Tagged CMS

Health Law’s 10 Essential Benefits: A Look At What’s At Risk In GOP Overhaul

As Republicans look at ways to replace or repair the health law, many suggest shrinking the list of services insurers are required to offer in individual and small group plans would reduce costs and increase flexibility. That option came to the forefront last week when Seema Verma, who is slated to run the Centers for Medicare & Medicaid Services in the Trump administration, noted at her confirmation hearing that coverage for maternity services should be optional in those health plans.

Maternity coverage is a popular target and one often mentioned by health law critics, but other items also could be watered down or eliminated.

There are some big hurdles, however. The health law requires that insurers who sell policies for individuals and small businesses cover at a minimum 10 “essential health benefits,” including hospitalization, prescription drugs and emergency care, in addition to maternity services. The law also requires that the scope of the services offered be equal to those typically provided in employer coverage.

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“It has to look like a typical employer plan, and those are still pretty generous,” said Timothy Jost, an emeritus professor at Washington and Lee University Law School in Virginia who is an expert on the health law.

Since the 10 required benefits are spelled out in the Affordable Care Act, it would require a change in the law to eliminate entire categories or to water them down to such an extent that they’re less generous than typical employer coverage. And since Republicans likely cannot garner 60 votes in the Senate, they will be limited in changes that they can make to the ACA. Still, policy experts say there’s room to “skinny up” the requirements in some areas by changing the regulations that federal officials wrote to implement the law.

Habilitative Services

The law requires that plans cover “rehabilitative and habilitative services and devices.” Many employer plans don’t include habilitative services, which help people with developmental disabilities such as cerebral palsy or autism maintain, learn or improve their functional skills. Federal officials issued a regulation that defined habilitative services and directed plans to set separate limits for the number of covered visits for rehabilitative and habilitative services.

Those rules could be changed. “There is real room for weakening the requirements” for habilitative services, said Dania Palanker, an assistant research professor at Georgetown University’s Center on Health Insurance Reforms who has reviewed the essential health benefits coverage requirements.

Oral And Vision Care For Kids

Pediatric oral and vision care requirements, another essential health benefit that’s not particularly common in employer plans, could also be weakened, said Caroline Pearson, a senior vice president at Avalere Health, a consulting firm.

Mental Health And Substance Use Disorder Services

The health law requires all individual and small group plans cover mental health and substance use disorder services. In the regulations the administration said that means those services have to be provided at “parity” with medical and surgical services, meaning plans can’t be more restrictive with one type of coverage than the other regarding cost sharing, treatment and care management.

“They could back off of parity,” Palanker said.

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Prescription Drugs

Prescription drug coverage could be tinkered with as well. The rules currently require that plans cover at least one drug in every drug class, a standard that isn’t particularly robust to start with, said Katie Keith, a health policy consultant and adjunct professor at Georgetown Law School. That standard could be relaxed further, she said, and the list of required covered drugs could shrink.

Preventive And Wellness Services And Chronic Disease Management

Republicans have discussed trimming or eliminating some of the preventive services that are required to be offered without cost sharing. Among those requirements is providing birth control without charging women anything out of pocket. But, Palanker said, “if they just wanted to omit them, I expect that would end up in court.”

Pregnancy, Maternity And Newborn Care

Before the health law passed, just 12 percent of health policies available to a 30-year-old woman on the individual market offered maternity benefits, according to research by the National Women’s Law Center. Those that did often charged extra for the coverage and required a waiting period of a year or more. The essential health benefits package plugged that hole very cleanly, said Adam Sonfield, a senior policy manager at the Guttmacher Institute, a reproductive health research and advocacy organization.

“Having it in the law makes it more difficult to either exclude it entirely or charge an arm and a leg for it,” Sonfield said.

Maternity coverage is often offered as an example of a benefit that should be optional, as Verma advocated. If you’re a man or too old to get pregnant, why should you have to pay for that coverage?

That a la carte approach is not the way insurance should work, some experts argue. Women don’t need prostate cancer screening, they counter, but they pay for the coverage anyway.

“We buy insurance for uncertainty, and to spread the costs of care across a broad population so that when something comes up that person has adequate coverage to meet their needs,” said Linda Blumberg, a senior fellow at the Health Policy Center at the Urban Institute.

