Insider's Guide Part 1: Medicare
The year 2019 has been a contentious one in politics. Despite the fact that very few bills have been signed into law, there has been Congressional activity, some public and some behind the scenes.This activity will eventually shape laws and policies that will affect the profession, whether in this Congress, or in the years to come. As always, AOTA Federal Affairs staff have been busy advocating on your behalf. Here is Part 1 of a guide to the key issues we have been working on, including why the issues are important, and an insider’s view on the process. Part 2 will discuss AOTA activities around education, aging in place, behavioral health and more.
Home Health Flexibility Act: Opening Cases in Home Health
Issue: Under current Medicare regulations, occupational therapists cannot conduct the initial visit or complete the comprehensive assessment for a Medicare Part A home health case, despite occupational therapy having long been recognized as a critical element of home health care. The Medicare Home Health Flexibility Act (H.R. 3127/S. 1725) would change this and allow the most clinically appropriate skilled service to conduct the initial assessment visit and to complete the comprehensive assessment for rehabilitation-only cases.
Why is this Important? The inability of occupational therapists to open Medicare Part A home health, rehabilitation cases has kept many from fully recognizing the value of OT in home health. As the new Patient-Driven Groupings Model (PDGM) takes effect, it is more important than ever that occupational therapy be seen as an equal and crucial part of the home health team. Home health agencies should be able to decide staffing based on beneficiary need, not on who can open cases, and cases should be opened by the most appropriate profession according to the client’s needs.
Action: Through grassroots efforts and professional lobbying, we have built a strong bi-partisan collation of well-positioned Members of Congress to fix this issue once and for all. For example, the lead sponsor of the bill is Rep. Lloyd Doggett, the chairman of the House Ways and Means Subcommittee on Health, the subcommittee that is responsible for Medicare Part A legislation. We are also gaining cosponsors for the bill from the Ways and Means Rural Health task force, a group that will have a legislative agenda in 2020.
Last July, AOTA staff met with the Center for Medicare and Medicaid Services (CMS) to discuss the issue and heard no major objections to occupational therapists opening home health, rehabilitation cases. Additionally, Congressional staff have reached out to CMS to get “technical assistance” (TA) on the legislation, the first step in a bill being considered for a vote.
Insider’s view: The past year has seen significant momentum for this bill, but challenges remain. Members of Congress believe occupational therapists are both capable of opening home health cases, and that they should be able to do so when they are the most appropriate professional. However, there is uncertainty whether CMS can change the policy on its own, or whether it needs Congressional legislation. This is crucial as Congress does not like to legislate when CMS can fix something on its own. So does the fix require Congressional action? We have not yet gotten a clear answer. The best way to get this answer is through the TA Congressional staff have requested. This year, major health care legislation in the House and Senate bumped CMS from working on the Home Health Flexibility Act. We hope with a lighter Congressional calendar in 2020, we can get a clear answer to this question, and pave the way for action.
Medicare Payment Changes
Issue: Over the last decade, Congress and CMS have been working to change how health care is paid for and delivered under Medicare, in order to provide higher quality, patient-centered services. As Medicare spending continues to grow, CMS is also continuously trying to assure that payments to Medicare providers are appropriate. This focus has resulted in implementation of a new payment system for Part A, Skilled-Nursing Facilities, the Patient-Driven Payment Model and Home Health Agencies, the Patient-Driven Groupings Model. Additionally, changes to how occupational therapy assistants will be paid under Medicare Part B will begin in 2022, and CMS is currently in the process of determining other wide-ranging Part B payment changes for 2021.
Why is this Important: As Medicare payment systems change, we must assure that beneficiaries have access to necessary occupational therapy services and that those services are paid for appropriately.
Insider’s View: Congress writes broad legislation that establishes the outline for Medicare policies, benefits and payment, but CMS is responsible for how this legislation will ultimately be implemented. AOTA Regulatory and Reimbursement staff work closely with CMS to help shape implementation and to communicate challenges with current policies or programs. For more information on all of these efforts, please visit the Volume to Value section of the AOTA website, as well as the Federal Regulatory news page.
