A Summary of Provisions in H.R. 6331 Relevant to Medicare Beneficiaries

As indicated, H.R. 6331 contains a number of provisions that make improvements for Medicare beneficiaries.  The Center will issue an Alert that discusses the provisions in more detail if and when H.R. 6331 is enacted into law.

Relevant sections provide:

1.      Provisions for Low-Income Individuals

• QI program:  Extends the QI program through December 31, 2009, and increases funding for the program.
• Low-income subsidy (LIS) and Medicare Savings Program (MSP):  Effective 2010, increases the assets test for MSP to the LIS asset level for full subsidy individuals.  This change includes indexing the MSP asset test for the first time since the program was authorized in 1986.
• MSP applications:  SSA is directed to provide LIS applications and information about MSPs to individuals potentially eligible for such subsidies, to provide assistance with applications, and to share LIS application information with states such that the receipt by the state of such information initiates an application for MSP.
• Out -of -pocket expenses:  Limits cost-sharing for beneficiaries who are dually eligible for Medicare and Medicaid and who enroll in Special Needs Plans to the cost-sharing under Medicaid.
• Late enrollment penalty:  Eliminates the Part D late enrollment penalty for LIS-eligible individuals.
• Eliminates estate recovery:  Eliminates the authority for states to collect from estates of deceased beneficiaries the amounts paid to MSP recipients.
• Changes to definitions of income and resources for LIS: Exempts value of life insurance policy (resources) and in-kind support and maintenance (income).
• Judicial review of LIS decisions:  Provides for a right to federal court review
• Translation of model form:  The model MSP application must be translated into languages most frequently used by Medicare beneficiaries and made available to states.
• Assistance to SHIPs and Area Agencies on Aging: Provides additional funding, some of which is targeted to LIS outreach.

2.      Part A and Part B Provisions:

• Extension of exceptions process for therapy caps:  The process is extended until December 31, 2009.
• Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS):  Delays for 18 months implementation of the competitive bidding acquisition process for DMEPOS, which went into effect in 10 areas on July 1, and modifies the competitive bidding process.
• Improvements to preventive services:  The Secretary can use the national coverage determination process to add coverage of new preventive services.  The "Welcome to Medicare" physical is extended from 6 months to 1 year, and the deductible does not apply.
• Mental health services:  Decreases over 6 years the coinsurance for mental health services to the 20% coinsurance rate for other Medicare services.
• Chronic obstructive pulmonary disease and other conditions:  Includes coverage of intensive cardiac rehabilitation programs and repeals transfer of ownership of oxygen equipment
• Medigap: Requires implementation of modifications made by NAIC to the standard Medigap plans.  The modifications contain restructuring of current benefit packages.

3.      Part C and Part D Provisions:

• Prohibitions and limitations on marketing of Medicare Advantage (MA) and prescription drug (PDP) plans:  Prohibits door-to-door sales, cold calling, cross selling of non-health-related products.  Requires limitations on commissions and gifts, and requires agents to abide by state appointment laws.  Some provisions would be effective in time for the 2008 Annual Enrollment Period.

• Phase-out of indirect medical education (IME):  Phases out an adjustment to MA payment rates for IME, but continues to pay teaching hospitals directly for their higher patient care costs.

  NOTE:  This provision is the only adjustment to Medicare Advantage payment rates. It adopts a recommendation of the Medicare Advisory Payment Committee (MedPAC) to eliminate these duplicate payments.

• Private Fee-for-Services (PFFS) changes:  Requires PFFS plans in counties where there are two HMOs or PPOs to form networks of providers, beginning in 2011. Also requires PFFS plans, effective 2010, to have the same quality improvement programs as local PPOs.

• Special Needs Plans (SNPs): Extends the authority of SNPs and the moratorium on new SNPs through December 31, 2010.  Includes new eligibility and care management requirements and quality reporting standards.

• Coverage of barbiturates and benzodiazepines: Permits coverage under Part D of barbiturates (for certain conditions) and benzodiazepines, effective January 1, 2012.

• Protected classes of drugs: Codifies current guidance concerning coverage of "protected classes" of drugs under Part D and authorizes modification of the protected classes through rulemaking.

• Medically accepted indication for drugs:  Authorizes Medicare to revise the compendia used for identifying medically accepted indication for Part D drugs, and provides that the criteria for anticancer drugs covered under Part D should be the same as the criteria for anticancer drugs covered under Part B.

The Center for Medicare Advocacy will provide provide further analysis of H.R. 6331.