Paul Ryan: Part 5 - A Closer Look at H.R. 3200


As part of a continuing series on unpacking the specific components of H.R. 3200, I will focus today’s column on a lengthy series of changes to Medicare and Medicaid.

Earlier posts on the first 215 pages of H.R. 3200 can be found here: Paul Ryan on Health Care.

Specific page numbers can be cross-referenced in the legislative text found here:

H.R. 3200 - America’s Affordable Health Choices Act of 2009

DIVISION B: Medicare and Medicaid

I will list briefly the changes called for by each section, along with the Congressional Budget Office estimate on the ten-year change in spending. The figures are in outlays in billions of dollars. So a negative number signifies estimated savings, or cuts in spending, while a positive number represents new spending.

Medicare Part A (page 223)
Section 1101: Skilled nursing facility payment update, -$26.0 billion.

Section 1102: Inpatient rehabilitation update, -5.3.

Section 1103: Incorporating productivity improvements into market basket updates, -101.6.

Section 1111: Payments to skilled nursing facilities, -6.0.

Section 1112: Medicare DSH and payment adjustments in response to coverage expansion, -10.2.

Medicare Part B (page 238)
Section 1121: Revises the formula that annually updates reimbursement rates for physician services in Medicare, +228.5.

Section 1122: Misvalued codes under the physician fee schedule, +0.2.

Section 1123: Payments for efficient areas, +0.5.

Section 1124: Modifications to the Physician Quality Reporting Initiative, +1.6.

Section 1125: Adjustment to Medicare payment localities, +0.3.

Section 1131: Incorporation of productivity adjustments into market basket updates, -40.1.

Section 1141: Eliminates the option for Medicare to purchase power-driven wheelchairs with a lump-sum payment at the time the chair is supplied, -0.8.

Section 1142: Extension of payment rule for brachytherapy, 0.0.

Section 1143: Home infusion therapy report to Congress, 0.0.

Section 1144: Ambulatory surgical centers required to submit cost data and other data, 0.0.

Section 1145: Review of payment systems for certain cancer hospitals, 0.0.

Section 1146: Medicare Improvement Fund, -22.3.

Section 1147: Payment for imaging services, -4.3.

Section 1148: Durable medical equipment program improvements, +0.1.

Section 1149: MedPAC study and report on bone mass measurement, 0.0.

Provisions related to Medicare Parts A and B (page 280)
Section 1151: Reducing potentially preventable hospital readmissions, -19.1.

Section 1152: Post acute care services payment reform plan, 0.0.

Section 1153: Freeze in the market basket update for home health agencies, -7.7.

Section 1154: Payment adjustments for home health care, -34.2.

Section 1155: Adjustments into the market basket update for home health services, -14.9.

Section 1156: Limitation on Medicare exceptions to the prohibition on certain physician referrals made to hospitals, -1.0.

Section 1157: Institute of Medicare study of geographic adjustment factors under Medicare, 0.0.

Section 1158: Revision of Medicare payment systems in an attempt to address geographic inequities, +8.0.

Medicare Advantage (page 331)
Section 1161: Reduces Medicare Advantage benchmarks to fee-for-service levels, -156.3.

Section 1162: Quality bonus payments for high-quality plans, +9.6.

Section 1163: Extension of Secretarial coding intensity adjustment authority, -15.5.

Section 1164: Simplification of annual beneficiary election periods, 0.0.

Section 1165: Extension of time period for which cost plans may operate in areas that have other health plan options, 0.0.

Section 1166: Limitation of waiver authority for employer group plans, 0.0.

Section 1167: Requires a study on the effectiveness of the Medicare Advantage risk adjustment system for low-income and chronically ill populations, 0.0.

Section 1168: Elimination of the Medicare Advantage regional plan stabilization fund, -0.2.

Section 1171: Limitation on cost sharing for individual health services, 0.0.

Section 1172: Continuous open enrollment for beneficiaries in plans with enrollment suspension, 0.0.

Section 1173: Publication of standardized information for beneficiaries on Medicare Advantage plan administrative costs, 0.0.

