Hello Chuck: THANK YOU VERY MUCH for sharing this report from AOTA!!!!!!
Merry Christmas, Ron ----- Original Message ----- From: Charles Willmarth <[EMAIL PROTECTED]> Sent: Tuesday, December 20, 2005 To: [email protected] <[email protected]> Subj: [OTlist] US Only: Details about Budget Reconciliation Bill. Approved by House; Pending in Senate CW> This detailed report was prepared by the AOTA Federal Affairs CW> Department. CW> ************ CW> A House/Senate conference committee reported out a compromise Budget CW> Reconciliation bill on December 18. The House voted to approve it on CW> December 19. At publication, the Senate has not voted on the bill. CW> Both houses must approve before it can be sent to the President for CW> signing into law. CW> The $39.7 billion budget package includes cuts to Medicare and CW> Medicaid, increases in Medicare, and assorted other provisions relating CW> to student loans and other programs. CW> Summarized below are the main Conference Report items important to CW> occupational therapy and consumers. CW> Medicare Part B Outpatient Cap CW> The bill enacts an exception to the annual cap for medically necessary CW> therapy for one year (2006). However, the beneficiary or a CW> representative of the beneficiary must apply for permission to provide CW> the additional therapy beyond next year's limit of $1740 for CW> occupational therapy and, separately, for physical therapy and CW> speech-language pathology services. The Centers for Medicaid and CW> Medicare Services (CMS) will have to institute a process by which CW> beneficiaries or providers apply for additional services. CW> The bill provides a protection for providers and consumers. If CMS CW> does not provide an answer within 10-days, the additional therapy will CW> be regarded as approved. Medically necessary will be defined as it is CW> in current regulation for therapy. CW> In addition, to produce some savings and also to promote payment only CW> for medically necessary therapy, the bill requires CMS to improve the CW> use of codes by providers to ensure that only appropriate therapy is CW> being provided. Original proposals for these "code edits" were designed CW> to apply a strict 3-unit limit per code per day. The final language CW> provides language to require that the codes are "clinically CW> appropriate," language suggested by AOTA. CW> While not a moratorium, the alternative extra therapy approval option CW> will allow patients to get needed therapy. The one-year limit will CW> require that additional action be taken next year to prevent CW> implementation of the cap in 2007. But most changes in the bill were CW> included for only one year, such as the physician fee schedule CW> increase. CW> Medicare Physician Fee Schedule Increase CW> Cuts to Medicare physician fee schedule (PFS )amounts of more than 4% CW> would be averted for one year and fees would remain essentially level CW> for 2006. All Medicare physician and therapy services are paid for CW> under the PFS. There is a complicated formula used to calculate the CW> payment amounts; over the past several years, the formula has resulted CW> in reductions in payments. Physicians and others have protested these CW> reductions and Congress has implemented limited changes to prevent cuts. CW> For 2006 a one year "freeze" on physician payments is allowed. CW> Earlier proposals to fix the PFS in both the House and Senate linked CW> any change to PFS amounts to the implementation of a "pay for CW> performance" system that would provide savings by paying for only CW> "quality" health care services. The final conference report only asks CW> for a study by the Medicare Payment Advisory Commission (MedPAC) of CW> changes that could be made to the PFS to better adjust payments as the CW> number of beneficiaries in Medicare increases. CW> Medicare Home Health CW> An adjustment for rural home health care payments for 2006 was CW> included. Also, a Home Health Quality Improvement program will be CW> instituted requiring each home health agency to submit data measuring CW> health care quality beginning in 2007. A MedPAC report on a detailed CW> structure of value based payment adjustment for home health services CW> under Medicare was included. CW> Medicare Post-Acute Care Payment Reform Demonstration Project CW> The Secretary of Health and Human Services (HHS) is charged with CW> establishing a 3-year demonstration program for purposes of CW> understanding costs and outcomes across different post-acute sites. CW> Under the demonstration, an individual who receives any post-acute care CW> services (outpatient, home health, rehabilitation hospital, or nursing CW> facility) services shall receive a single comprehensive assessment on CW> the date of discharge from the actue care. The assessment would be used CW> to examine the needs of the patient and the clinical characteristics of CW> the diagnosis to determine the appropriate post-acute setting for that CW> patient. CW> Included within the demonstration project is a standardized patient CW> assessment instrument to be used across all post-acute care settings to CW> measure functional status and other factors during the treatment and at CW> the time of discharge from each post-acute provider. CW> AOTA submitted testimony to the Subcommittee on Health, House of CW> Representative Committee on Ways and Means in June of 2005 that focused CW> on current financing for post-acute care services in Medicare; the CW> services available across the various post-acute settings; the patient CW> assessment instruments used in each settings and the commonalities CW> between them; and prospects and suggestions for moving ahead with a CW> common patient assessment tool and more rational payment system based on CW> beneficiary need rather than institutional setting. AOTA stressed that CW> occupational therapy be an integral part of the plan of care of people CW> transitioning into post-acute care and will continue to work with CW> Congress and HHS to ensure the inclusion of occupational therapy within CW> this demonstration project. Click here to view AOTA's testimony. CW> http://waysandmeans.house.gov/hearings.asp?formmode=view&id=3968 CW> Medicare Inpatient Rehabilitation Hospitals CW> A one-year extension was included in the budget reconciliation bill on CW> the phase-in of the inpatient rehabilitation facility (IRF) CW> classification criteria - or "75% rule." The bill retains the 60% CW> threshold for 2006, a 65% threshold for 2007, and will begin the 