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

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Docs Bill Medicare for End-of-Life Advice As ‘Death Panel’ Fears Reemerge

End-of-life counseling sessions, once decried by some conservative Republicans as “death panels,” gained steam among Medicare patients in 2016, the first year doctors could charge the federal program for the service.

Nearly 14,000 providers billed almost $35 million — including nearly $16 million paid by Medicare — for advance care planning conversations for about 223,000 patients from January through June, according to data released this week by the Centers for Medicare & Medicaid Services. Full year figures won’t be available until July, but use appears to be higher than anticipated.

Controversy is threatening to reemerge in Congress over the funding, which pays doctors to counsel some 57 million Medicare patients on end-of-life treatment preferences. Rep. Steve King, R-Iowa, introduced a bill last month, the Protecting Life Until Natural Death Act, which would revoke Medicare reimbursement for the sessions, which he called a “yet another life-devaluing policy.”

“Allowing the federal government to marry its need to save dollars with the promotion of end-of-life counseling is not in the interest of millions of Americans who were promised life-sustaining care in their older years,” King said on Jan. 11.

While the fate of King’s bill is highly uncertain — the recently proposed measure hasn’t seen congressional action — it underscores deep feelings among conservatives who have long opposed such counseling and may seek to remove it from Medicare should Republicans attempt to make other changes to the entitlement program.

Proponents of advance care planning, however, cheered evidence of program’s early use as a sign of growing interest in late stage life planning.

“It’s great to hear that almost a quarter million people had an advance care planning conversation in the first six months of 2016,” said Paul Malley, president of Aging with Dignity, a Florida nonprofit. “I do think the billing makes a difference. I think it puts it on the radar of more physicians.”

Use of the counseling sessions are on track to outpace an estimate by the American Medical Association, which projected that about 300,000 patients would receive the service in the first year, according to the group, which backed the rule.

Providers in California, New York and Florida led use of the policy that pays about $86 a session for the first 30-minute office-based visit and about $75 per visit for any additional sessions.

The rule requires no specific diagnosis and sets no guidelines for the end-of-life discussions. Conversations center on medical directives and treatment preferences, including hospice enrollment and the desire for care if patients lose the ability to make their own decisions.

The new reimbursement led Dr. Peter Sutherland, a family medicine physician in Morristown, Tenn., to schedule more end-of-life conversations with patients last year.

“They were very few and far between before,” he said. “They were usually hospice-specific.”

Now, he said, he has time to have thorough discussions with patients, including a 60-year-old woman whose recent complaints of back and shoulder pain turned out to be cancer that had metastasized to her lungs. In early January, he talked with an 84-year-old woman with Stage IV breast cancer.

“She didn’t understand what a living will was,” Sutherland said. “We went through all that. I had her daughter with her and we went through it all.”

The conversations may occur during annual wellness exams, in separate office visits or in hospitals. Nurse practitioners and physicians’ assistants may also seek payment for end-of-life talks.

The idea of letting Medicare reimburse such conversations was first introduced in 2009 during debate on the Affordable Care Act. The issue quickly fueled allegations by some conservative politicians, such as former Republican vice presidential candidate Sarah Palin and presidential candidate John McCain, that they would lead to “death panels” that could disrupt care for elderly and disabled patients.

The idea was dropped “as a direct result of public outcry,” King said in a statement.

“The worldview behind the policy has not changed since then and government control over this intimate choice is still intolerable to those who respect the dignity of human life,” he said.

But in 2015, CMS officials quietly issued the new rule allowing Medicare reimbursement as a way to improve patients’ ability to make decisions about their care.

End-of-life conversations have occurred in the past, but not as often as they should, Malley said. Many doctors aren’t trained to have such discussions and find them difficult to initiate.

“For a lot of health providers, we hear the concern that this is not why patients come to us,” Malley said. “They come to us looking to be cured, for hope. And it’s sensitive to talk about what happens if we can’t cure you.”

2014 report by the Institute of Medicine, a panel of medical experts, concluded that Americans need more help navigating end-of-life decisions. A 2015 Kaiser Family Foundation poll found that 89 percent of people surveyed said health care providers should discuss such issues with patients, but only 17 percent had had those talks themselves. (KHN is an editorially independent program of the foundation.)

