Medicare Physician Care and Other Services
- Physician Payment Update. The 0.5% update for 2010 included in the underlying Senate bill was repealed by the Manager’s Amendment. (PPACA §§ 3101, 10310)
- Primary Care. Establishes a 10% Medicare bonus payment for certain primary care providers (PCPs) for select codes. Provides a 10% bonus for general surgeons providing major surgical procedures in health professional shortage areas. Effective 1/1/11 through 12/31/15. (PPACA §§ 5501,10501(h))
- FQHCs. Establishes a Medicare prospective payment system for FQHCs, effective 10/1/14. (PPACA § 5502, which was replaced by §10501(i))
- Adjustments to Physician Fee Schedule. Extends, through 2010, the work GCPI floor. Limits variation in practice expense GCPI with a hold harmless for current values. Requires analysis of current methods of establishing practice expense geographic adjustments; the feasibility of using actual or survey data; the office expense portion of the geographic adjustment; and the weights assigned each category. Adjustments are to be incorporated based on the analysis starting 2012. (PPACA § 3102)
- Medicare Therapy Caps. Extends the therapy cap exceptions process from 12/31/09 through 12/31/10. (PPACA § 3103)
- Physician Pathology Services. Extends the technical component for certain pathology services through 2010. (PPACA§ 3104)
- Ambulance Add-on Extension. Extends, through 1/1/11, the ground ambulance add-on; air ambulance add-on; and super rural ambulance add-on. (PPACA §§ 3105, 10311)
- LTC Hospital Payment Rules. Extends certain payment rules for LTC hospitals and the moratorium from establishing certain hospitals from 3 years to 5 years. (PPACA §§ 3106, 10312)
- Mental Health Add-On. Extends, from 12/31/09 to 12/31/10, the Part B mental health add-on. (PPACA § 3107)
- Physician Assistants. Effective 2011, permits physician assistants to order post-hospital extended care services. (PPACA § 3108)
- Pharmacy Accreditation Exemption. Beginning 2011, exempts from pharmacy accreditation requirements pharmacies with less than 5% total Medicare sales based on the average sales the 3 previous years; the pharmacy is enrolled as a Medicare DME supplier, has had a Medicare provider number for at least 5 years and has had no adverse actions against them in the past 5 years; the pharmacy submits attestation to these 2 categories; and the pharmacy submits materials or to an audit to verify that it meets the criteria of the 2 first categories. (PPACA § 3109)
- SEPs for Disabled TRICARE Beneficiaries. Establishes a 12-month Part B special election period for disabled TRICARE beneficiaries. (PPACA § 3110)
- Bone Density Tests. Establishes payment for dual-energy X-ray absorptiometry for bone density testing and requests an IOM study. (PPACA § 3111)
- Medicare Improvement Fund. Eliminates the remaining $22.29 billion in the Medicare Improvement Fund. (PPACA § 3112)
- Complex Lab Tests. Establishes a 2-year demonstration project starting 7/1/11 to evaluate payment rules for complex lab tests including those that: analyze gene protein expression, topographic genotyping, or cancer chemotherapy sensitivity assay; HHS determines does not have an equivalent; is billed using a Health Care Procedure Coding System code other than a not otherwise classified code; is approved by the FDA or covered under Medicaid; and is a diagnostic test under section 354 of the PHSA, diagnostic lab test or other diagnostic test. Payments under the demo may not exceed $100 million. HHS is required to report to Congress not later than 2 years after the conclusion of the demonstration project. (PPACA § 3113)
- Certified Nurse Midwife Services. Increases reimbursement for certified nurse-wife services starting in 2011. (PPACA § 3114)
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Improved Medicare Payment Accuracy
- Home Health Care. Makes a number of changes in payments for home health care, including: phased-in rebasing home health prospective payments to reflect the number and mix of services, level and intensity of services and the average cost of providing care; revisions to the HH outlier cap; and a 3% add-on payment for HH providers serving rural areas during 2010-2015. (PPACA §§ 3131, 10315)
- Hospice Payment Reform. Requires HHS to revise payments to hospices after collecting additional data and consulting with hospice providers and MedPAC. (PPACA § 3132)
- Medicare DSH. Beginning in 2015, reduces Disproportionate Share Hospital (DSH) payments by 75%. A portion of these savings are returned to hospitals as additional payments to reflect uncompensated care costs. Aggregate amount of additional payments is determined by percent reduction in the national uninsured population. E.g., if uninsured rate falls by 20%, 80% of the 75% reduction would be returned to hospitals based on each hospital’s share of total uncompensated care provided by all hospitals. (PPACA §§ 3133, 10316)
- Misvalued Physician Codes. Beginning 2013, requires HHS periodically to identify physician services as being potentially misvalued and make appropriate adjustments under the physician fee schedule in a budget neutral manner. (PPACA § 3134)
- Imaging Services. Beginning in 2011, sets the equipment utilization assumption in the physician fee schedule equal to 75% for expensive equipment (>$1 million). Beginning in 2011, increases the multiple imaging discount for certain procedures involving contiguous body parts from 25% to 50%. Excludes reduced expenditures from calculation of budget neutrality. (PPACA § 3135)
- Power Wheelchairs. Adjusts payments for power-driven wheelchairs, effective 1/1/11. (PPACA § 3136)