75% CW> rule in 2008. CW> CMS recently implemented the 75% Rule for IRFs, requiring that a CW> percentage of patients, increasing over the next few years up to 75%, CW> must be treated for one of thirteen specific conditions identified in CW> 1984 in order for a facility to retain IRF status. IRF status gives the CW> hospital the ability to receive adequate Medicare compensation due to CW> the intense rehabilitation services that are provided. The list of CW> conditions is viewed by most as outdated, failing to take into account CW> medical advances of the past two decades and changing patient needs. CW> AOTA will continue to work with Congress, HHS, and the CMS to study the CW> impact this rule could have on occupational therapy and IRFs. Go to CW> AOTA's Legislative Action Center to read more about the history of the CW> 75% rule and to contact your Representatives and urge them to support CW> the "Preserving Patient Access to Inpatient Rehabilitation Hospitals Act CW> of 2005" (S. 1405/H.R. 3373) - a bill that freezes the phase in CW> requirement at 50% while Congress and the Department of Health and Human CW> Services study the impact of the restriction. CW> Medicaid CW> Although AOTA was successful in eliminating Medicaid cuts that CW> specifically targeted therapy services, the impact of the Medicaid cuts CW> proposed in the Conference report would be very damaging to Medicaid CW> beneficiaries and could negatively impact access to occupational CW> therapy. CW> The cuts impact beneficiaries in many ways but the three most CW> problematic changes include: CW> * Changes to Early and Periodic Screening, Diagnostic, and CW> Treatment service for children (EPSDT). CW> * Increased Cost Sharing CW> * Limitations on Targeted Case Management Services CW> The Conference report allows states to reduce benefit packages for CW> specific populations including the 29 million children on Medicaid. CW> These changes could result in the elimination of EPSDT coverage mandates CW> completely. Even if a state chooses not to eliminate EPSDT services, CW> access would likely be reduced dramatically. Benefit changes including CW> EPSDT are estimated by the Congressional Budget Office (CBO) to cut CW> Medicaid by $1.3 billion over 5 years and $6.1 billion over 10 years. CW> Increased cost-sharing or co-payments has a two-fold effect upon CW> savings for the government and reduced access for beneficiaries. Cost CW> sharing provides initial savings as beneficiaries are responsible for CW> portions of their care with some low-income Medicaid beneficiaries CW> having to pay 10% of their Medical bills. In addition, cost sharing has CW> been demonstrated and is known to reduce utilization, particularly among CW> low income families. This reduced utilization of medical care provides CW> additional short term savings because people hold off and do not obtain CW> the medical care they need. This section of the bill has been the most CW> controversial because of its direct impact on beneficiaries and on CW> long-term health outcomes. Cost sharing will cut Medicaid by $1.9 CW> billion over 5 years with cuts exploding to $10.1 billion over 10 years. CW> The bill tightens the definition of Targeted Case Management (TCM), CW> reducing access to essential supportive services for Medicaid CW> beneficiaries, particularly people with mental illness and people with CW> developmental disabilities. These populations, among others, benefit CW> from services covered under this category in order to maintain CW> compliance with their medical and social service care plans. Changes in CW> the bill shift costs from the federal government to states who will CW> likely be forced to reduce access to targeted case management because of CW> the inadequate funding provided in the bill. Changes to TCM are CW> estimated to cut Medicaid by $750 million over 5 years and $2 billion CW> over 10 years. CW> The bill does make some improvements to Medicaid such as implementation CW> of the Family Opportunity Act and the "Cash and Counseling" program as CW> well as establishment of a demonstration project for "Money Follows the CW> Person." (See below.) CW> Family Opportunity Act CW> The Conference Report includes a provision known as the "Family CW> Opportunity Act" that gives states the option to allow families to CW> purchase Medicaid coverage for children with disabilities. The language CW> includes guidelines and limitations on who can participate in the CW> program but allows significantly increased access to Medicaid for CW> families below 300% of the poverty level and even includes exceptions CW> for states to provide additional opportunities for families above that CW> income threshold who have children with disabilities. CW> Expansion of the "Cash and Counseling" Program CW> The Cash and Counseling project that allows people with disabilities to CW> purchase self-directed personal care services has been expanded and is CW> now an available option for state Medicaid programs. This provision CW> allows increased flexibility and control for people with disabilities to CW> hire and supervise people they choose to provide the care they need. CW> Demonstrated benefits of this program include more flexible timing of CW> service that better meet the need of people with disabilities and CW> empowerment by providing control directly to the beneficiary over the CW> hiring and scheduling process. Safeguards and some reasonable CW> limitations are included in the bill to help ensure quality care and CW> safety for people choosing this option, but significant flexibility CW> remains. CW> Money Follows the Person Rebalancing Demonstration Project CW> Organizations that advocate on behalf of people with disabilities and CW> the professionals who work with them, including AOTA, have long lobbied CW> for a seamless source of funding that would support an individual CW> regardless of the care setting. Money Follows the Person will increase CW> the continuity of care and help improve access to and the utilization of CW> home and community based services. It will do this by eliminating CW> funding barriers that often discourage and delay transition from CW> institutional care to home and community based services. The CW> demonstration project will provide Congress with additional information CW> to use when considering future measures to rebalance the use of home and CW> community based services rather than institutional long term care. -- Unsubscribe? 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