Medicare Compliance & Reimbursement

Past the initial deadline for a final bill, experts say process could go until December.  As MLR goes to press, Medicare negotiators are still meeting, trying to hammer out the conceptual deal that Sen. Charles Grassley (R-IA) and others had suggested would have been at hand by late October. Indications are that conferees are still facing serious divides on several issues. That's not to say that the negotiators have not been making notable progress in some key areas. For instance, according to reports based on documents prepared by the offices of Sens. Max Baucus (D-MT) and John Breaux (D-LA) - the only Democrats whom Republicans have allowed to participate in the negotiations - conferees have tentatively agreed on a structure for the drug benefit that, like the House's, provides substantial up-front help with initial drug expenses. After a $275 deductible, Medicare would pay 75 percent of drug expenses up to $2,200. Then the "doughnut hole" would kick in, with beneficiaries responsible for 100 percent of their drug costs until they spend $3,600 out of pocket. That would occur after about $5,050 in total drug expenses, barring employer-based retiree contributions. Employer payments do not count against the beneficiaries' OOP obligation under the "true OOP" concept included in both the Senate and the House bills, although negotiators are said to be considering ameliorating that to stem concern that employers might drop coverage. Once seniors reach the OOP maximum, Medicare would pay 95 percent of additional drug expenses. Legislators are still battling over the following issues: Can Local and Regional PPOs Coexist? Both the Senate and the House bill have two tracks for private plans: a new, competitive-bidding based Medicare+Choice system, under which plans would serve counties as under the current M+C program; and a new track under which plans would serve regions. The Senate would allow PPOs only in the regional track, but the House would allow PPOs to be either regional or limited to a single county. Speaking Oct. 22 at the American Association of Health Plans/Health Insurance Association of America Medicare conference, Centers for Medicare & Medicaid Services Administrator Tom Scully predicted that the conferees would adopt the House approach. While Scully said he favored this choice, he emphasized several times that it raised a serious concern: Why would any health plan bid, for instance, on the whole Midwest or the whole mid-Atlantic if it could pick just the counties it wants? "If we want to make this regional PPO structure work and to make sure we have access in rural counties, then we do have to have some differentiation, some benefit, whether it's a different premium mix or slightly different rules," that "makes it attractive for plans to offer regional [...]