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In light of HCFA's steadfast position that repeal in whole
of the requirement would increase cost, the requirement should
be repealed in part.
Specific types of patient situations
be identified for which the prior hospital requirement is not
cost-effective nor necessary to control inappropriate utilization.
Examples of patient situations include the following:
who need skilled nursing services for a terminal illness; benefi
ciaries receiving Medicare bone health services who develop
an intensified nursing need; beneficiaries who are non-Medicare
nusing home residents who need further care at the more intensive
skilled nursing service level; and beneficiaries who have not
ended a "spell of illness" either because 60 days have not lapsed
AHCA believes that the requirement can be completely eliminated,
the statute's cost-effectiveness criterion.
on this issue is
most thorough, objective examination to date a three-year HCFA demonstration project in Oregon and Massachusetts
needs of beneficiaries who require only sk!lled nursing services.
those who "game" the program by arranging for
unnecessary (and costly) hospital stays in order to become eligible
for Medicare SNF benefits.
In addition, there are individuals
receiving hospital care who would benefit as much from SNP care
not transferred because
the paperwork (e.g.,
transfer of medical records, treatment plan) and the financial
disincentives (e. 8., no cost sharing is required after the hospital
deductible until the 61st day).
Spelle Mllness Definition
AHCA recommends eliminating inconsistencies in the "spell
illness" definition so that a "spell" ends when a beneficiary
neither under Medicare inpatient hospital nor SNF coverage
followed by the requisite time period.
In general, the Medicare
program limits the duration of covered services to the period
between the beginning and ending of a "spell of illness
present law, a Medicare beneficiary, must remain for 60 consecutive
days out of a hospital or SNF in order to renew Medicare eligibility
for these benefits.
There are inconsistencies in the SNF criteria used to start
and end a spell of illness.
For purposes of starting a spell
of illness and receiving benefits, the beneficiary must be in
a facility which is licensed as
an SNF, certified under Medicare
as a SNF, and meets all of the program's requirements for participa
only for purposes of ending a Medicare spell of illness.
a result, a beneficiary in an ICF, which is classified by Medicare problems develop.
as providing skilled nursing care for spell of illness purposes,
might not receive Medicare coverage when he needs to go back
a bospital for SNF.
Coverage would not be received because
the spell of illness had been deemed not to have ended.
A similar HCFA policy adversely affects beneficiary coverage
Por durable medical equipment (e.g., oxygen therapy, alternating
pressure mattresses, and pacemaker bonitors).
The durable medical
equipment is available to beneficiaries at home or in an institution,
available to a beneficiary who is neither under Medicare inpatient
monitoring care, providng routine medical services, and appro
priately involving the supervisory physician if major medical
has already recognized the value
practitioners to augment physicians in
titioners, acting under the supervision of a physician and within
the scope of their license, be allowed to conduct Medicare required
visits and recertifications.
Thank you for the opportunity to present our recommendations
for Medicare long term health care services.
There are opportunities
for new policies which would conserve program spending, improve
service to beneficiaries, and enhance the provision of long term
We hope that you will provide the charted course
nursing home benefits can finally become what beneficiaries need
and think they have.
JAMES E. CUNNINGHAM, PRESIDENT