Medicare Payment Policy

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Separate appeals and grievances processes for Medicare and Medicaid services are another barrier to integration. The current appeals and grievances processes for Medicare Part A and Part B have different rules and timelines from the appeals and grievances processes for Medicaid. It can be confusing and time-consuming for beneficiaries to navigate these separate processes. An aligned appeals and grievances process would alleviate this barrier, but the Secretary does not have the authority to do so, as it would require a change in law by the Congress. The current MA standards for appeals and grievances should represent a minimum standard. An alignment with the Medicaid process should result in an appeals and grievances standard that is an improvement over what is currently available through MA. 5 ReCoMMenDAtIon 14-4 For dual-eligible special needs plans (D–snps) that assume clinical and financial responsibility for Medicare and Medicaid benefits, the Congress should: • grant the secretary authority to align the Medicare and Medicaid appeals and grievances processes; • direct the secretary to allow these D–snps to market the Medicare and Medicaid benefits they cover as a combined benefit package; • direct the secretary to allow these D–snps to use a single enrollment card that covers beneficiaries’ Medicare and Medicaid benefits; and • direct the secretary to develop a model D–snp contract. 328 Medicare Advantage special needs plans RAtIonALe 14-4 This recommendation would alleviate misalignments between the Medicare and Medicaid programs that are barriers to an integration of program benefits. Under this recommendation, D–SNPs that are clinically and financially integrated would have aligned appeals and grievances processes for Medicare and Medicaid benefits. They would also be able to market all the benefits they cover as a combined benefit package, and it would be easier for them to give enrollees a single enrollment card to access their Medicare and Medicaid services. Under this recommendation, the Secretary would develop an example of a model Medicaid contract with a D–SNP for states to use as a resource. IMpLICAtIons 14-4 spending • This recommendation would not affect program spending but would alleviate administrative barriers between the Medicare and Medicaid programs. Beneficiary and plan • We expect this recommendation to have a positive effect on beneficiaries and plans by fostering the coordination of Medicare’s and Medicaid’s separate benefits for the beneficiaries who are dually eligible for both sets of benefits. ■
endnotes 1 Employer plans are another type of MA plan that can limit enrollment. They are not included in the analysis in this chapter. 2 Fifteen conditions are currently approved by CMS for C–SNPs: chronic alcohol and other drug dependence; autoimmune disorders; cancer, excluding precancer conditions or in situ status; cardiovascular disorders; chronic heart failure; dementia; diabetes mellitus; end-stage liver disease; end-stage renal disease requiring dialysis; severe hematologic disorders; HIV/AIDS; chronic lung disorders; chronic and disabling mental health conditions; neurologic disorders; and stroke. 3 The NCQA approval process, required as of 2012, evaluates the extent to which plans adhere to these “model of care” requirements. A separate NCQA process evaluates the structure and processes of SNPs. 4 MedPAC analysis of plan participation of Medicaid managed long-term care programs and SNP enrollment files from CMS. 5 CMS is currently working with a number of states on demonstrations for integrated care programs for dualeligible beneficiaries and will likely alleviate many of these misalignments for the plans that participate in the demonstrations. Report to the Congress: Medicare Payment Policy | March 2013 329
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RepoRt to the CongRess Medicare Pay
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RepoRt to tHe CongRess Medicare Pay
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with the structure of the payment s
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table of contents Acknowledgments .
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executive summary
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of services—and pressure on feder
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current Medicare payments are adequ
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outpatient dialysis services Outpat
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some facilities are willing to acce
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coverage for conventional treatment
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of care for these conditions should
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Context for Medicare payment policy
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4 Context for Medicare payment poli
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FIguRe FIGURE 1-2 1-2 12% Out of po
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the level of health care spending a
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1-4 FIguRe 1-4 140 120 100 80 60 Do
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FIguRe 1-6 1-6 Growth rate (in perc
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FIGURE FIguRe Share of GDP (in perc
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Share of GDP (in percent) FIGURE 1-
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FIGURE FIguRe 1-10 1-10 8% African
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FIguRe 1-12 1-11 1800 1600 1400 120
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Americans than for other racial and
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References Agency for Healthcare Re
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Medicare Payment Advisory Commissio
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Assessing payment adequacy and upda
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The goal of Medicare payment policy
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may go up when payment rates go dow
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hospitals and that hospitals shift
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individual payment systems but also
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Hospital inpatient and outpatient s
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Hospital inpatient and outpatient s
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covered the fully allocated costs o
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3-1 3-1 FIguRe 100 80 60 40 Number
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Visits or claims per 1,000 benefici
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3-4 3-4 FIguRe 2012 dollars (in bil
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of physicians employed directly by
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FIguRe FIGURE Annual percent change
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FIGURE FIguRe Margin (in percent) 3
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FIGURE FIguRe Margin (in percent) 3
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tABLe 3-5 performance of efficient
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Act, the EHR Incentive Program also
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as Medicaid expands, the new insura
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ates for separately paid drugs resu
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endnotes 1 From 2002 to 2011, 479 h
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References Agency for Healthcare Re
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C H A p t e R4 physician and other
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physician and other health professi
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from the SGR system in its October
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4-1 4-1 FIguRe 40 35 30 25 20 15 10
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tABLe 4-1 Most aged Medicare benefi
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tABLe 4-2 Medicare beneficiaries ha
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payment adjustments for health prof
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tABLe 4-3 Year physicians primary c
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provider’s characteristics, geogr
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tABLe 4-4 type of service Change in
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tABLe 4-5 type of imaging Change in
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the patient-centered medical home T
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FIguRe FIGURE Cumulative percent ch
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References ABIM Foundation. 2012. C
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Ambulatory surgical center services
