would also provide coverage of intermediate care facility services under the program beginning July 1, 1978, greatly expanded psychiatric care benefits including inpatient, day care patient, and outpatient, dental services on an unlimited basis including preventive, diagnostic, therapeutic, and restorative services and other professional and supportive services such as professional services of optometrists and podiatrists, diagnostic services of independent pathology laboratories and diagnostic and therapeutic radiology furnished by independent radiology services, mental health day care services provided by an HMO, a hospital, or community mental health center, or, to the extent of not more than 160 full days during or following a benefit period, when provided by a service affiliated with a hospital or when provided by a day care service approved by the Secretary of HEW for this purpose, professional services of chiropractors and ambulance and other emergency transportation services. The Medicare Amendments of 1974 would expand the coverage of drugs (including biologicals) so as to include, in addition to those furnished to hospital and skilled nursing facility inpatients or in a physician's or dentist's office, drugs furnished to enrollees of a participating HMO and prescribed drugs dispensed by pharmacies, except that during the first five years, only if listed on a list of maintenance drugs established by the Secretary and thereafter only if listed as appropriate in a list, established by the Secretary, designed to provide practitioners with an armamentarium 34-275 (Pt. 8) O 75-9 - 20 necessary and sufficient for rational drug therapy incident to comprehensive care. Moreover, the present coverage under Medicare of prosthetic and other devices, appliances, and equipment would be extended by these amendments to all others (including eye glasses and hearing aids) listed by the Secretary as important for the maintenance or restoration of health or employability or self management of individuals. Medicare Amendments of 1974 would confront directly the problem of benefit durational limitations under existing law. Present limitations on duration of general inpatient hospital care, skilled nursing facility care, and home health services would be abolished. The Medicare Amendments of 1974 would eliminate all requirements for premium payments, and so-called deductibles and coinsurance. Instead, a system of copayments with respect to inpatient hospital services, skilled nursing services, home health services, physician's and dentist's services, mental health day care, diagnostic outpatient services and independent laboratory or independent radiology services, devices, appliances and equipment, certain drugs, and ambulance services would be established. However, these copayments and any remaining limitations on benefits would be subject to a catastrophic protection feature pursuant to which such copayments or limitations would be eliminated in the case of low-income persons and in the case of other persons, would be eliminated after such persons have incurred out-of-pocket expenses in a maximum amount related to their income. · 21 All providers of services, not merely institutional providers as under present law, would be required to qualify as participating providers (except in emergencies and certain cross-the-United States-border hospital services). The term "provider" would be defined to include independent practitioners with respect to their private patients and suppliers who furnish items (e.g. drugs, or prostheses or appliances) to an individual in their own right and not in behalf of another. Pursuant to these Amendments, participating hospitals and other institutional providers would be required to submit annually a budget and schedule of proposed rates and charges, based on the cost of efficient delivery of services, for approval to the Secretary of HEW or to the state rate review agency in any state that . has an equivalent institutional rate review and approval law; reimbursement for services to such providers would be based on the predetermined approved rates, thus providing incentives for efficiency and economy for such providers. Moreover, physician and other services generally available to institution patients, whether performed by employed staff or under arrangements made by the institution, would be treated as institutional services, except for services by physicians, dentists, or podiatrists with respect to their private patients. With respect to non-institutional services of independently practicing physicians, dentists, podiatrists, or other licensed professional practitioners, payment would be provided in accordance with annually predetermined fee schedules for local areas. These schedules would be established, to the extent feasible and subject to public hearing, through negotiations of representatives of appropriate professional societies and representatives of associations of retired persons (or associations otherwise representative of Medicare beneficiaries) and based on a forecast of fair and equitable compensation (not exceeding "reasonable charges") in the area in the applicable fiscal year. Finally, with respect to reimbursement procedures, a provider would be required, as a condition precedent to participation, to agree to accept the Medicare payment (plus any copayment) as the full charge for the services. Under the Medicare Amendments of 1974 beneficiaries would have the option of having all covered care provided (or, in the case of emergencies or urgent out-of-area services paid for) by an HMO, including within the definition thereof a medical foundation, with which the Secretary would contract and which, as under present law, would be reimbursed either on a risk-sharing or cost reimbursement basis, with interim per capita payments during the contract year. These Amendments would also amend the present Medicaid program to make it, in the case of those entitled to health care benefits under these Amendments, supplementary to Medicare on a transitional basis, primarily for long-term care, until all durational limitations in Medicare have expired or been repealed. Finally, under Title III of these Amendments, studies and reports to Congress would be required with respect to a comprehensive plan or plans for making long-term health and health-related 23 institutional care readily and appropriately available to all who need such care. Studies would also be required with respect to the need for, and the most equitable means of meeting the cost of, additional facilities of various kinds for the long-term institutional care of persons who, because of age or disability or other cause, are unable to live at home without assistance as well as with respect to the need for additional services to enable such persons (if possible) to live in their own homes and the best way to provide and finance such services. B. DETAILED COMPARISON OF THE MEDICARE AMENDMENTS OF 1974 WITH 1. In General a. Present Law Title XVIII of the Social Security Act, 20known of ficially as Health Insurance for the Aged and Disabled, - 21 Hospital Insur contains two programs of medical care 22 Each of these programs has its own eligibility requirements, benefit package, limitation and cost-sharing features, reimbursement procedures, financing mechanism, and trust fund. b. The Medicare Amendments of 1974 The Medicare Amendments of 1974 would repeal Parts A and B of Title XVIII, except Section 1817 (provisions 2042 U.S.C. §§1395b-1 to 1395pp (1970). 21Soc. Sec. Act 1811-1818. 22 Soc. Sec. Act §§1831-1844. 34-275 (Pt. 8) O 75 - 10 |