New Medicare+Choice rules aim to end exodus
Will it be a kinder, gentler program?
The Health Care Financing Administration (HCFA) has released final rules for its beleaguered Medicare+Choice program intended to sooth concerns that have led to a mass exodus of HMOs from the program.
The rule changes are aimed at quieting criticism that regulations for the risk-based program regulations were too harsh and reimbursement rates too low. The regulations released June 19 will "allow the agency to continue to ensure that Medicare beneficiaries enrolled in Medicare+Choice plans will receive quality health care without imposing new, unnecessary costs on the organizations that provide the care," claimed HCFA administrator Nancy-Ann DeParle.
HCFA plans to extend the transition period for adjusting risk rates in response to health plan complaints that a more gradual phase-in of risk adjustment to would ease the transition to the new system.
The Medicare +Choice program was created in 1997. About 6.2 million, or 16% of all Medicare beneficiaries, are currently enrolled in a Medicare HMO. According to HCFA, the proposal will help streamline the Medicare+Choice program by:
• increasing flexibility in establishing a provider network, which will allow more health care providers to serve plan enrollees;
• improving freedom of choice by allowing plans to offer beneficiaries a point-of-service option that broadens access to health care services from both in-network and out-of-network providers;
• allowing organizations that left Medicare+ Choice to return in two years, instead of five;
• easing compliance plan reporting by eliminating the self-reporting component of the Medicare+Choice program.
The regulations also include a number of key elements that were part of earlier Medicare+ Choice regulations. Those measures:
• speed the appeals process to ensure that beneficiaries’ appeals are heard based on their health needs;
• simplify the certification of payment data and adjusted community rate submissions by Medicare+Choice organizations that establish a good-faith standard for the certification of data. Medicare+Choice organizations now will certify the accuracy of payment information to their "best knowledge, information, and belief"
• clarify provider anti-discrimination rules that state Medicare+Choice organizations can no longer discriminate against providers based solely on their licensure and certification. However, this requirement does not preclude organizations from contracting with the providers they choose and setting their payment rates, consistent with their quality and cost control responsibilities under the statute;
• allow out-of-area Medicare beneficiaries to convert to a Medicare+Choice plan. This will expand the opportunity for a seamless conversion to Medicare+Choice for beneficiaries who wish to continue receiving health care services through their managed care organization when they become eligible for Medicare;
• implement a bonus payment program to encourage Medicare+Choice plans to serve beneficiaries in areas that currently do not have Medicare+ Choice options.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content