Medicare+Choice presents potential PSO suitors with details
August 1, 1998 4 minutes read
Medicare+Choice presents potential PSO suitors with details
150-page HCFA document provides details for direct contracting
The Health Care Financing Administration pretty much summed up the situation when it noted in the preamble to its proposed regulations that "the introduction of the Medicare+Choice program is arguably the most significant change in the Medicare program since its inception in 1965."
The 150-page document, published June 26, provides administrative details and requirements governing the operation of Medicare+Choice, a new managed care product that permits physicians to use a number of vehicles to enter into Medicare risk contracts based on legislation passed in last year's Balanced Budget Act.
The Clinton administration's public relations machine has focused on the numerous new treatment options Medicare+Choice will give senior patients. "The Medicare program is moving into the new century by offering beneficiaries an unprecedented degree of choice about their health care while continuing to protect and strengthen original Medicare (benefits)," says HHS secretary Donna E. Shalala.
"Medicare+Choice offers beneficiaries new insurance options that broaden the ways in which they can receive health care. Importantly, that also includes the option to stay right where they are. If beneficiaries are happy with the way they get their health care now, they don't have to do anything," says HCFA administrator Nancy-Ann Min DeParle.
While there are more options available to Medicare patients, health policy mavens admit the driving force behind the Medicare+Choice program is to use these choices to speed the movement of more seniors into managed care and in turn slow the dramatic rise in beneficiary medical bills that threatens to bankrupt the Medicare system.
For instance, some 17 % of Medicare beneficiaries are currently enrolled in some form of managed care risk plan, HCFA reports. The agency projects that number to grow to nearly 30% by 2005, due in large part to enrollment in Medicare+Choice plans.
This swing in Medicare managed care participation presents both opportunities and challenges for provider groups as they see more of their senior patients moved into Medicare managed care risk contracts.
At the same time, the proposed Medicare+ Choice rule "presents about as many unanswered questions as answers for providers, while many other specific policies have not yet been made available for public scrutiny because they are still being developed," says Medicare expert Wendy Krasner, JD, a partner in the Washington, DC, law offices of McDermott, Will and Emery.
To help Medicare beneficiaries sort out their Medicare options, HCFA is planning a $95 million national information campaign designed to provide consumers with information about available plans, answers to frequently asked questions, and additional information resources.
The campaign eventually will include a national Internet site with comparative information on available plans, a toll-free hotline service to assist beneficiaries, and a comprehensive Medicare reference handbook, "Medicare and You."
Medicare hopes to have its educational campaign pilot-tested and phased in by October 1999. However, the program already has run into delays, forcing it to severely limit its product test phase. This, in turn, has generated hard questioning from Sen. Charles Grassely (R-IA) regarding whether potential enrollees will receive the timely information they'll need to make informed decisions about the new Medicare+Choice program options.
Here's what Medicare+Choice enrollees can expect once the program is up and running:
· An annual coordinated election period. Beneficiaries do not have to choose a plan until fall 1999. If they are already in an organization that falls under the Medicare Part C program (such as an existing Medicare HMO), they will simply stay in that program unless they specifically choose another plan. Seniors not enrolled in a managed care plan who do not choose to enter a risk plan are automatically enrolled in the traditional fee-for-service program.
Once participants elect a carrier, they have the right to change plans. From 1998 to 2001, participants can elect to change programs monthly. During 2002, they can change programs only one time during the first six months of the year, or during the first six months after becoming eligible for Part C. In 2003 and after, plan changes are limited to once a year and must take place during the first three months of the year.
· Benefits and premiums. Each plan must offer uniform benefits, premiums, and cost sharing to all Medicare beneficiaries in its service area.
· Consumer protections. The regulation shadows president Clinton's proposal to extend a Patients' Bill of Rights to all Medicare beneficiaries. As such, female patients are guaranteed direct access to women's health specialists within the network for routine and preventive care. Also, all Medicare+Choice plans must have procedures for the identification, assessment, and development of treatment plans for people with complex needs. Other consumer protections include:
- Appeal rights. All patient appeals of plan decisions to deny, reduce, or terminate care must be conducted as expeditiously as the beneficiary's health condition dictates (expedited decisions must generally occur within 72 hours). The maximum allowable time for initial decisions on appeals is 14 days, and 30 days for reconsideration appeals.
- Quality assurance. All Medicare+Choice plans must report on standardized quality performance measures for the purposes of consumer information, and plans with provider networks must achieve performance levels on standardized quality measures and conduct performance improvement projects in specified areas.
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