Use of the new rule was limited in the first six months of 2016. In California, which recorded the highest Medicare payments, about 1,300 providers provided nearly 29,000 services to about 24,000 patients at an overall cost of about $4.4 million — including about $1.9 million paid by Medicare.

The data likely reflect early adopters who were already having the talks and quickly integrated the new billing codes into their practices, said Dr. Ravi Parikh, an internal medicine resident at Brigham and Women’s Hospital in Boston, who has written about advance care planning. Many others still aren’t aware, he said.

Data from Athenahealth, a medical billing management service, found that only about 17 percent of 34,000 primary care providers at 2,000 practices billed for advance care planning in all of 2016.

The numbers will likely grow, said Malley, who noted that requests from doctors for advance care planning information tripled during the past year.

To counter objections, providers need to ensure that informed choice is at the heart of the newly reimbursed discussions.

“If advance care planning is only about saying no to care, then it should be revoked,” Malley said. “If it truly is about finding out patient preferences on their own turf, it’s a good thing.”

KHN’s coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation.

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El secretario de Salud Tom Price podría cambiar rápido 5 temas clave de salud

Después de un proceso accidentado, el Senado confirmó la madrugada del 10 de febrero al representante republicano por Georgia, Tom Price, para dirigir el Departamento de Salud y Servicios Humanos (HHS), por un voto de 52 a 47.

Como secretario, Price tendrá una autoridad significativa para reescribir las reglas de la Ley de Cuidado de Salud Asequible (ACA), popularmente conocida como Obamacare, algunas de las cuales ya están casi listas para poner en acción.

Pero ahora, Price tiene una influencia de muy largo alcance, como jefe de una agencia con un presupuesto de más de $ 1 billón para el año fiscal actual. Puede interpretar las leyes de formas diferentes a las de sus predecesores y reescribir las regulaciones y las guías, que definen cómo se ponen en marcha legislaciones importantes.

“Virtualmente, la forma en que se administra el HHS afecta todo lo que la gente hace todos los días”, dijo Matt Myers, presidente de la Campaign for Tobacco-Free Kids. Las responsabilidades del departamento de salud incluyen: seguridad de alimentos y medicamentos, investigación biomédica, prevención y control de enfermedades, así como supervisión de todo, desde laboratorios médicos hasta hogares de ancianos.

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Price, un médico de Georgia que se opone a ACA, al aborto y a la financiación de Planned Parenthood, entre otras cosas, podría tener un impacto rápido, incluso sin una orden presidencial o un acto del Congreso

Algunos que lo apoyan están entusiasmados con esa posibilidad. “Con el doctor Price tomando el timón de la política de salud de los Estados Unidos, los médicos y los pacientes tienen razones sólidas para esperar un cambio bienvenido y esperado desde hace mucho tiempo”, dijo Robert Moffit, miembro de la Heritage Foundation, en un comunicado, cuando se anunció la nominación de Price.

Otros son menos entusiastas. Cuando se le preguntó sobre qué políticas podría promulgar, Topher Spiro, del Center for American Progress, dijo en ese momento: “No sé si quiero pensar en las malas ideas que podría llevar a cabo”.

Las siguientes son cinco acciones que el nuevo secretario del HHS podría tomar, según los defensores de ambas partes, que perturbarían las políticas de salud actualmente vigentes:

Cobertura de métodos de control de la natalidad: bajo ACA, la mayoría de los planes de las aseguradoras deben proporcionar a las mujeres cualquier forma de anticoncepción aprobada por la Administración de Alimentos y Drogas (FDA) sin costo adicional. Esto ha sido particularmente polémico en lo que respecta a los empleadores religiosos quienes se oponen a la anticoncepción artificial, lo que ha llevado a alteraciones en las reglas, y ha resultado en dos decisiones separadas de la Corte Suprema, una sobre los derechos de las firmas privadas de tener objeciones religiosas y otra sobre los hospitales religiosos sin fines de lucro y escuelas.

