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Thursday, August 13, 2009

Health Care Pages 325 - 400

Ready to get started again? Not sure how much time I'll have tonight, but I should be able to get through a few pages. Here's the link to the Health Care Bill if you need it.

Okay, last time we were talking about the bill mentions physicians must let their patients know if they have any ownership or interest in any hospitals they refer to and if they don't they are subject to various and sundry civil fines not to exceed $10,000 per day and that hospitals cannot expand unless they apply to the Secretary.

Onward:

Page 328 - yet another study to be conducted regarding the "geographic adjustment factors under medicare".
(c) EVALUATION.—Such study shall, within the context of the United States health care marketplace, evaluate and consider the following:
(1) The effect of the adjustment factors on the level and distribution of the health care workforce and resources, including—
(A) recruitment and retention that takes into account workforce mobility between urban and rural areas;
(B) ability of hospitals and other facilities to maintain an adequate and skilled workforce; and
(C) patient access to providers and needed medical technologies.
(2) The effect of the adjustment factors on population health and quality of care.
(3) The effect of the adjustment factors on the ability of providers to furnish efficient, high value care.
Yes, this study is also funded, but this time they just say that they'll be funded whatever it takes to do the study.

Some time if I can stand it I need to go back through the whole bill and just write down how much money is going toward "studies" and "pilot programs" and "reports".

Page 331 starts the section that discusses Medicare Reforms.

SEC. 1161. PHASE-IN OF PAYMENT BASED ON FEE-FOR SERVICE COSTS.
SEC. 1162. QUALITY BONUS PAYMENTS.
SEC. 1163. EXTENSION OF SECRETARIAL CODING INTENSITY ADJUSTMENT AUTHORITY.
SEC. 1164. SIMPLIFICATION OF ANNUAL BENEFICIARY ELECTION PERIODS
Now, I don't know much of anything about the current Medicare program - but if my health care depended on it, I would be certain to read these sections of the Health Care bill, because it deals with tons of adjustments, amendments to the Social Security Act, establishment of benchmarks for payments, cost-sharing, beneficiary information, medical loss ratios, auditing authority, authority to reject bids, etc.

Page 353 - Regarding Special Needs and Medicare - the Social Security Act is amended as follows:
‘‘(C) The plan does not enroll an individual on or after January 1, 2011, other than during an annual, coordinated open enrollment period or when at the time of the diagnosis of the disease or condition that qualifies the individual as an individual described in subsection (b)(6)(B)(iii).’’.
Now previously, the bill discussed an ongoing open enrollment for Medicare, but apparently there is going to be some restriction for special needs based on the statement above and this section on page 354:
SEC. 1177. EXTENSION OF AUTHORITY OF SPECIAL NEEDS PLANS TO RESTRICT ENROLLMENT.
Page 356 starts talking about improvements to Medicare, again, not knowing much about Medicare some of these seem like they might be okay - but I'm not sure of the cost involved:
‘‘(B) INCREASE IN INITIAL COVERAGE LIMIT.—For a year beginning with 2011
‘‘(C) DECREASE IN ANNUAL OUT-OF-POCKET THRESHOLD
page 358: (b) REQUIRING DRUG MANUFACTURERS TO PROVIDE DRUG REBATES FOR FULL-BENEFIT DUAL ELIGIBLES.—

‘‘(1) IN GENERAL.—In this part, the term ‘covered part D drug’ does not include any drug or biologic that is manufactured by a manufacturer that has not entered into and have in effect a rebate agreement described in paragraph (2).
‘‘(2) REBATE AGREEMENT.—A rebate agreement under this subsection shall require the manufacturer to provide to the Secretary a rebate for each rebate period (as defined in paragraph (6)(B)) ending after December 31, 2010, in the amount
specified in paragraph (3) for any covered part D drug of the manufacturer dispensed after December 31, 2010, to any full-benefit dual eligible individual (as defined in paragraph (6)(A)) for which payment was made by a PDP sponsor under part D or a MA organization under part C for such period. Such rebate shall be paid by the manufacturer to the Secretary not later than 30 days after the date of receipt of the information described in section 1860D–12(b)(7), including as such section is applied under section 1857(f)(3).
So, this appears to mean that the government expects a rebate on medications they are providing to certain Medicare patients and the drug will not be allowed to be a covered drug by Medicare if a rebate is not offered to the govt. by the manufacturer - that's how it reads to me.

