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  1. Connecticut Congressional Delegation Concerned about Medicare Advantage Network Provider Terminations in the State
  2. House Companion to Part D Extra Help Bill Introduced
  3. The Patient Driven Payment Model is Here – What Does It Mean for Residents?

Connecticut Congressional Delegation Concerned about Medicare Advantage Network Provider Terminations in the State

As noted in a press release issued by Rep. Rosa DeLauro’s office, on September 30, 2019, members of Connecticut’s congressional delegation sent a letter to the President of Anthem Blue Cross Blue Shield to “express our concern regarding the recently announced provider terminations from Anthem Blue Cross and Blue Shield’s (Anthem) Medicare Advantage (MA) network in Connecticut.”

Although the number of physicians being terminated is not clear, an early estimate by the Connecticut State Medical Society indicated that Anthem is terminating almost 2,000 physicians in the state from at least one of their MA plans, effective January 1, 2020.

The congressional letter notes that “Anthem’s decision to terminate Connecticut physicians from its network will leave an insufficient network that will not provide adequate access to care for many in our state, particularly for certain specialties in medically underserved areas of the state.”

As noted by the Connecticut news website CT News Junkie, this isn’t the first time that a large number of providers have been terminated by an MA plan: “In a similar situation with a different insurer in 2013, a federal judge agreed with two medical associations that United Healthcare should stop dropping doctors from its Medicaid Advantage network. The insurance company appealed the decision and the federal Centers for Medicaid and Medicare Services said the networks were adequate.”

The 2013 MA doctor cuts occurred in numerous states, after people had already made their enrollment choices for the year. As we enter the Medicare enrollment period for 2020, advocates and beneficiaries should remember that these kinds of changes to physicians and health care providers can occur in Medicare Advantage.

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House Companion to Part D Extra Help Bill Introduced

This week Rep. Brad Schneider (D-IL) introduced a House companion to the Senate Medicare Extra Rx HELP Act (S. 691H.R. 4583) introduced by Sen. Bob Casey (D-PA) in March 2019.  The bill would expand Part D Low Income Subsidy/ Extra Help by eliminating the asset test, streamlining program administration, and providing full benefits to those living on the edge of poverty.

The Center for Medicare Advocacy has expressed support for Sen. Casey’s bill in the past, including in the Center for Medicare Advocacy’s June 6, 2019 comments on Part D improvements to the House Ways and Means and Energy and Commerce Committees in response to draft legislation. Stating that “[t]o ensure that all seniors with limited income have access to LIS, we recommend Congress eliminate the program’s asset test and extend $0 premiums, $0 deductibles and fixed copays to Medicare beneficiaries under 200% FPL, as outlined in the Medicare Extra Rx HELP Act (S. 691) introduced by Sen. Casey.” The Center for Medicare Advocacy supports the House companion bill expanding LIS to more low income beneficiaries.

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The Patient Driven Payment Model is Here – What Does It Mean for Residents?

On October 1, 2019, the Centers for Medicare & Medicaid Services (CMS) began implementing a new payment system for Medicare-covered nursing home care. The payment system is called the “Patient Driven Payment Model” (PDPM). PDPM creates a new set of financial incentives for nursing homes to consider when admitting and discharging residents, as well as providing resident care. Following is an example of some these incentives.

Nursing homes have a higher incentive to admit a resident if the resident
is . . .  

    • A man
    • Younger than 65 years old but not older than 74
    • Disabled or has End-Stage Renal Disease
    • Cognitively impaired (severely)

Nursing homes have a higher incentive to admit a resident if the resident
needs . . .  

    • No therapy (or just one type of therapy)
    • IV medication
    • Tracheostomy and/or respiratory care
    • Infection isolation

Nursing homes have a higher incentive to discharge a resident within . . .

    • 15 days

Note: For CMS’s full impact analysis, please see the Final Rule.

While it will take some time to assess PDPM’s effects on resident care, PDPM makes clear that skilled therapy will no longer be driving Medicare-covered nursing home care. Thus, a major concern is that residents may receive less therapy under the new payment system. Unfortunately, making matters worse for residents in need of skilled therapy, PDPM also allows 25 percent of a resident’s total therapy regimen, by discipline, to be provided in group and/or concurrent therapy settings. Although CMS acknowledges that individual therapy is the best option because it is tailored to specific care needs, CMS makes clear that nursing homes will not be penalized for going over the 25 percent limit. As a result, in addition to less therapy services overall, residents may receive less individualized therapy under PDPM.

The Center for Medicare Advocacy and Long Term Care Community Coalition are especially concerned by PDPM’s impact on maintenance therapy. As confirmed in the Jimmo v. Sebelius Settlement Agreement, Medicare beneficiaries in nursing homes are entitled to receive skilled therapy to maintain their condition or to slow/prevent further decline. PDPM’s preference for skilled nursing over skilled therapy, and incentives to discharge residents sooner, may mean that Medicare beneficiaries in need of maintenance therapy will ultimately pay the biggest price under the new payment system.

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For additional information and resources, please visit
www.nursinghome411.org and www.medicareadvocacy.org.


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