Changed rules may limit services under Medicare, Medicaid, and Title X.


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Recent changes to regulations that govern payments by the federal government for health care services may affect beneficiaries of public programs in several arenas.

Figure. New Medicare... - Click to enlarge in new windowFigure. New Medicare reimbursement policies have resulted in some skilled nursing facilities placing less emphasis on focused individual sessions with a therapist (above) and more on group physical therapy. Photo (C) Burger / Phanie / Agefotostock.

Home health care. Modifications to how Medicare pays home health care agencies kicked in January 1, and concern is mounting about the impact on patients with long-term rehabilitative needs (Medicare Advantage plans are not affected). Previously, payments were made according to the amount of therapy or the number of visits provided. Now, the Centers for Medicare and Medicaid Services calculates payments via an evaluative tool called the Patient-Driven Groupings Model (PDGM), which authorizes payment based on patients' diagnoses, underlying complications or comorbidities, level of impairment, expected duration of services, and whether the home care referral follows hospitalization or in-patient rehabilitative treatment. Payments are higher for patients discharged from a facility and for the first 30 days of home care. The regulatory change came in response to evidence that some home health care agencies were providing excessive therapy under the old reimbursement system. But according to a Kaiser Health News report (https://khn.org/news/why-home-health-care-is-suddenly-harder-to-come-by-for-medi), the new system could incentivize providers to serve patients with shorter-term needs, such as postsurgical care, rather than those with chronic conditions, since payment rates drop after 30 days. According to home health industry groups, some agencies are responding by reducing patient visits and laying off therapists and other staff. But others, such as the Visiting Nurse Service of New York, say they prepared for PDGM and are continuing to provide therapy as needed. More information on PDGM is available at http://www.cms.gov.


Reproductive health care. The so-called federal gag rule, which bars referral for abortion services by clinics that receive Title X money, has nearly halved the number of patients who can be cared for through the program's family planning network, according to an analysis by the Guttmacher Institute (http://www.guttmacher.org/article/2020/02/trump-administrations-domestic-gag-rul). Title X, which was established as part of the Public Health Service Act in 1970, provides federal funding for family planning services, and clinics in the network mostly serve low-income women. The gag rule prohibits abortion referrals, although clinics can still include some abortion counseling. The Trump administration imposed the gag rule last year, making funding through Title X conditional on clinics ceasing referral for abortion care, among other requirements. Court challenges blocked enforcement of the rule until February when a federal appeals court upheld it. In response, about one in four Title X sites, or 1,000 clinics, including the Planned Parenthood network, forfeited the funds in order to continue providing comprehensive family planning counseling and services to their patients. Because these 1,000 clinics serve a high volume of patients, their departures reduced the Title X network's capacity to serve female contraceptive patients by 46%, likely affecting 1.6 million patients. The impact varies, however, since some states have made up for the loss of federal money, enabling clinics that have refused Title X funding to continue their work. For more information, go to http://www.guttmacher.org.


Medicaid access. A proposed Medicaid Fiscal Accountability Rule would establish new reporting requirements for states and upper payment limits for Medicaid providers. The changes, designed to increase federal oversight, were prompted by substantial increases in federal payments for Medicaid over the past few years. The changes are technically complex and will undoubtedly affect provider reimbursements and state budgets for Medicaid. Implications for enrollees regarding eligibility, benefits, and access to care are unclear. Citing a lack of data on impact, governors, payers, and providers have warned that Medicaid beneficiaries are likely to suffer from reduced access to care, should the proposal come to pass.-Joan Zolot, PA