Wonder how this will play out with the formularies versus drugs that are just dropped from the plan????

Page 364 onward then discusses the requirements for these drug providers to give reports to the Secretary of incredibly extensive information with once again, a civil penalty of not more than $10,000 day for not reporting and not more than $100,000 for reporting false info:
‘‘(i) information (by National Drug Code number) on the total number of units of each dosage, form, and strength of each drug of such manufacturer dispensed to full-benefit dual eligible Medicare drug plan enrollees under any prescription drug
plan operated by the PDP sponsor during the rebate period;
‘‘(ii) information on the price discounts, price concessions, and rebates for such drugs for such form, strength, and period;
‘‘(iii) information on the extent to which such price discounts, price concessions, and rebates apply equally to full benefit dual eligible Medicare drug plan enrollees and PDP enrollees who are notfull-benefit dual eligible Medicare drug plan enrollees; and
‘‘(iv) any additional information that the Secretary determines is necessary to
enable the Secretary to calculate the average Medicare drug program full-benefit
dual eligible rebate amount (as defined in paragraph (3)(C) of such section), and to
determine the amount of the rebate required under this section, for such form,
strength, and period.
Page 368 starts the same wording, except now it applies to discounted drugs, instead of rebated drugs.

Page 380 starts the discussion about a Telehealth Advisory Committee:
to make recommendations to the Secretary on policies of the Centers for Medicare & Medicaid Services regarding telehealth services as established under section 1834(m), including the appropriate addition or deletion of services (and HCPCS codes) to those specified in paragraphs (4)(F)(i) and (4)(F)(ii) of such section and for authorized payment under paragraph (1) of such section.
Apparently this has something to do with Rural Medicare health services - the committee will have 9 members who will meet twice a year with the Secretary.

Page 386 starts the following section:
Medicare Beneficiary Improvements: Subtitle A—Improving and Simplifying Financial Assistance for Low Income Medicare Beneficiaries
(D) by inserting after subclause (II) the following new subclauses:
‘‘(III) for 2012, $17,000 (or $34,000 in the case of the combined value of the individual’s assets or resources and the assets or resources of the individual’s spouse)
What is so irritating about trying to read much of this bill is that they are constantly referring to other acts / codes and talking about "striking such and such paragraph and replacing it with..." or "changing the last sentence to read..." and if you don't have the other document, you have no idea what they are referring to.

Page 390 - eliminating barriers to enrollment for the low income subsidy program:
‘‘(iii) CERTIFICATION OF INCOME AND RESOURCES.—For purposes of applying
this section—
‘‘(I) an individual shall be permitted to apply on the basis of self-certification of income and resources; and
‘‘(II) matters attested to in the application shall be subject to appropriate methods of verification without the need of the individual to provide additional documentation, except in extraordinary situations as determined by the Commissioner.’’.
Not sure about this one good or bad or if it is new to this program - for the regular health care plan - applicants could have to show tax returns, etc in order for them to determine which level of care plan you qualify for (if I'm reading this right), but not for this section.

page 398 brings us: SEC. 1205. INTELLIGENT ASSIGNMENT IN ENROLLMENT
(a) IN GENERAL.—Section 1860D–1(b)(1)(C) of the Social Security Act (42 U.S.C. 1395w–101(b)(1)(C)) is amended by adding after ‘‘PDP region’’ the following: ‘‘or
through use of an intelligent assignment process that is designed to maximize the access of such individual to necessary prescription drugs while minimizing costs to such individual and to the program under this part to the greatest extent possible. In the case the Secretary enrolls such individuals through use of an intelligent assignment process, such process shall take into account the extent to which prescription drugs necessary for the individual are covered in the case of a PDP sponsor of a prescription drug plan that uses a formulary, the use of prior authorization or other restrictions on access to coverage of such prescription drugs by such a sponsor, and the overall quality of a prescription drug plan as measured by quality ratings established by the Secretary.’’
Which concludes our review for this evening. Picking up on page 400 starting tomorrow, where the topic will be:

Subtitle B—Reducing Health Disparities
SEC. 1221. ENSURING EFFECTIVE COMMUNICATION IN MEDICARE.

1 comment:

matthiasj said...

I'm going to post these reviews on APN tomorrow. You're doing a great job!

matthiasj
Kentucky Preppers Network

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