However, Congress also has the responsibility for oversight of CMS and can change or influence CMS actions if they do not line up with Congressional intent. AOTA Federal Affairs is working to make sure that Congress understands the possible, full impact of CMS policies on access to therapy services. Congressional staff have multiple issues to deal with, both trying to create new legislation and monitor how CMS is implementing past legislation. In this environment, it is easy for therapy to get lost in the shuffle.Through grassroots efforts, individual outreach and coalition work, we can engage Congress to make sure CMS policies align with what Congress intended, and ensure access to therapy services.
Action: AOTA federal affairs has brought each of these issues to Congress, in order to share our concerns. In some cases, we work with committee staff, the people who tend to be experts on issues, exercise oversight over CMS and control what legislation is considered. In other cases we have engaged individual Congressional offices to make sure they understand the effects of new policies on their constituents, as well as helping to promote grassroots engagement so you can share your story with Congress. In the months ahead, we will continue to provide grassroots opportunities and to work with coalition partners such as APTA, AHSA and patient advocates, to make sure Congress understands how all of these payment changes may work together and threaten access to therapy services.
Expanding Occupational Therapy Medicare Telehealth Services
Issue: Many services provided through Medicare Part B are allowed to be provided via telehealth, within certain parameters. Unfortunately, occupational therapy, physical therapy and speech language pathology are not among these services. Furthermore, while some legislation has include therapy services within the telehealth provisions, legislation passed last Congress expanded Medicare telehealth services to Medicare Advantage (MA) and Accountable Care Organizations (ACOs) but failed to include therapy. AOTA is working with our therapy partners to encourage Congress to include OT as well as PT and Speech-Language Pathology services in current telehealth legislation introduced in this Congress.
Why is this Important: As healthcare evolves, telehealth and other remote services are going to become an increasingly important means of ensuring access to Medicare services and best meeting the needs of beneficiaries. Further, expansion of telehealth under MA plans, ACOS, or other proposed telehealth waivers will help to develop the evidence for use of telehealth across Medicare settings. If therapy is not included in these smaller scale opportunities, it is highly unlikely it will be included in a larger expansion of telehealth services under Part B.
Action: Since the start of this Congress AOTA, APTA and ASHA have been advocating for inclusion of therapy services within telehealth legislation. We were successful in this effort when the House and Senate Telehealth Caucuses introduced the CONNECT for Health Act (H.R.4932/S.2741) which would allow providers to seek waivers to provide OT (and other therapy) services via telehealth. Inclusion in this legislation, which was carefully reviewed and drafted by Congressional telehealth experts, is a critical step to ensure that OT is not excluded when telehealth options are eventually covered more broadly by Medicare. In addition, AOTA is working with Congressional telehealth champions to introduce an amendment that would allow Medicare Advantage plans to provide OT and other therapy services via telehealth when appropriate.
Insider’s View: Vocal advocacy on inclusion of therapy services under Medicare Part B telehealth is crucial, in part because of the way different professionals are defined under Medicare statute. Telehealth statutes generally refer to “physicians” and “providers”. “Providers” under Medicare statute includes physician’s assistants and nurse practitioners, but also social workers, psychologists, and others. However occupational therapy practitioners, physical therapy practitioners, and speech-language pathologists are defined as “suppliers” under Medicare. It is unclear whether the exclusion of therapy services in previous legislation was an oversight based on these definitions, and the failure to include "suppliers". Moving forward, we are working to guarantee the inclusion of therapy services in any Medicare telehealth legislation.
Stay tuned for Part 2 in early 2020 where we will discuss the insider’s view of AOTA activities around education, aging in place, behavioral health and more. We will also have more information on how OT priorities fared in the FY2020 funding bill, and how legislation being debated in Congress related to surprise billing and prescription drug prices might affect the profession.
You can write to Congress and these and other issues by visiting www.aota.org/takeaction
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