As you have likely hear by now, the fiscal cliff deal passed by Congress on January 1, 2013 (the American Tax Payer Relief Act) has made a number of changes to a number of important laws and programs in this country
While the deal itself does not contain significant changes or cuts to traditional Medicare, serious and fundamental threats to the Medicare program are expected to arise in the coming months as Congress grapples with broad budgetary issues. As a result, programs like Medicare, Medicaid, and Social Security are poised to take center stage in discussions about Sequestration, the debt ceiling, and decreasing the national debt.
Important Medicare-Related Provisions of the Deal
- Sustainable Growth Rate (SGR) – Physician Payment
The Sustainable Growth Rate, also known as the "doc fix", is a formula created in 1997 to control the rate of Medicare cost growth by setting targets for expenditures on physician services. Despite being law, Congress has not followed the SGR formula and has voted each year to override the SGR formula in order to avoid steep cuts in provider reimbursements. The Relief Act once again pushes back the application of SGR for another year. Another round of discussions over SGR is expected as part of efforts to replace the formula.
- Outpatient Therapy Caps
Current Medicare law places a yearly dollar amount cap on all outpatient physical and speech therapy services ($1,900 in 2013). Beneficiaries and their providers, however, have been able to file for an exception when the provision of additional therapy services is determined to be medically necessary. This exceptions process was set to expire on December 31, 2012, but the fiscal cliff deal extended the exceptions process to December 31, 2013.
- Medicare Private Health Plans
The authority of Medicare Advantage Special Needs Plans (SNPs) to restrict enrollment to specified groups of beneficiaries (for example, dual eligible individuals) was extended until January 1, 2015.
The authority for Medicare Cost Plans, a type of Health Maintenance Organization (HMO) through which Medicare beneficiaries may choose to receive their benefits, was extended until January 1, 2014. These plans are only authorized to operate in certain regions of the country.
- Outreach to Enroll Medicare Beneficiaries in Low-Income Programs
Funding to improve enrollment in programs for low-income Medicare beneficiaries was reauthorized for another year. This funding is allocated to State Health Insurance Programs (SHIPs), Area Agencies on Aging (AAA), Aging and Disability Resource Center (ARDCs), and the National Center for Benefits Outreach and Enrollment. The money is intended to help eligible individuals enroll in Medicare Savings Programs, the Part D Low Income Subsidy, and other programs.
- Commission on Long Term Care
The Relief Act established a fifteen member commission to develop a plan for implementing and financing a comprehensive, coordinated and high quality system that ensures the availability of long term services and supports (LTSS). Efforts in the Affordable Care Act to enact such a system, known as the CLASS Act, were repealed in the Relief Act.
Commission members will be appointed this month by House and Senate leaders as well as the White House. The Commission will be tasked with producing a comprehensive and detailed report with recommendations for legislative or administrative action within 6 months. If approved by a majority of the Commission members, this report will be introduced as a Senate bill.
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The Relief Act also included a number of provisions adjusting how Medicare providers are paid. Many affect how certain Medicare hospitals are paid. There are also provisions affecting Medicare payment of radiology services, ESRD treatment, diabetic supplies and ambulance transportation, among others.
The Medicare provisions in the Relief Act are not as harmful to the program as many of the dangerous proposals offered to Congress over the past few months. There have been proposals made to double look back periods and decrease Medicare and Medicaid benefits. Drastic cuts are still on the table as policy-makers seek to address the looming sequestration and debt ceiling with savings from health care programs. For real health savings that address the underlying problem of health care costs system wide, policy-makers and advocates should begin with solutions that improve the health and well-being of Medicare beneficiaries while preserving the Medicare program for those who depend on it now and in the future.
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