Medicare: Pending Issues and Opportunities

1
Medicare Pending Issues and Opportunities

• Roger Schwartz, Director of State Affairs
• NACHC
• Presented at the Texas Association of Community
  Health Centers
  
• 21st Annual Conference
• October 26, 2004

2
The Medicare FQHC Payment Cap

• Cap Limits Congressional Intent for Cost-based
  payments
  
• Used Rural Health Clinic data to create cap and
  has never been revised, despite 12 years of FQHC
  data
  
• Fails to account for new Medicare benefits
• Affects more than half of all FQHCs today
• Millions of dollars in revenue lost
• Disincentives to add services, see seniors with
  more complex health needs
  
• Can be corrected administratively
• CMS can fix it directly Congress has urged CMS
  to move on this, and fast CMS seems willing
  

3
Medicare Modernization Act of 2003 Summary of
Major Provisions

• New Prescription Drug Benefits
• Drug Discount Cards available in June, 2004
• Discounts on prescription drugs
• 600 annual assistance for 7.5M low-income
  seniors
  
• Full Prescription Drug Benefit in January, 2006
• Drug plans to be offered by HMOs, insurers, PBMs
• Intended to cover ½ or more of most seniors drug
  costs
  
• 6 8 million low-income seniors gain full
  coverage
  
• Every health center should be helping seniors to
  enroll NOW!

4
Health Center Provisions in Medicare ReformWhat
We Got In

• Safe Harbor for Health Center Arrangements for
  donated or discounted services supplies
  provided to health center uninsured patients by
  others that expand access to care for the
  uninsured (retroactive to 2003)
• Direct payments to Health Centers that provide
  care to patients in Skilled Nursing Facilities
  (in 2005)
  
• Preservation of Medicare cost-based reimbursement
  through creation of a wrap-around payment for
  care provided to Medicare Advantage enrollees (in
  2006)

5
Prescription DrugsMedicare-approved Discount
Drug Cards

• What are they?
• Provide discounts on retail prices for Rx
• Provide up to 1,200 over 15 months for
  low-income seniors
  
• Issues for Health Centers Patients
• Dont Let Poor Seniors Leave 1,200 on the table
• Sign up by 12/31/2004 or lose 600
• Pharmacy Assistance Programs only available after
  TA
  
• Education, outreach and enrollment opportunities
• CMS guidance allows FQHC pharmacies to participate

6
Prescription DrugsMedicare-approved Discount
Drug Cards and 340B Program Interaction

• Point of Comparison for Patients Patient OOP
  Expenditures, Not Discount v. 340B Price
  
• With 5 and 10 copays, pay only a fraction of
  retail and, in many cases, 340B prices
  
• FQHCs with Pharmacies can use 340B prices in
  connection to Medicare Drug Cards
  
• Stretches TA even farther
• June 21, 2004 CMS Guidance and NACHCs Issue
  Brief August 2004
  
• Opportunities Build relationships with PBMs,
  develop pharmacy capacity, outreach to low-income
  seniors

7
Prescription Drugs and Medicare Part
DAssistance for Low-Income Beneficiaries

• Near total coverage for low-income seniors below
  150 FPL 80 of all health center patients
  nationwide
  
• No donut hole
• Lower copays from those above 150 FPL
• 340B for TrOOP for those between 150 and 200?
• Dual Eligibles Drug Coverage Federalized All
  Medicare, Not Medicaid Coverage

8
Prescription Drugs and Medicare Part DIssues
for Health Centers

• Education, Outreach, and Assistance Opportunities
  for patients
  
• Consideration of Participating in 340B and
  Providing Pharmacy Services
  
• Understanding the program

9
Prescription Drugs and Medicare Part DIssues
for Health Centers with Pharmacies

• Prescription Drug Plan (PDP) Network
  participation
  
• Rx only provided through networks, not like
  traditional Medicare program
  
• Provide Rx, must be part of PDP
• Potential loss of pharmacy users
• Pharmacy services at FQHCs built on seniors drug
  needs
  
• Could impact pharmacy and medical practices
• Medication Therapy Management Services payment
  for pharmacy services
  
• Expanding limited dispensaries to a full pharmacy

10
Medicare Managed CareIssues for Health Centers

• Retaining and being reimbursed for seniors that
  enroll in MedicareAdvantage
  
• Financial incentives for health center patients
  to join lower cost MA plans
  
• MedicareAdvantage Wrap-Around
• Financial hold-harmless for FQHCs AND Plans
• Be mindful of contact period no regs leaves
  implementation of wrap-around in question
  
• Special Needs MedicareAdvantage Plans targeted
  for dual eligibles and other special populations

11
Medicare and Health Centers

• For more information
• www.nachc.com
• NACHC Members NACHCs Medicare/Medicaid Federal
  Policy Update
  
• Contact information
• Chris Koppen, NACHC
• [phone]
• Ckoppen_at_nachc.com