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Ambulatory surgical center services
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Background An ambulatory surgical c
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Differences in types of patients tr
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Differences in types of patients tr
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number of services grew from 2006 t
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tABLe 5-7 rapidly than nonowning ph
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Creating a value-based purchasing p
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Revisiting the ambulatory surgical
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endnotes 1 Because CMS updates paym
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Medicare Payment Advisory Commissio
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R e C o M M e n D A t I o n 6 The C
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128 Outpatient dialysis services: A
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tABLe 6-1 Characteristics of FFs di
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Physicians Association has publishe
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tABLe 6-3 Increasing number and cap
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Number of FFS dialysis beneficiarie
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FIguRe 6-3 Percent of dialysis bene
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and 2011, the proportion of adult h
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anticipated under the modernized pa
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endnotes 1 In this chapter, we use
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References ABIM Foundation. 2012. C
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C H A p t e R7 post-acute care prov
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encourages more 60-day episodes. Fu
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C H A p t e R8 skilled nursing faci
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skilled nursing facility services C
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adjust for differences in patients
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Description of beneficiaries who us
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snF prospective payment system and
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Number of SNFs FIguRe FIGURE 8-1 7-
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FIGURE FIguRe Percent 7-2 8-2 30 25
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and other SNF users were essentiall
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FIguRe FIGURE Program spending (in
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7-8 8-6 FIguRe 30 25 20 15 10 Medic
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(e.g., whether there is a requireme
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the Commission’s 2012 update reco
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tABLe 8-9 non-Medicare margins were
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found to be associated with one or
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Smith, V. K., K. Gifford, E. Ellis,
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R e C o M M e n D A t I o n s (The
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188 Home health care services: Asse
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tABLe 9-1 use and growth of home he
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FIGURE FIguRe Number of new agencie
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tABLe 9-2 of services. The review a
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tABLe 9-4 Community-admitted home h
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tABLe 9-5 type of county Claims dat
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tABLe 9-6 state County are collecte
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tABLe 9-8 Medicare margins for free
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tABLe 9-11 provider characteristics
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tABLe 9-12 Medicare visits per full
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strengthening incentives for effect
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endnotes 1 The exceptions pertain t
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C H A p t e R10 Inpatient rehabilit
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Inpatient rehabilitation facility s
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FIguRe FIGURE 10-1 9-1 Note: IRF (i
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Medicare IRF classification require
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tABLe 10-2 type of IRF 2004 2005 20
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tABLe 10-4 number of IRF beds decre
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weight for compliant cases was 1.39
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unobserved factors regarding patien
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freestanding IRFs were about $4,340
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increase for changes in the outlier
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References Centers for Medicare & M
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R e C o M M e n D A t I o n 11 The
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Quality of care—LTCHs only recent
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FIguRe FIGURE 11-1 10-1 Source: Med
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short-stay outlier cases in long-te
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tABLe 11-1 growth in the number of
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Chronically critically ill benefici
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Quality measures for long-term care
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tABLe 11-4 type of LtCH per case pa
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temporary legislative relief from s
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16 We observed growth over time in
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Durairaj, L., J. C. Torner, E. A. C
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Hospice services C H A p t e R12
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Hospice services Chapter summary Th
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Background Medicare began offering
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March 2009 Commission recommendatio
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March 2009 Commission recommendatio
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number peaking in 2009). With rapid
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tABLe 12-4 Hospice use has increase
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tABLe 12-5 Characteristic insurers
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three settings, respectively) (Tabl
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Page 311: C H A p t e R13 the Medicare Advant
Page 314 and 315: 288 The Medicare Advantage program:
Page 317 and 318: The Medicare Advantage (MA) program
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Page 337 and 338: C H A p t e R14 Medicare Advantage
Page 339 and 340: Medicare Advantage special needs pl
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Page 370 and 371: FIGURE FIguRe Percent of all Part D
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Page 395: A p p e n D I X Moving forward from
Page 398 and 399: well as the cost of temporary repri
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achieving a total estimated 10-year
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would be costly, too, and they are
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payment accuracy. For example, such
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Final regulations on the ACO progra
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statemen nt of MedPAC’s position
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Cumulative percent change 70 7 60 6
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390 Moving forward from the sustain
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Note: The availability and scoring
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Acronyms AAgR average annual growth
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op outpatient opD hospital outpatie
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Commission members glenn M. Hackbar
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a state society of the National Med
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on the Advocate Physician Partners
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425 eye street, nW • suite 701
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Medicare Payment Policy

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