New Bill Advances Care for Adults with Complex Needs

Dec 14, 2018 at 11:04 am by steve

James Henry

A new law enacted by Congress as part of the Bipartisan Budget Act of 2018 was created for the purpose of advancing care for adults with complex needs. The Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act, passed and signed on February 9th, makes significant policy changes to advance the goals of integrated person-centered care for Medicare Advantage beneficiaries and for those who are dually eligible for Medicaid and Medicare. It also expands supplemental benefits to meet the needs of chronically ill Medicare Advantage enrollees.

"The intent of the CHRONIC Care Act (CCA) is to better integrate care between Medicare and Medicaid," says James Henry, an attorney with Cabaniss, Johnston, Gardner, Dumas & O'Neal in Birmingham. "It's a movement to make health care and health insurance plans more tailored to individual patient needs instead of population statistics. We have talked about patient-centered care for a long time, but this is a law that can move us in that direction."

The CCA addresses three aspects of care for Medicare and dually eligible beneficiaries. One aspect encourages the use of flexible new tools to manage care for people with complex needs. Henry says it encourages home-centered care, particularly for people with multiple chronic conditions. The benefits include Telehealth use in certain circumstances and may cover house calls.

It is part of what is called the Independence at Home demonstration. A demonstration is a temporary program put in place for evaluation by the Centers for Medicare and Medicaid Services. It also includes coverage for certain non-medical benefits like grab bars, wheelchair ramps and other things that aren't necessarily thought of as medical equipment.

"That coverage is helpful because it allows people with chronic conditions to remain in their homes longer," Henry says. "Formerly, in order to be covered, supplemental benefits had to prevent, cure or diminish an illness or injury. That standard has been changed. Supplemental benefits now can provide for things that have a reasonable expectation of improving or maintaining the health of a chronically ill patient."

Henry adds that the CCA also expands Telehealth services, currently a big movement to provide better access for people in rural areas and for chronically ill patients. "Patients with conditions like kidney disease are susceptible to other sources of infection and could be compromised by sitting in a doctor's office waiting room. Providing services via Telehealth could provide not only convenience for these people, but also better outcomes," Henry says.

A second part of the CCA protects and builds on key programs that serve individuals with complex care needs. The law permanently authorizes Medicare Advantage plans to create three Special Needs Plans (SNPs), one for those who are eligible for both Medicare and Medicaid; one for chronic, severe or disabling conditions, such as HIV-AIDS, end-stage renal disease or chronic and disabling mental illness; and a third for people who are in institutions.

"Traditionally, Medicare plans have had to provide the same benefits for everyone within the plan, but under these SNPs, Medicare Advantage can create plans that are tailored more to individual patient needs," Henry says. "It also extends and expands a demonstration where physicians serve high-need Medicare beneficiaries in their homes to avoid institutional care."

A third aspect of the CCA indicates that care coordination is an essential purpose of the SNPs. This law requires SNPs to integrate care by creating unified plans for dual eligible individuals as well as providing a single pathway for grievances and appeals.

"Medicare and Medicaid each have their own coverage and appeal provisions. If beneficiaries are denied coverage for a service, they will no longer have two separate tracks to go down if they are eligible for Medicare and Medicaid," Henry says. "This is part of an effort to coordinate care so it is less confusing and easier to navigate."

"I believe the new law will be well-received. This act has bipartisan support in Congress. I'm sure there is a lot to be learned in the implementation phases of these new programs. From what we know about the law so far, it seems to be a positive piece of legislation."

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