What's in a Name Change?

The Health Care Financing Administration has recently become the Centers for Medicare & Medicaid Services (CMS). [1] In addition to the name change, the agency is being restructured around three centers that reflect the agency's major lines of business: the Center for Medicare Management, the Center for Beneficiary Choices, and the Center for Medicaid and State Operations.

The Center for Medicare Management will focus on management of the traditional fee-for-service Medicare program. This includes development of payment policy and management of the Medicare fee-for-service contractors. The Center for Beneficiary Choices will focus on providing beneficiaries with information on Medicare, Medicare Select, Medicare+Choice, and Medigap options. It also includes management of the Medicare+ Choice plans, consumer research and demonstrations, and grievance and appeals functions. The Center for Medicaid and State Operations will focus on programs administered by states. These include Medicaid, the State Children's Health Insurance Program (SCHIP), insurance regulation functions, survey and certification, and the Clinical Laboratory Improvements Act (CLIA).

In an effort to help consumers identify the agency that administers their health insurance, the Centers for Medicare & Medicaid Services will launch a $35 million national media campaign in the fall of 2001 (corresponding with the 2002 open enrollment period) designed to strengthen the health care services and information available to nearly 70 million Medicare and Medicaid beneficiaries and the health care providers who serve them. Few beneficiaries understand Medicare and the coverage options and costs associated with it. Results from the 1999 Medicare Current Beneficiary Survey found that nearly half of Medicare beneficiaries do not know they can select among different health plan choices within Medicare, and about one-fourth do not know that Medicare does not pay for all of their health care expenses.

The CMS plans to provide Web-based information and learning available to beneficiaries and physicians through the Internet. The plan includes:

(1) Developing a web-based decision tool. A Decision Support Tool will enhance the suite of consumer information databases that currently reside on the Medicare website at www.medicare.gov. This new tool will allow users to narrow down the health plan choices (available in their zip code) based on what is most important to them. It will also allow them to do a direct out-of-pocket cost comparison between all health insurance options, and get more detailed information on the plans that best meet their needs. The final tool will be implemented October 1, 2001.

(2) Expanding the physician information available on the Internet. The CMS will make more information available to practicing physicians and members of their office staff at www.hcfa.gov. The CMS is creating a new Internet architecture that organizes existing information so it will be easier for the physician to use.

The CMS will develop a legislative proposal to be submitted to Congress that would provide for competitive bidding of claims processing services. This legislation will be aimed at reforming the relationship of the CMS with the private companies that process and pay fee-for-service Medicare claims. Collectively, these private health insurance companies employ about 22,000 individuals and handle more than 900 million Medicare claims each year. The laws that govern these contracts are more restrictive than general federal contract laws. The Centers for Medicare & Medicaid Services will be working with Congress to develop legislation that will allow the agency to competitively award these contracts by using performance-based incentives to improve the level of service to beneficiaries and providers, reduce administrative costs, and improve efficiency.

Does the new name reflect the scope of the agency's mission to serve Medicare and Medicaid beneficiaries? Listed below are the coverage improvements in preventive benefits that became effective July 1, 2001.

BIENNIAL SCREENING PAP SMEAR AND PELVIC EXAMINATION

Prior Law:

* Screening Pap smears and pelvic examinations (including a clinical breast examination) are covered every 3 years, or annually for women of childbearing age who have had an abnormal Pap smear during the preceding 3 years, or women at high risk for cervical or vaginal cancer. There is no beneficiary cost-sharing for clinical laboratory tests (including Pap smears). Application of the Part B deductible is waived for other aspects of the benefit.

Provision:

* The provision increases the current periodicity of general coverage of Pap smears and pelvic examinations by providing for coverage every 2 years.

SCREENING COLONOSCOPY FOR AVERAGE-RISK INDIVIDUALS

Prior Law:

* Colorectal cancer screening procedures are covered as follows: (1) fecal-occult blood tests for persons aged 50 years and over are covered annually, (2) flexible sigmoidoscopy for persons aged 50 and over are covered every 4 years, (3) colonoscopy for persons at high risk for colorectal cancer are covered every 2 years, and (4) other procedures are covered as the Secretary finds appropriate. Barium enemas are also covered as a substitute for a flexible sigmoidoscopy or a colonoscopy.

Provision:

* The provision authorizes coverage of screening colonoscopy for all individuals, not just those at high risk. For persons not at high risk, a screening colonoscopy is covered 10 years after a previous screening colonoscopy or 4 years after a screening flexible sigmoidoscopy.

Following is an outline of other preventive benefits gaining coverage improvements that will become effective January 1, 2002.

COVERAGE OF SCREENING FOR GLAUCOMA

Prior Law:

* Glaucoma evaluation procedures are covered only for diagnostic purposes, for individuals with signs or symptoms indicating the possible presence of glaucoma.

Provision:

* The provision authorizes annual coverage of glaucoma screening for individuals at high risk for glaucoma, individuals with a family history of glaucoma, and individuals with diabetes.

