2006 Legislative Impact on Home Care
Joan Kohorst, MA, RRT
Apria Healthcare
AARC Home Care Section Chair
2006
Inhalation drugs Competitive bidding Quality standards Mandatory accreditation 36 month oxygen CTS OIG Advisory Opinion # 06-20
Inhalation Drug Therapy Coverage
Medicare Part B Coverage Covers inhalation drugs administered via a nebulizer under
the DME benefit
CMS has decreased reimbursement for inhalation drugs three times in the last two years
CMS added a dispensing fee in 2005 and decreased the dispensing fee by 50% in 2006
Inhalation Drug Therapy Coverage
CMS studied need for dispensing fee and found that the dispensing fee covered shipping/handling, pharmacy activities and services Patient education Compliance monitoring / refill calls Caregiver training Care coordination In home visits
Inhalation Drug Therapy Coverage
CMS does not believe Congress intended that Medicare pay for pharmacy care management services as part of dispensing fee
Hence the 50% decrease in dispensing fee in 2006
Metered Dose Inhalers
MDIs are covered under Part D AARC strongly recommended that CMS
recognize the importance of education and training in effective use of MDIs/DPIs Qualified / credentialed health
professionals Separate payment to physicians
Metered Dose Inhalers
CMS already provides payment for beneficiary training by a physician or physician’s staff
DME fee includes, in part, amounts for training beneficiaries on use of nebulizer equipment
Local Coverage Determination for Nebulizers
Levalbuterol DuoNeb Amikacin, atropine, beclomethasone,
betamethasone, bitolerol, dexamethasone, flunisolide, formoterol, gentamicin, glycopyrrolate, terbutaline & triamcinalone
Competitive Bidding
MMA requires Medicare to replace the current DME payment method with competitive bidding process Durable Medical Equipment Enteral Nutrition Orthotics and Prosthetics
Objectives of Competitive Bidding
Reduce Medicare expenditures Determine appropriate prices for
categories of DME Protect beneficiary access Reduce beneficiaries’ out of pocket Reduce proliferation of certain DME
items
Phased-In Implementation
10 of largest MSAs in 2007 (probably October)
80 of the largest MSAs in 2009 Additional areas after that May be phased in first among highest
cost and highest volume items and services
Status on Competitive Bidding
Final rules for accreditation of DME providers for competitive bidding program were released by CMS on August 1, 2006
www.cms.hhs.gov/competitiveacqforDMEPOS
Quality Standards for DME Providers
MMA requires DME providers to comply with standards
Final version of the Quality Standards were released August 2006
www.cms.hhs.gov/CompetitiveAcqforDMEPOS/04
_New_Quality_Standards
Quality Standards for DME Providers
Appendix A: Respiratory Equipment, Supplies and Services defines respiratory services as encompassing the provision of home medical equipment and supplies that require technical and professional services
Quality Standards for DME Providers
Appendix A goes on to require that “the supplier shall comply with the current American Association for Respiratory Care Practice Guidelines” on oxygen therapy in the home,
long term invasive mechanical ventilation in the home, and intermittent positive pressure breathing
Quality Standards for DME Providers
Appendix A further requires that “suppliers shall provide training to beneficiaries consistent with the current AARC CPGs” on long term invasive mechanical
ventilation in the home, O2 therapy in the home, IPPB, suctioning of the pt in the home and and providing patient and caregiver training
Quality Standards for DME Providers
The AARC asked volunteers from the Home Care Section to take on the task of revising these five CPGs
We made our recommendations consistent with best practices and standards of care
Quality Standards for DME Providers
Our revisions were submitted to the AARC for approval on 09/29/06
Draft guidelines are making their way through the CPG Committee’s final review process now
DME Accreditors
All DME providers who plan to participate in the competitive bidding process must be accredited by an independent accrediting entity
CMS recommends obtaining accreditation by early 2007 accrediting providers in MSA areas first
Deemed Accreditors
JCAHO CHAP HQAA NBAOS BCP
www.cms.hhs.gov/competitiveacqforDMEPOS
ACHC BO/PC NABoP CARF ABCOP The Compliance Team
Legislative Changes / Oxygen
The Deficit Reduction Act (DRA), section 5101 requires providers to transfer title of oxygen equipment to beneficiary after 36 continuous months
36 month rental period began on January 1, 2006
www.cms.hhs.gov/HomeHealthPPS/downloads/CMS1304F
Legislative Changes / Oxygen
BBA requires budget neutrality Proposed monthly oxygen payments:
2007- 2008 = $198.40 /mo 2009 = $193.21 /mo 2010 = $189.39 /mo 2007 oxygen content will increase = $77.45 /mo 2007 add-on for transfilling equipment and
portable oxygen concentrators = $51.63
Legislative Changes / Oxygen
Maintenance/service will be paid if reasonable and necessary and based on criteria determined by the Secretary CMS will pay for M&S visits Q 6 months for
pt owned equipment CMS will pay for “loaner” while pt owned
equipment is repaired CMS will pay for supplies (NC, tubing, etc)
Legislative Changes / Oxygen
Impact on beneficiaries Saves Medicare money Should not increase beneficiary out of
pocket expenses
Legislative Changes / Oxygen
Supplier requirements Furnish the item throughout the entire
rental period If switch-out required, replace with
equipment of equal or greater value Replace equipment that doesn’t last for
reasonable ‘lifetime’ Disclosure of intentions re: accepting
assignment
OIG Advisory Opinion# 06-20 (posted 11/08/06)
It is a violation of the Civil Monetary Penalties Act (CMP) and a violation of the Anti-kickback Statute to: Provide Medicare patients with free home
oxygen until the patient qualifies for coverage
Provide Medicare patients with free overnight oximetry testing
What We Can Do
The AARC will continue to advocate on behalf of our patients thru the efforts of our Government Affairs and PACT committees
Our efforts can make more of an impact with your participation
435 Activation
December 2005: AARC asked the PACT chairs to activate the 435 committee in each state
Committee members were asked to contact Congressmen to urge members of Congress to vote “NO” on S1932
The Response…
In the first two days there were over 1000 messages sent to Congress thru Capitol Connection, 6000+ messages in five weeks
75% of the States responded that they activated their plan during the holiday week
S 1932 Not on the winning side of the vote
Washington did hear us loud and clear Nine (9) Republicans voted against S.1932 the
first time around….Thirteen (13) voted against it on 2/1/06
AARC will continue to monitor the creation of the rules and regulations regarding the DME issue Our goal is to make sure we have input on
behalf of our patients
Please Join the Effort! Political
Become informed about issues that affect access to care
Advocacy Speak out on behalf of our patients
Contact Phone, write, e-mail, visit our legislators
Team Participate!
How to Use Capitol Connection
Go to www.aarc.org Click on Advocacy Enter your zip code to find your legislators Choose your topic and use the talking points
to write your message in the text box Make sure to include your name, voting
address, phone number and e-mail Hit send