Section 1174: Strengthening of audit authority, 0.0.

Section 1175: Clarification of the CMS’ authority to deny plan bids, 0.0.

Section 1176: Ensures that chronic condition special needs plans enroll beneficiaries only during their eligibility periods, 0.0.

Section 1177: Extension of authority of special needs plans to restrict enrollment, +0.1.

Medicare Part D (page 355)
Sections 1181-1182: Eliminates the Part D donut hole and discounts certain Part D drugs, paid for by requiring drug manufacturers to provide Medicare rebates for drugs used by full dual eligibles, -29.7.

Section 1183: Repeal of provision relating to submission of claims by pharmacies located in or contracting with long-term care facilities, 0.0.

Section 1184: Includes costs incurred by AIDS drug assistance programs and Indian Health Service in providing prescription drugs toward the annual out-of-pocket threshold under Part D, +0.8.

Section 1185: Permitting mid-year changes in enrollment for formulary changes that adversely affect an enrollee, 0.0.

Medicare Rural Access (page 379)
Section 1191: Telehealth expansion and enhancements, 0.0.

Section 1192: Extension of outpatient hold-harmless provision, +0.4.

Section 1193: Extension of section 508 hospital reclassifications, +0.5.

Section 1194: Extension of geographic floor for work, +1.3.

Section 1195: Extension of payment for technical component of certain physician pathology services, +0.2.

Section 1196: Extension of ambulance add-ons, +0.1.

Medicare Beneficiary Changes (page 386)
Sections 1201-1207: Expanding access to Medicare Savings Program and low-income subsidy program, +11.9.

Sections 1221-1224: Requires study on effectiveness of language services in Medicare; Creates demonstration program to promote access for Medicare beneficiaries with limited English proficiency by providing reimbursement for culturally and linguistically appropriate services, 0.0.

Section 1231: Extension of therapy caps exceptions process, +1.8.

Section 1232: Extended coverage of immunosuppressive drugs for kidney transplant patients, +0.4.

Section 1233: Provides coverage for advance care planning consultation, and instructs CMS to incorporate end-of-life planning resources in informational materials, +2.7.

Section 1234: Provides Part B special enrollment period and waiver of limited premium enrollment penalty for TRICARE beneficiaries, 0.0.

Section 1235: Part B premium adjusted in case of capital gains from sale of primary residence, 0.0.

Section 1236: Creation of a demonstration program on use of patient decision aids.

Primary Care, Mental Health Services, and Coordinated Care (page 443)
Section 1301: Creation of an Accountable Care Organization pilot program, -2.0.

Section 1302: Creation of a Medical Home pilot program, +1.8.

Section 1303: Increased payment incentive for selected primary care services, +6.4.

Section 1304: Increased reimbursement rate for certified nurse-midwives, +0.1.

Section 1305: Waives all Medicare cost-sharing for preventive services, +2.8.

Section 1306: Waives the deductable for colorectal cancer screening tests, 0.0.

Section 1307: Exclusion of clinical social worker services from coverage under the Medicare skilled nursing facility prospective payment system, 0.0.

Section 1308: Marriage and family therapist services and mental health counselor services are added as Medicare providers, +0.5.

Section 1309: Increases the payment rate for psychiatric services by 5% for two years, +0.1.

Section 1310: Expands access to vaccines, +1.5.

Quality, Graduate Medical Education, and Waste/Fraud/Abuse (page 501)
Section 1401: Establishes a Center for Comparative Effectiveness Research within the Agency for Healthcare Research and Quality. The Center will be overseen by the “Comparative Effectiveness Research Commission,” which will determine national priorities for research, identify research methods and standards of evidence, and more, +1.1.

Sections 1411-1432: Establishes a series of nursing home transparency provisions, 0.0.

Sections 1441-1445: Establishes a series of quality measurements, +0.3.

Section 1451: Requires the electronic reporting of any payments or financial relationships between manufacturers or distributors of covered drugs, devices, biologicals, or medical supplies under Medicare, Medicaid, or CHIP and physicians and other health care entities, 0.0.