* Covered services include an eye examination with dilation, intraocular pressure measurement, and direct ophthalmoscopy or slitlamp biomicroscopic examination for the early detection of glaucoma. Services must be furnished by, or under the direct supervision of, an optometrist or ophthalmologist who is legally authorized to perform such services in the state where the services are furnished.

MODERNIZATION OF SCREENING MAMMOGRAPHY BENEFIT

Prior Law:

* Screening mammograms are covered annually for all women aged 40 years and over, and one baseline mammogram is covered for women aged 35 to 39. Application of the Part B deductible is waived for screening mammography. Medicare pays the lowest of: (1) the actual charge, (2) the physician fee schedule amount, or (3) a national limit set by statute ($55 in 1991, updated annually by the Medicare Economic Index).

Provision:

* The provision moves payment for screening mammography to the physician fee schedule (the same payment method used for diagnostic mammography), thereby eliminating the statutory payment limit set by the prior law.

* The provision specifies payment rates for two new forms of mammography that utilize digital technology for services furnished April 1, 2001, through December 31, 2001 (applicable to both screening and diagnostic mammograms). Payment for technologies that directly take digital images is set at 150% of payment for a bilateral diagnostic mammogram under the physician fee schedule. Payment for technologies that convert standard film images to digital form is set at the statutory limit for a screening mammogram for 2001, plus $15.

* The Secretary must determine whether a new HCPCS code is required for new-technology mammograms furnished after 2001.

Effective Date:

* Payment for screening mammography under the physician fee schedule is effective January 1, 2002. The specified payment rates for mammography utilizing digital technology begin April 1, 2001, and end December 31, 2001.

MEDICAL NUTRITION THERAPY SERVICES FOR BENEFICIARIES WITH DIABETES OR A RENAL DISEASE

Prior Law:

* Medical nutrition therapy services are not covered as a preventive benefit or as a distinct treatment modality under Medicare. Such services are covered as a component of outpatient diabetes self-management training, and may be provided by a hospital, skilled nursing facility, dialysis facility, hospice, or home health agency as part of a bundle of services such entities provide to their patients. "Medically necessary" nutrition counseling may also occur as part of a physician office examination or "incident to" a physician's services. Enteral and parenteral nutrition are covered to a limited degree under the prosthetic device benefit.

Provision:

* The provision authorizes Medicare coverage of medical nutrition therapy services for beneficiaries who have diabetes or a renal disease. The benefit is limited to beneficiaries who: (1) have not received diabetes outpatient self-management training within a designated time period (to be determined by the Secretary), (2) are not receiving maintenance dialysis paid for by Medicare, and (3) meet other eligibility criteria established by the Secretary, in consultation with professional groups.

* Medical nutrition therapy services are defined as nutritional diagnostic, therapy, and counseling services for the purpose of disease management, which are furnished by a registered dietitian or nutrition professional, pursuant to a physician's referral.

* Payment for such services equals 80% of the lesser of the actual charge or 85% of the payment that would be made under the physician fee schedule. Assignment is required for all claims. Sanctions may be applied for billing violations.

* The Secretary must submit a report to Congress by July 1, 2003, with recommendations for expansion of the benefit to other beneficiary populations.

Effective Date:

* January 1, 2002.

Demonstration Projects and Studies

STUDY ON MEDICARE COVERAGE OF ROUTINE THYROID SCREENING

Prior Law:

* Routine thyroid screening is not covered by Medicare.

Provision:

* The provision directs the Secretary to request the National Academy of Sciences, in conjunction with the US Preventive Services Task Force, to conduct a study on the addition of a new preventive benefit for coverage of routine thyroid screening, using a thyroid stimulating hormone test for some or all Medicare beneficiaries. The Secretary must report to Congress on the study's findings, including the long- and short-term benefits and costs to the Medicare program.

STUDIES ON PREVENTIVE INTERVENTIONS IN PRIMARY CARE FOR OLDER AMERICANS

Prior Law:

* The studies conducted by the US Preventive Services Task Force are not focused on any particular subpopulations or age groups.

Provision:

* The provision directs the Secretary, acting through the US Preventive Services Task Force, to conduct a series of studies to identify preventive interventions that can be delivered in primary care settings, and that are most valuable to older Americans.

* The mission statement of the US Preventive Services Task Force is amended to include the evaluation of services of particular relevance to older Americans.

* Not later than 1 year after enactment, and annually thereafter, the Secretary must report to Congress on the conclusions of the Task Force's studies, along with recommendations for legislation and administrative actions, as appropriate.

From the Department of Practice Management Services, SMA Services, Inc., a subsidiary of Southern Medical Association, 35 Lakeshore Dr, P0 Box 190088, Birmingham, AL 35219-0088.

References

(1.) First steps taken in reforming Medicare & Medicaid Agency. HHS Secretary announces new Centers for Medicare & Medicaid Services focused on improving beneficiary services and information. HHS News. US Department of Health and Human Services, June 14, 2001. Available at the Health and Human Services Web site, www.hhs.gov/news

(2.) HCFA Legislative Summary, March 2001. Available at www.hcfa.gov/regs/leg_sum2001.pdf