Establishment grant, which is provided to states that are further along in building their Exchange and offers funding over multiple years.

In 2010, 49 states and the District of Columbia received Exchange Planning grants totaling more than $54 million; in 2011, seven states received more than $249 million in Early Innovator grants; and to date, 34 states and the District of Columbia have received more than $856 million in Establishment grants.  

States can apply for Exchange grants through the end of 2014, and these funds are available for states to use beyond 2014 as they continue to establish Exchange functionality. This ensures that states have the support and time necessary to build the best Exchange for their residents. 

To see a detailed state-by-state breakdown of grant awards and what each state plans to do with its Exchange funding, visit our new map tool on HealthCare.gov - http://www.healthcare.gov/news/factsheets/2011/05/exchanges05232011a.html 

New guidance for states: Today’s guidance includes an Exchange Blueprint states may use to demonstrate how their Affordable Insurance Exchange will work to offer a wide range of competitively priced private health insurance options. The Blueprint also sets forth the application process for states seeking to enter into a Partnership Exchange. If a state chooses to operate its own Exchange or a Partnership Exchange, HHS will review and potentially approve or conditionally approve the Exchange no later than Jan. 1, 2013, so it can begin offering coverage on Jan. 1, 2014. To see the state Exchange Blueprint, visit http://cciio.cms.gov/resources/other/index.html#hie 

Exchanges in every state: Consumers in every state will have access to coverage through an Affordable Insurance Exchange on Jan. 1, 2014. If a state decides not to operate an Exchange for its residents, HHS will operate a Federally-facilitated Exchange (FFE). This guidance describes how HHS will consult with a variety of stakeholders to implement an FFE, where necessary, how states can partner with HHS to implement selected functions in an FFE, and key policies organized by Exchange function. To see the guidance on the FFEs, visit http://cciio.cms.gov/resources/regulations/index.html#hie 

The Department will conduct implementation forums in the coming months to work with states and stakeholders on their questions and the work to be done in building Exchanges. The Department will also engage in consultation with Tribes, Tribal Governments, and Tribal Organizations on how Exchanges can serve their populations.

For more information on Exchanges, including fact sheets, visit http://www.healthcare.gov/exchanges.

Today's Datapoint

Roughly 6 million additional prescriptions were picked up by CVS Caremark Corp. as a result of the contract dispute between Walgreen Co. and Express Scripts Holding Co., according to CVS.

Understanding the Medicare Trust Fund

In their recently released report, the Medicare trustees have projected that the Part A trust fund, also known as the Medicare Hospital Insurance (HI) trust fund, will remain solvent through 2024. This is the same conclusion that the trustees made last year. Reforms included in the Affordable Care Act (ACA) have strengthened Medicare’s financial outlook and extended solvency through 2024. The Part A trust fund and its solvency are frequently misunderstood. The trust fund is a financing mechanism for Medicare Part A, which covers inpatient services such as hospital stays and skilled nursing facility care. The trust fund is financed through a combination of payroll taxes and other revenues. Although, as noted above, the trustees have recently reported that the trust fund is solvent through 2024; that does not mean that the trust fund or Medicare will cease to exist in 2025. The trustees found that the Part A trust fund will be able to cover 100 percent of the costs of Medicare’s Part A benefits through 2024. After 2024, the trust fund will still be able to provide coverage, though at a lesser rate. According to the Center on Budget and Policy Priorities (CBPP), starting in 2025, Medicare will still be able to cover 87 percent of all inpatient costs, and over the next 75 years, the trust fund, on average, will be able to cover 74 percent of Medicare’s inpatient costs. A number of factors can affect the Medicare Part A trust fund. For example, since the trust fund is partially paid for through payroll taxes, an economic downturn could result in less people paying into the system. As the economy recovers, so will the trust fund. Medicare Part B, which covers outpatient services such as visits to doctors’ offices, and Medicare Part D, which covers prescription drugs, are financed through beneficiary premiums and general revenues, not through the trust fund. While action will need to be taken to make up for the future financing shortfalls of Medicare Part A after 2024, it is important to recall that congress has been taking this kind of action since 1970 to extend the life of the trust fund to ensure that people with Medicare are able to access affordable, comprehensive and quality coverage. Unfortunately, supporters of drastic changes to Medicare, such as premium support, point to the potential insolvency of the trust fund to justify proposals that would shift substantially higher out of pocket costs onto beneficiaries and their families as well as undermine the consumer protections and guaranteed benefits that the Medicare program currently provides. Strengthening the Medicare trust fund can be done without gutting Medicare’s guarantees.

