FutureFocus May 23, 2018: Medicare Advantage Plans and PAC Providers - New Insights

Lisa Remington

In this week’s FutureFocus, we continue our discussions on Medicare Advantage Plans and new insights for PAC providers and patients. Our first article explores the differences in Medicare Advantage plans and fee-for-service and why Medicare Advantage plans should coordinate with PAC providers. Attorney Elizabeth Hogue explores the new Medicare Advantage Plans allowable supplemental benefits for home-based palliative care, in-home support services and caregivers. In our Washington Report, we look at the next overhaul of the private sector care program for the VA.

Lisa Remington, President, Remington Health Strategy Group

By: Ronald M. Schwartz, Writer, The Remington Report

A major expansion of community care coverage for veterans outside the VA system would happen under pending legislation that cleared the House last week and could pass the Senate and be signed into law by Memorial Day or shortly thereafter. Under the bill—its short title is the VA Mission Act of 2018--the Veterans Community Care Program (VCCP) provision, Section 101, would replace the troubled Veterans Choice Program (VCP) a year from enactment.

The Act has been endorsed by 38 veterans’ organizations and the Trump administration. How much will the government increase spending when the VCCP takes effect? According to the Congressional Budget Office, which “scores” pending legislation, “CBO estimates that implementing Section 101 [Establishment of Veterans Community Care Program] would cost $21.4 billion over the 2019-2023 period.”

"The Act would enable VA to establish payment rates for community care as, to the extent practicable, the Medicare rate."

The basis for CBO’s estimate: “In the early years of the program, roughly 640,000 additional veteran patients would be referred out to community care each year at an average cost of $8,600 per patient. In addition, while VA faced a number of problems implementing the VCP, CBO expects that the experience gained in starting up that program will allow VA to more expediently implement the VCCP.”

Specifically, under the VCCP, VA would be required to enter into contracts to establish networks of health care providers outside of VA to furnish hospital care, medical services, and extended-care services to veterans enrolled in the VA health care system.

VA would be required to coordinate veterans’ care which involves:

  • Ensuring the scheduling of medical appointments in a timely manner. 
  • Ensuring continuity of care and services. 
  • Coordinating coverage for veterans who utilize care outside of a region from where they reside. 
  • Ensuring veterans do not experience a lapse in health care services. 

Criteria for access to community care, under the Act: VA does not offer the care or services the veteran requires; VA does not operate a full-service medical facility in the state a veteran resides; the veteran was eligible for care in the community under the 40-mile rule in the Veterans Choice Program and meets certain other criteria; VA is not able to furnish care within the designated access standards established by VA; or, a veteran and the veteran’s referring clinician agree that furnishing care or services in the community would be in the best medical interest of the veteran after considering a number of factors including whether the veteran faces an unusual or excessive burden to accessing care or services from the VA medical facility where the veteran has sought care.

Expedited Processing of Claims

Currently, department standards require VA to process 90 percent of claims for reimbursement of non-VA health care within 30 days. However, VA has been unable to meet such standards. Under section 111 of the Act, VA would be required to reimburse non-VA providers within 30 (clean electronic) to 45 calendar days (clean paper) of receiving a completed claim form.

According to the Government Accountability Office and information from VA, CBO estimates that the department would need 340 additional claims processors at an average annual compensation of $51,000 to meet the expedited time frame for reimbursing existing non-VA health care. This expedited processing would cost $68 million over the 2019-2023 period.

The Act would enable VA to establish payment rates for community care as, to the extent practicable, the Medicare rate. It would authorize VA to pay higher rates in highly rural areas. VA would be allowed to incorporate, to the extent practicable, value-based reimbursement models to promote high-quality care. 

The Act also would expand eligibility for VA's Comprehensive Assistance for Family Caregivers Program.

VA operates the nation's largest integrated healthcare system and provides care to approximately nine million veteran/patients.