Como secretario, Price tendría dos opciones principales. Podría ampliar la exención de este requisito a todo empleador con objeciones religiosas. O, porque la inclusión específica del control de la natalidad se estableció a través de una regulación y no por la ley en sí, podría simplemente eliminar la cobertura anticonceptiva sin copago de la lista de beneficios que los planes de seguro deben ofrecer. (Esto supone la continuación de la existencia de la ley de salud, al menos en el corto plazo.)

Cambios en el pago de Medicare: la ley de salud creó una agencia dentro del Medicare, llamada el Center for Medicare and Medicaid Innovation, cuya tarea es explorar nuevas formas de pagar a médicos y hospitales, que reducirían los costos y mantendrían la calidad. El secretario del HHS puede obligar a que los médicos y los hospitales participen en los experimentos y en los nuevos modelos de pago. Algunos de ellos han demostrado ser poco populares, en particular la idea de pagar a los proveedores por paquetes de atención, en lugar de permitirles facturar artículo por artículo.

Uno de estos paquetes cubre reemplazos de cadera y rodilla, desde el momento de la cirugía hasta la rehabilitación postquirúrgica. Price, como ex cirujano ortopédico, probablemente actuaría para reducir, retrasar o cancelar ese proyecto, ya que “ha sido un crítico en el pasado”, dijo Dan Mendelson, CEO de Avalere Health, una firma consultora con sede en Washington.

Financiamiento de Planned Parenthood: los republicanos han estado movilizándose literalmente por décadas para sacarle a Planned Parenthood su financiamiento federal. El Congreso tendría que cambiar la ley del Medicaid para quitarle este financiamiento de manera permanente al grupo de salud de la mujer, que también realiza abortos (con fondos no federales) en muchos de sus sitios. Pero un secretario del HHS tiene muchas herramientas a su disposición para hacerle la vida miserable a la organización.

Por ejemplo, durante las administraciones de Ronald Reagan y George H.W. Bush, se impusieron reglas, eventualmente confirmadas por la Corte Suprema, que prohibían al personal de clínicas de planificación familiar financiadas por el gobierno federal ofrecer consejería o referir a mujeres con un embarazos no deseados que buscaran un aborto. La subsiguiente administración de Bill Clinton abolió las reglas, pero podrían regresar bajo el liderazgo del nuevo secretario.

Price también podría arrojar el peso del departamento en las investigaciones en curso sobre los vínculos de Planned Parenthood con firmas que supuestamente vendían tejido fetal con fines de lucro.

Regulación del tabaco: después de años de discordia, el Congreso finalmente acordó, en 2009, otorgar a la FDA una autoridad (limitada) para regular los productos de tabaco. “La autoridad central está permitida”, dijo Matt Myers de la Campaign for Tobacco-Free Kids, quien abogó por la ley. Eso significa que el Congreso tendría que actuar para eliminar muchos de sus cambios. Pero una Secretaría que se oponga a la ley (Price votó en contra de ella en ese momento) podría debilitar su aplicación, dice Myers. O podría reescribir y anular algunas reglas, incluyendo las recientes que afectan a los cigarros y a los cigarrillos electrónicos.

“El secretario tiene una autoridad discrecional muy amplia para no aplicar, o implementar vigorosamente el estatuto de una manera agresiva”, dijo Myers.

Protecciones de conciencia: al final del gobierno de George W. Bush, el HHS publicó reglas destinadas a aclarar que los profesionales de la salud no tenían que participar en la realización de abortos, esterilizaciones u otros procedimientos que violaran una “creencia religiosa o convicción moral”.

Los opositores a las reglas se quejaron, sin embargo, de que eran tan vagas y extensas que podían aplicarse no sólo a los opositores al aborto, sino también a aquéllos que no quieren proporcionar control de la natalidad a las mujeres solteras, o tratamiento del VIH a los homosexuales.

El gobierno de Barack Obama revisó exhaustivamente las reglas, ante la continua consternación de los conservadores. Estaban entre los pocos artículos relacionados con el tema incluidos en la sección de salud del sitio web del presidente electo antes de que la página fuera retirada. Decía: “La Administración actuará para proteger la conciencia individual en el cuidado de la salud”. Muchos esperan que las reglas vuelvan a su forma original.

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