- Hospital Wage Index. Extends the hospital reclassifications authorized by Section 508 of the MMA until 9/30/10 and generally requires use of the wage index promulgated 8/27/09. Requires HHS to report to Congress by 12/31/11 with a plan, developed with stakeholder consultation, to comprehensively reform the Medicare inpatient hospital wage index system taking into account the goals set forth in the June 2007 MedPAC report. (PPACA §§ 3137, 3141, 10317)
- Cancer Hospitals. Requires HHS to study if the outpatient costs of PPS-exempt cancer hospitals with respect to Medicare’s APCs exceed costs incurred by hospitals reimbursed under Outpatient Prospective Payment System (OPPS). Requires HHS to adjust payments if such costs are found to be excessive, effective 1/1/11. (PPACA § 3138)
- Hospice Demonstration. Creates a Medicare Hospice Concurrent Care 3-year demonstration program. (PPACA § 3140)
- Study on Urban Medicare-Dependent Hospitals. Requires HHS study on the need for additional payment for urban Medicare dependent hospitals for inpatient hospital services. (PPACA § 3142)
- Revision to SNF PPS. Delays implementation of certain skilled nursing facility “RUGs-IV” payment system changes by one year to 10/1/11. (PPACA § 10325)
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Improved Access to Preventive Services
- Coverage of Annual Wellness Visit. Starting 1/1/11, requires Medicare coverage of an annual wellness visit with no cost-sharing, including creation of a personalized prevention plan that includes a health risk assessment. Requires such risk assessments be completed prior to or as part of the annual wellness visit. Requires HHS to develop guidelines and a model for health risk assessments. (PPACA § 4103)
- Removal of Barriers to Preventive Services. Starting 1/1/11, removes cost-sharing for specified preventive services and waives the deductible for colorectal cancer screening tests, effective 1/1/11. (PPACA §§ 4104, 10406)
- Evidence-Based Coverage of Preventive Services. Allows HHS to modify coverage of any preventive services to the extent consistent with USPSTF recommendations, including services included in the initial physical exam. Allows HHS to withdraw coverage for services not rated A, B, C, or I. (PPACA § 4105)
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Medicare Rural Access
- Program Extensions
- Outpatient Hold Harmless. Extends for services rendered by 1/1/11 the outpatient hold harmless provision and includes sole community hospitals regardless of bed size. (PPACA § 3121)
- Reasonable Cost Payments for Certain Lab Tests. Extends, through 7/1/11, the reasonable cost payment provision for certain clinical diagnostic lab tests furnished in certain rural hospital areas. (PPACA § 3122)
- Rural Community Hospital Demonstration. Extends, for 5 years, the rural community hospital demonstration program, expands the number of states to 20 and increases the maximum number of hospitals to 30. (PPACA §§ 3123, 10313)
- Medicare-Dependent Hospital Program. Extends, through 10/1/12, the Medicare-dependent hospital program. (PPACA § 3124)
- Medicare Rural Hospital Flexibility Program. (PPACA § 3129)
- Temporary Improvements to Payments for Low-Volume Hospitals. Temporarily improves Medicare payments to low-volume hospitals for FY 2011 and 2012 and increases the threshold to 1,600 discharges. (PPACA §§ 3125, 10314)
- Demonstration Improvements. Makes improvements to the demonstration project on community health integration models in certain rural counties. (PPACA § 3126)
- MedPAC Study on Payment Adequacy. Requires MedPAC study on the adequacy of Medicare payment for services and supplies in rural areas. Report due no later than 1/1/11. (PPACA § 3127)
- Technical Corrections for Critical Access Hospitals. Provides for critical access hospital services to be reimbursed at 101% of reasonable costs – retroactively effective as if included in the MMA. (PPACA § 3128)
- Frontier States Provision. Provides a floor on the hospital and outpatient wage index and physician practice expense index for “frontier states,” defined as states where at least half of the counties have a population per square mile of less than 6 (i.e., Montana, North Dakota, South Dakota, Utah and Wyoming). (PPACA § 10324)
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Medicare Sustainability
- Market Basket Updates and Productivity Improvements. Reduces annual market basket updates for inpatient and outpatient hospitals, home health, SNF (productivity reductions), hospice and other providers, in addition to productivity adjustments. (PPACA §§ 3401, 10319)
- Part B Premium Adjustment. Freezes income thresholds related to Part B premium subsidies for the period 2011-2019. (PPACA § 3402)
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Other
- New Standards for Certain Medigap Plans. Directs the NAIC to develop revised standard Plans C and F to include requirements for nominal costsharing to encourage the use of appropriate physician services under Medicare Part B. Effective for benefit packages as of 1/1/15. (PPACA § 3210)
- Senior Housing Facility Demonstration. Beginning 2010, makes the MA senior housing demonstration permanent and permits the plan to limit their service area to the geographic area of the housing facility. (PPACA § 3208)
- Coverage for Individuals Exposed to Environmental Health Hazards in Montana. Establishes Medicare eligibility for individuals exposed to environmental health hazards who resided in or around the Libby, Montana, geographic area as of 6/17/09. Individuals eligible are diagnosed with one or more of asbestos poisoning, mesothelioma or other condition deemed necessary by HHS. Coverage could be extended to individuals in other areas for which a future public health emergency declaration is made under the Comprehensive Environmental Response, Compensation and Liability Act of 1980. (PPACA § 10323)
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