How Much Do The Nation’s Pre-Eminent Hospitals Cost Medicare?

By Jordan Rau MAY 14TH, 2012, 12:14 PM Can you cut health care spending without undermining the quality of care? It’s a major concern as Medicare prepares to prod hospitals to provide medical care more efficiently by giving bonuses to those whose patients cost less and taking money away from places that send the government higher bills. Last week, Capsules culled through the Medicare data to identify the hospitals whose patients cost Medicare the most, from the three days before admission to a month afterward. Here is an admittedly unscientific first pass at how the nation’s best-regarded hospitals rate in terms of their patients’ Medicare spending. Kaiser Health News looked at the 16 hospitals that U.S. News includes in its widely followed “Best Hospitals’ Honor Roll,” which is calculated based on a mix of quality indicators and reputation surveys. (One hospital, Johns Hopkins in Baltimore, was omitted because Medicare didn’t provide figures for Maryland hospitals.) As a group, the average cost to Medicare for a patient at a U.S. News top hospital was $17,808, or 1 percent below the national median spending of $17,988. The least expensive of these hospitals had patients who, on average, cost Medicare 5 percent below the median (represented as a ratio of 0.95). The most expensive hospital had patients who, on average, cost Medicare 3 percent above the median (1.03). • New York-Presbyterian Hospital (New York, N.Y.): $17,089 (0.95) • University Of Washington Medical Center (Seattle, Wash.): $17,089 (0.95) • Mayo Clinic St. Mary’s Hospital (Rochester, Minn.): $17,269 (0.96) • Mount Sinai Hospital (New York, N.Y.): $17,269 (0.96) • Ronald Reagan UCLA Medical Center (Los Angeles, Calif.): $17,628 (0.98) • UCSF Medical Center (San Francisco, Calif.): $17,628 (0.98) • Duke University Hospital (Durham, N.C.): $17,628 (0.98) • Cleveland Clinic (Cleveland, Ohio): $17,808 (0.99) • Barnes Jewish Hospital (Saint Louis, Mo.): $17,808 (0.99) • Vanderbilt University Hospital (Nashville, Tenn): $17,808 (0.99) • Stanford Hospital (Stanford, Calif.): $17,808 (0.99) • UPMC Presbyterian Shadyside (Pittsburgh, Penn.): $18,168 (1.01) • University Of Michigan Health System (Ann Arbor, Mich.): $18,168 (1.01) • Brigham And Women’s Hospital (Boston, Mass.): $18,348 (1.02) • Hospital Of University Of Pennsylvania (Philadelphia, Penn.): $18,348 (1.02) • Massachusetts General Hospital (Boston, Mass.): $18,528 (1.03) None were outliers among the 3,346 hospitals that Medicare evaluated. In fact, more than a quarter of the nation’s hospitals were more costly than all of the “honor roll” hospitals and another quarter of the hospitals were less expensive than all of the “honor roll” hospitals.

