This is the third of four installments of our summary of provisions from the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), Pub. Law 110-275.  The two previous installments are available on our Weekly Alert page. The final installment will focus on provisions relating to Medicare Parts C and D. 

This installment is a potpourri of MIPPA provisions.  Of particular interest is the range of provisions that move toward parity in payments for mental health services, as well as provisions that establish programs and services to expand services to persons in rural areas, address inequities in payment for outpatient mental health services, and provide incentives toward greater use of new technologies in the delivery of health care, particularly internet-based delivery approaches such as prescribing services and medications electronically – or "e-prescribing." Most of the provisions described below are effective in 2009 and beyond. 

Additional Beneficiary Improvements

• Section 102. Elimination of discriminatory co-payment rates for Medicare outpatient psychiatric services.  Beginning in 2010, for expenses reflecting the Medicare approved amount that are incurred in a calendar year in connection with the treatment of outpatient psychiatric services, Medicare will begin to increase the percentage (currently 50 percent) that it will cover as follows: 55 percent of expenses incurred in 2010 or 2011; 60 percent in 2012; 65 percent in 2013; 80 percent in 2014 or in any subsequent calendar year.  As explained in this section of MIPPA, "treatment" does not include brief office visits for the sole purpose of monitoring or changing drug prescriptions used in the treatment of psychiatric disorders or partial hospitalization services not directly provided by a physician.
   

• Section 104.  Improvements to the Medigap program.  The Secretary is to provide for the implementation of changes in standard Medigap polices recommended by the National Association of Insurance Commissioners (NAIC) on March 11, 2007 as modified by MIPPA and the Genetic Information Nondiscrimination Act of 2008 (Pub. Law 110-233).  NAIC is to complete modifications by October 31, 2008 and each state will have one year from the date of adoption of the revised model law and regulation by NAIC to conform its regulatory program to reflect the revised model law and regulation (with allowances for when state legislatures meet).  Medigap products must meet the new standards by June 1, 2010.
  See http://www.naic.org/documents/committees_b_senior_issues_080805_
  medigap.pdf for the draft NAIC model guidelines.

Provisions Relating to Medicare Part A

• Section 121. Expansion and extension of the Medicare Rural Hospital Flexibility Program.  The Secretary may award grants to states that have submitted applications to increase the delivery of mental health services or other health care deemed necessary to meet the needs of veterans of Operation Iraqi Freedom and Operation Enduring Freedom living in rural areas.  These grants emphasize coordination with state and local entities, the Veterans Administration, and other entities that serve the intended populations.  The bulk of this grant activity is applicable to Fiscal years 2008, 2009, and 2010.
   

• Section 123.  Demonstration project on community health integration models in certain rural counties.  The Secretary is to establish a demonstration project to test new models in no more than four states for the delivery of health care services in counties with six or fewer residents per square mile to improve access to and integrate acute and extended care services to Medicare beneficiaries.  Each entity applying for these grants must select up to six counties in the state in which the entity is located for purposes of the demonstration. Selected health care providers will be reimbursed on a reasonable cost rate basis for the demonstration projects.  Grants are for a three-year period beginning October 1, 2009.
   

• Section 125. Revocation of unique deeming authority of the Joint Commission.  Effective 24 months from the date of the enactment of MIPPA (July 15, 2008), the Joint Commission, which accredits hospitals, will no longer have this unique accrediting status whereby hospitals that meet the standards of the Joint Commission are deemed to meet the standards required by the Secretary for accreditation.  Rather, accreditation by other national accrediting bodies meeting criteria established by the Secretary will also be deemed to meet the standards required by the Secretary.

Provisions Relating to Physician's Services – Medicare Part B

• Section 132.  Incentives for electronic prescribing.  For 2009 through 2013, for covered professional services furnished by an eligible successful electronic prescriber, as defined in MIPPA, in addition to Medicare's established fee schedule for payment for services, Medicare will pay an amount equal to the applicable electronic prescribing percentage established by the Secretary.  The percentages are 2.0 percent for 2009 and 2010; 1.0 percent for 2011 and 2012; and 0.5 percent for 2013.  Persons engaging in electronic prescribing will have to adhere to certain quality standards and measures as established by the Secretary.
   

• Section 133.  Expanding access to primary care services.   This provision gives the Secretary authority to expand (to an extent deemed appropriate by the Secretary) the duration and scope of the "Medical Home Demonstration Project."  This demonstration, focusing on payment incentives to physicians and physician practices for care coordination, is expected to improve the quality of patient care without increasing spending.  Funding is from the Supplementary Medical Insurance Trust Fund in the amount of $100 million.  This funding is outside the budget-neutrality framework applicable to fee schedules established beginning with 2009 as described in the legislation. [In general, "budget-neutrality" relates to the notion that a provision can not increase current budgetary expenditures without a corresponding budgetary offset.]
   

