HCFA issues changes to Medicare+Choice program
April 1, 1999
HCFA issues changes to Medicare+Choice program
Rules now apply just to physicians
The Health Care Financing Administration (HCFA) has issued a final rule announcing limited changes to the Medicare+Choice regulations. The following changes were effective as of March 19, 1999:
• The provider participation rules now apply only to physicians. The Health Care Financing Administration (HCFA) originally had applied the Medicare+Choice regulatory requirements to health care professionals other than physicians.
• Plans must have provider appeals processes only for cases involving termination or suspension. This, however, does not include initial denials of applications for participation.
• Plans must make their best effort to conduct an initial assessment of an enrollee’s health status. Previously, HCFA had required an initial assessment of an enrollee’s health status within 90 days.
• Plans are only required to offer enrollees an opportunity to use a source of primary care, and then provide that primary care source to enrollees who desire it. The original HCFA rule required health plans to provide each enrollee with a source of primary care.
• Plans now are required to develop policies that define under what circumstances and when care must be coordinated. This coordination of patient care is no longer limited to one provider.
• Plans are only required to notify providers in writing concerning the following terms of a policy: payment; credentialing; and, other rules directly related to participation decisions.
In addition to the HCFA action, the Medicare Payment Advisory Commission (MedPAC) has delivered several recommendations to Congress for the program.
• MedPAC endorsed a new risk adjuster that boosts payments to Medicare+Choice HMOs that enroll sicker beneficiaries. The panel said it was too soon to tell if recent departures of health plans from the Medicare+Choice program called for changes in payment rates. MedPAC said it remained hopeful that the program would provide beneficiaries with a variety of plan choices.
• MedPAC recommended that Congress move back the deadline to later in the year for health plans to submit proposals under Medicare+ Choice. Plans now face a May 1 deadline for projecting payments and costs for six months in the future. That date "has appeared to create hardships for Medicare+Choice organizations," the panel concluded.
• MedPAC also recommended that Congress require independent assessments of need for beneficiaries who receive 60 or more home health visits and that a copayment, with an annual cap, be charged for each home visit.
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