Lawsuit Challenges Medicaid Managed Care Decision In Missouri

By ELANA GORDON, KCUR MAY 09, 2012 Which marketplace is better: a crowded one with lots of choices or a streamlined one with just a few options? Those competing ideals are the backdrop of a legal battle playing out this month in Missouri, where the state’s efforts to winnow contracts for its Medicaid managed care business are being challenged by one of the companies left out in the cold. Molina Healthcare is suing the state arguing that Missouri changed the rules in the midst of a competitive bidding process. Molina is one of five companies currently managing care for about 430,000 of the state’s Medicaid beneficiaries, who are mainly low-income children and pregnant women. Molina’s contract was not renewed for next year. Instead Missouri awarded contracts to two insurers already active in the state and one new company. Judge Bernhardt Drumm of Cole County circuit court could rule on the case any day now, and the dispute adds an element of uncertainty for beneficiaries, as it comes smack in the middle of open enrollment, which runs April 19 through June 16. In Missouri’s managed care system, instead of paying doctors and health facilities directly for services, the state contracts with companies to oversee patients’ care in 54 counties. “From the state’s point of view -- and this is why it [managed care] is attractive to the state -- it’s very easy for them to manage their costs,” says Dr. Corrine Walentik, a neonatologist in St. Louis and head of the state’s Medicaid oversight committee. The state pays these insurance companies a fixed member-per-month fee. The companies negotiate rates with a network of physicians and hospitals to provide that care. They also have people who specifically help enrollees navigate the system. The model is similar to an HMO, where patients have a primary care doctor who makes referrals when needed. “It becomes the managed care plan’s job to make sure they do a good job managing these patients, so that they don’t have their costs accelerated at a higher rate than they should, and run out of money. Cause then they’d go under,” says Walentik, who has worked with the managed care program since Missouri started it in the mid-90s, but was not involved in the state’s recent contract selection and review process For the first time, the state has limited the number of managed care contracts it awarded to just three, instead of granting a contract to any company that meets certain requirements. Having a cap could save the state $16 million over two years, according to officials with the state, through reduced administrative costs from having to work with fewer companies. . The state also expects money to be saved from better rates that companies will be able to negotiate with providers because each company will have more members and more leverage. Walentik says St. Louis may provide a good lesson for why less is better. When Missouri started its managed care program there in 1995, seven plans participated. “That was a disaster,” says Walentik. “There were too many plans and not enough lives. Part of way the it works in any place is you have to have a big enough population to spread the risk across the population.” She says three plans ultimately survived. The new awards, issued in February and effective July 1, didn’t include Molina Healthcare. Molina was founded in California 30 years ago, specifically to manage healthcare for low-income people in government health programs. It has been in Missouri for 16 years. The company currently manages about a fifth of enrollees in the program (including around 13,000 people in the Western region), and was one of five companies currently with a contract in Missouri. The state instead awarded a new contract to Centene’s Home State Health Plan. Based in St. Louis, the company hasn’t had a contract in Missouri for six years. The other two companies awarded contracts – Missouri Care, an Aetna health plan, and HealthCare USA, a Coventry health care plan– are already operating in the state. In March, Molina filed a lawsuit, challenging the state’s contract decisions. “We believe the state changed the rules after proposals had been submitted and is illegally limiting the number of health plans serving Medicaid members in the state of Missouri,” says Amy Dobberteen, an attorney with Molina. Molina wants the court to put a halt on the new contracts. The contracts total about $1.1 billion (with the federal government footing about $700 million of the bill). Wanda Seeney, a spokesperson with the Missouri Office of Administration, said the state “conducted a competitive bid process for the managed care contract. Points were awarded for each bid based on quality; the method of performance; organizational experience; and most importantly, access to care.” Molina didn't score as high as the other plans on the various quality and access measures At least one provider concurs with the state’s motives to limit contracts. “We always felt having five options was more than necessary,” says Bob Finuf, an executive with Children’s Mercy Hospital, the main children’s hospital in Kansas City. “It’s not efficient and added complexity for providers.” The whole legal dispute comes at an inopportune time for beneficiaries. The state has already sent out information on the new contracts, and people are starting to choose plans for the coming coverage period. “I’ve had patients tell me they’re in Harmony but are switching to HealthcareUSA,” says Walentik. “So people are making decisions already.” As of late last week, the state had documented nearly 52,000 people enrolled in new plans, so the vast majority of the 430,000 beneficiaries still have to choose plans. Ian McCaslin, the state’s Medicaid director, said in a court deposition that putting a hold on these new contracts would cause “turmoil” and confusion in an enrollment process that’s already underway. He said the state could also have trouble extending its current managed care contracts. In the Kansas City area, the locally-based nonprofit insurance company, Blue Cross Blue Shield of Kansas City, also didn’t get a new contract, so the some 31,000 people who’ve been with the company are starting to choose a new plan. “We would be happy to continue to serve this population, to continue to serve these members until things are worked out,” says Bryan Camerlinck, a financial services director for Blue Cross, who was also disappointed the company didn’t get a new contract. He says some of the insurer’s Ob-Gyn providers may not be covered on the new plans. In St. Louis, Walentik worries about what would happen if the contracts are blocked. “It would really put things in chaos,” says Dr. Walentik. “Because I think it takes a while to get patients educated and to get providers up and running, and it would be really hard if we had to cancel everything that’s been done and start all over again." Monday marked the court’s deadline for all parties to file certain evidence and briefs, so Judge Drumm could now rule at any time on whether to grant an injunction to stop the enrollment process or dismiss the case. This story is part of a reporting partnership that includes KCUR, and Kaiser Health News. http://www.kaiserhealthnews.org/Stories/2012/May/09/missouri-medicaid-managed-care-lawsuit.aspx