• Section 135.  Imaging provisions.  Beginning January 1, 2012, advanced diagnostic imaging services suppliers must be accredited by an accreditation organization designated by the Secretary.  The provision applies to diagnostic magnetic resonance imaging, computed tomography, and nuclear medicine (including positron emission tomography) and such other diagnostic imaging services as specified by the Secretary in consultation with physician specialty organizations and other stakeholders.  No later than January 1, 2010, the Secretary shall designate organizations to accredit suppliers furnishing the technical component of advanced diagnostic imaging services.  A final report, due no later than March 1, 2014, is to be submitted by the Comptroller General to the Congress with recommendations for legislative and administrative action to address the effects of an accreditation requirement on access to imaging services, the number and types of facilities available, including access to services in rural areas.
   

• Section 138.  Adjustment for Medicare mental health services.  For services furnished under the physician fee schedule during the period beginning on July 1, 2008, and ending on December 31, 2009, the Secretary shall increase the fee schedule otherwise applicable for specified services by five percent.  Budget-neutrality provisions shall not apply.  Specified services are defined as categories of common procedure codes consisting of psychiatric therapeutic procedures furnished in office or other outpatient facility settings or inpatient hospital, partial hospital, or residential care facility settings.  The adjustment is only applicable to services that are insight oriented, behavior modifying, or supportive psychotherapy or interactive psychotherapy. 

Other Payment and Coverage Improvements

• Section   142.  Extension of payment rule for brachytherapy and therapeutic radiopharmaceuticals.  This provision extends payment rules through January 1, 2010 for brachytherapy (cancer treatment) and therapeutic radiopharmaceuticals (nuclear medicine). The MIPPA provision extends a payment rule established by the Tax Relief and Health Care Act of 2006 (TRHCA) which extended the provision from January 1 2008 until July 1, 2008. The initial provision was included in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. Law 108-173) and required Medicare's outpatient prospective payment system to make separate payments for specified brachytherapy sources and therapeutic radiopharmaceuticals using a hospital's charges adjusted for their costs.
   

• Section   143.  Speech-language pathology services.  Effective for services furnished on or after July 1, 2009, this MIPPA provision establishes a separate definition for outpatient speech-language pathology services and permits speech-language pathologists practicing independently to bill Part B using the same conditions that apply to physical and occupational therapists in independent practice.
   

• Section 147. Extension and expansion of the Medicare hold harmless provision under the prospective payment system for hospital outpatient department (HOPD) services for certain hospitals.  This provision allows small rural hospitals (with no more than 100 beds) or sole community hospitals (SCHs) to receive additional Medicare payments if their outpatient prospective payment system (OPPS) payments are less than those under the pre-Balanced Budget Act of 1997 (Pub. Law 105-33) amount.  The provision establishes that small rural hospitals will receive 85 percent of the payment difference in 2008 and 2009.  SCHs with not more than 100 beds will receive 85 percent of the payment difference for covered HOPD services furnished on or after January 1, 2009, and before January 1, 2010.
   

• Section 149. Adding certain entities as originating sites for payment of telehealth services.  This provision adds hospital-based or critical access hospital-based renal dialysis centers (including satellites), skilled nursing facilities, and community mental health centers as originating sites for payment of telehealth services furnished on or after January 1, 2009.

Other Provisions

• Section 183.  Contract with a consensus-based entity regarding performance measurement.  This provision allows the Secretary to contract with a consensus-based entity such as the National Quality Forum (NQF) that will develop and endorse health care quality measures. For this purpose, the Secretary may use up to $10 million from the Medicare Part A and Part B Trust Funds for the period of fiscal years 2009 through 2012. The Government Accountability Office (GAO) will study the performance of the consensus-based entity and report on its performance and its cost in fulfilling its duties.  Reports are due not later than 18 months and 36 months after the effective date of the first contract, together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate.
   

• Section 185.  Addressing health care disparities.   This provision gives the Secretary the authority to initiate data collection and analysis to address health care disparities across race, ethnicity, and gender. The Secretary will prepare reports that identify approaches for identifying and collecting and evaluating data on health care disparities for traditional Medicare.  The report is to include recommendations on the most effective strategies and approaches to be used in reporting Healthcare Effectiveness Data and Information Set (HEDIS) quality measures and other nationally recognized quality performance measures on the basis of race, ethnicity, and gender.  The Secretary is to implement identified approaches no later than 24 months after the date of enactment.
   

• Section 186. Demonstration to improve care to previously uninsured. Within one year after enactment, the Secretary is to establish a two-year demonstration project to determine the greatest needs and most effective methods of outreach to Medicare beneficiaries who were previously uninsured.  The demonstration will be in no fewer than 10 sites and will include state health insurance assistance programs, community health centers, community-based organizations, community health workers, and other service providers under Medicare Parts A, B, and C.  The Secretary is to submit a report on the outcomes of the demonstration to Congress within one year of the completion of the project.

Conclusion

MIPPA provisions correct, reaffirm, or continue vital programs and services.  There are also a number of important studies to be conducted, many of which advocates may want to follow.  Advocates may also want to seek to participate in the design and focus of relevant studies. Similarly, advocates may find opportunities to work with local and state agencies in the design of various Medicare outreach programs, particularly those of relevance to persons dually eligible for Medicare and Medicaid.