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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be repealed in part.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

can

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:

beneficiaries

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

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AHCA believes that the requirement can be completely eliminated,

even

under

the statute's cost-effectiveness criterion.

The

on this issue is

most thorough, objective examination to date a three-year HCFA demonstration project in Oregon and Massachusetts

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needs of beneficiaries who require only sk!lled nursing services.

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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

but who

are

not transferred because

of

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

of

illness" definition so that a "spell" ends when a beneficiary

is

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

Under

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

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only for purposes of ending a Medicare spell of illness.

As

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

to

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,

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available to a beneficiary who is neither under Medicare inpatient

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monitoring care, providng routine medical services, and appro

priately involving the supervisory physician if major medical

Congress

has already recognized the value

of physician

assistants and

nurse

practitioners to augment physicians in

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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

so Medicare

care.

nursing home benefits can finally become what beneficiaries need

and think they have.

JAMES E. CUNNINGHAM, PRESIDENT
NEW JERSEY ASSOCIATION OF HEALTH
CARE FACILITIES

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