Section 1461: Requires public reporting by hospitals and ambulatory surgical centers on health care-associated infections, 0.0.

Sections 1501-1505: A series of provisions aimed to promote Medicare Graduate Medical Education, including the training of primary care physicians, +1.5.

Sections 1601-1653: A series of provisions aimed to curb waste, fraud and abuse in Medicare, -1.3.

Medicaid and CHIP (page 740)
Section 1701: Establishes the following Medicaid eligibility levels:
- Requires State Medicaid programs to cover non-disabled, childless adults under 65 with income at or below 133% of federal poverty level (FPL). The federal government would pay 100% of the costs of Medicaid coverage for this population;
- Requires State Medicaid programs to cover parents and individuals with disabilities under 65 with income at or below 133% of federal poverty level. The federal government would pay 100% of the costs of Medicaid coverage for those with incomes between the levels in effect in the State and 133% of FPL;
- Requires State Medicaid programs to cover newborns up to the first 60 days of life who do not otherwise have acceptable coverage upon birth. The federal government would pay 100% of the costs of Medicaid coverage for these newborns.

Section 1702: Requires State Medicaid programs to enter in a memorandum of understanding with the Health Choices Commissioner to coordinate the enrollment of low-income individuals into the Exchange or Medicaid as appropriate.

Section 1703: Prohibits States from adopting additional restrictions to their CHIP and Medicaid programs. Maintenance of efforts ends upon the opening of the Health Insurance Exchange in 2013.

Section 1704: Reduces Medicaid DSH payments to the States by a total of $10 billion.

Section 1705: Requires State Medicaid programs to allow adults to apply to Medicaid coverage at locations beyond welfare offices.

Section 1711: Require State Medicaid programs to cover preventive services, +7.1.

Section 1712: Prohibits State Medicaid programs from excluding tobacco cessation programs from coverage, +0.1.

Section 1713: Allows State Medicaid programs to cover of nurse home visitation services, +0.8.

Section 1714: Allows State Medicaid programs to cover family planning services, 0.0.

Section 1721: Requires that State Medicaid programs reimburse primary care practitioners at no less than 80% of Medicare rates in 2010, 90% in 2011, and 100% in 2012 and beyond.

Section 1722: Establishes a 5-year medical home pilot program, +0.5.

Section 1723: Provides a 75% federal matching rate for the costs of translation or interpretation services for Medicaid-eligible adults for whom English is not the primary language, +0.2.

Section 1724: Allows State Medicaid programs to cover services provided by freestanding birth center services, 0.0.

Section 1725: Allows for the inclusions of public health clinics under the Vaccines for Children program, +1.0.

Section 1731: Allows State Medicaid programs to cover low-income HIV-infected individuals, +1.0.

Section 1732: Extends transitional Medicaid assistance, +2.4.

Section 1733: Requires 12-month continuous coverage under certain CHIP programs.

Sections 1741-44: Medicaid pharmacy reimbursement and prescription drug rebate provisions, -18.3.

Sections 1751-1760: A series of provisions aimed to curb waste, fraud and abuse in Medicaid, +1.0.

Section 1771: Provides additional federal Medicaid matching payments to Puerto Rico and the territories, +10.4.

Section 1801: Authorizes the IRS to disclose to the Social Security Administration certain taxpayer return information to assist SSA in identifying Medicare Part D eligible individuals.

Section 1802: Establishes the trust fund for the Comparative Effectiveness Research Program.

Section 1901: Repeals the Medicare trigger.

This brings us to page 856 of the 1017-page bill. The final column in this series will highlight the “Public Health and Workforce Development” provisions of H.R. 3200.

As always, your feedback is important to me, and I’d encourage you to write, call or participate in one of my 19 listening sessions and community forums in the weeks ahead. I will be in Racine on Thursday, August 27 from 1:30-2:30 pm at Gateway Technical College, Racine Building, Great Lakes Room #114 (901 Pershing Drive).

For my contact information and for an updated listening session schedule, please visit:

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