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8. We have made every effort to facilitate physician participation in the program. An example of this is the development of a special billing form for physicians' services provided persons who are eligible for benefits from both title XVIII (B) and the State Medical Assistance Program. This revised form, developed in April 1967, eliminated the need for duplicate billing and, at the same time, made possible the effective administration of the State Medicaid Program with the significant advantage of avoiding duplication of charges against the State Agency.
SKILLED NURSING HOME AND INTERMEDIATE CARE FACILITIES
1. Scope of service
(a) All admissions to Skilled Nursing Homes and Intermediate Care Facilities are based upon prior authorization. (Medical and Social Service Review)
(b) For those recipients who are Medically Needy Only, Skilled Nursing Home care is limited to a maximum of 90 days in a nursing home per incident of illness. (c) For the Money Payment Recipients (OAA, AB, APTD), Skilled Nursing or Intermediate care placements can be authorized for as long as this type of care is medically indicated.
2. Definition of types of care
(a) Skilled Nursing Home Care. This level of care is authorized for those in need of professional nursing services or whose needs are such that they cannot be accommodated at a lesser level of group care home.
(b) Intermediate Care Facility-I. This level of care is authorized for those who may not be fully ambulatory or whose needs include a requirement for some nursing services. Licensed practical nurse service is mandatory in Intermediate Care I homes on a 24-hour basis.
(c) Intermediate Care Facility-II. This level of care is authorized for those not in need of day-to-day nursing services but in need of room, board, general supervision and/or some assistance in daily activities, including the administration of oral medications.
(d) Group Foster Home Care for the Elderly. This level of care is interchangeable with Intermediate Care Facility-II. Foster Homes are used as a primary resource for the placement of patients from the Institute of Mental Health and the Geriatrics Unit of the Rhode Island Medical Center General Hospital who have mental or emotional disorders.
3. Expenditures for skilled nursing home and intermediate care facilities through title XIX
(a) Total group care expenditures have increased from $4,519,600 in the fiscal year 1967-1968 to $9,631,000 in the fiscal year 1970-1971. The caseload has increased (see attached chart) from approximately 2,500 persons in July of 1968 to approximately 3,300 persons in July of 1971.
(b) The most notable increase in group care expenditures can be seen for Skilled Nursing Homes (see chart) from the period 1969-1970 to the period 1970-1971 where the expenditures for Skilled Nursing Home care increased from $4,298,000 to $6,107,000.
CHART VI.-EXPENDITURES FOR SKILLED NURSING HOME AND INTERMEDIATE CARE FACILITY SERVICES (1967-68 TO 1970-71)
1 In January of 1969, 30 skilled nursing homes were reclassified as intermediate care facilities, thus the drop in caseload for skilled nursing and the corresponding increase in intermediate care.
Some of this increase in cost can be attributed to an increase in caseload. However, we can note from the chart that the expenditure for Intermediate Care did not increase as drastically as the expenditure for Skilled Nursing care although the caseload for Intermediate Care increased proportionately with the caseload for Skilled Nursing Home care.
(c) One of the underlying reasons for the increased expenditure for Skilled Nursing Home care must be attributed to the recently-imposed rigid interpretation of policy pertinent to qualification for admission to Extended Care Facilities as conceived by Federal Medicare.
Since 1969, very few cases have been approved for the maximum 100-day Extended Care Facility allowance under the provisions of Federal Medicare (Part A), therefore making it necessary for Medical Assistance to assure responsibility for the payment of the full cost of Nursing Home care at a time earlier than the anticipated maximum of 100 days.
For example, in cases of cataract operations, Federal Medicare usually allows a maximum of five days of care, including hospital care, which usually means that only two days of extended care are authorized whereas under the Medical Assistance Program, we would normally allow up to 30 days of Skilled Nursing Home care after a cataract operation.
(d) Currently, out of a caseload of approximately 1,700 recipients of Medical Assistance in Skilled Nursing Homes, only 125 or 7.5% of these are currently receiving extended care benefits under Federal Medicare. National statistics show that only 5% of the some 340,000 beds certified as Medicare extended care are currently in use. Why such a small utilization rate?
(e) In planning for our Medicaid Program which was implemented in 1966, we anticipated that a large percentage of these patients would be cared for through the provisions of Title XVIII(A) of Federal Medicare in so-called Extended Care Facilities.
Our budgetary planning for Medicaid was predicated upon the fact that the State Agency would be relieved of a substantial burden as it relates to these people in Skilled Nursing Homes.
It is indeed frustrating to anticipate that our elderly recipients will be accepted by Federal Medicare as fulfilling their requirements for admission to an Extended Care Facility only to have their application denied without so much as an explanation for the denial. We consider this a very serious shortcoming of Federal Medicare as it applies to the administration of their Federal Medicare Program and certainly a very undesirable impact on our State Medical Assistance Program.
4. The following pre-requisites are required for Medicare coverage in an Extended Care Facility.
(a) The services furnished must be required for:
(1) Treatment of a condition or conditions for which the beneficiary was receiving in-patient hospital services prior to transfer to the Extended Care Facility:
(2) Treatment of a condition which arose while receiving Extended Care for treatment of a condition or conditions for which he was receiving inpatient hospital services.
(b) A physician's certification (and recertification when services are provided over a period of time) is required.
(1) This must include an estimate of the time required to accomplish rehabilitation;
(2) Certification that treatment of this condition or conditions requires skilled nursing care (not exclusively limited to R.N. or L.P.N. services but must include other paramedical services such as physical therapy and occupational therapy) on a continuing basis.
(c) Interpretation of Skilled Service-Are Too Restrictive
(1) The classification of a particular service as skilled is based on the technical or professional health training required to effectively perform or supervise the service. For example, a patient following instructions can normally take a daily vitamin pill. Consequently, the act of giving the vitamin pill to a patient who is too senile to take it himself would not be a skilled service.
(2) The importance of a particular service to an individual patient does not necessarily make it a skilled service. For example, a primary need of a non-ambulatory patient may be frequent changes of position in order to avoid development of decubiti. Since changing of position can ordinarily be accomplished by unlicensed personnel, it would not be a skilled service.
(3) The possibility of adverse effects from improper performance of an otherwise unskilled service does not make it a skilled service.
(4) In addition to meeting the definition of skilled nursing services, the services must be needed on a continuing basis. For example, a person may
require intramuscular injections on a regular basis every second day. If this is the only skilled service required, it would not necessitate the continuing availability of skilled nurses.
N.B.-I would continue to pose the basic question pertinent to the intent of Public Law 89-97 as it applies to the utilization of Extended Care Facilities. I simply urge a more liberal approach to this important area of admission of seriously-ill patients to Extended Care Facilities.
D. PHARMACY SERVICES
1. In the development of the Public Assistance Medical Care Program in 1952; consideration was given-from the beginning-to the inclusion of all those medical services and supplies which were considered basic requirements of adequate medical care. This approach was influenced by the conviction that certain medical supplies are essential, that high quality medical care for the needy represents a sound investment of public funds to prevent chronic dependence, and that physical and social rehabilitation of Public Assistance recipients restores many to gainful employment and self-help.
2. From the inception of the Public Assistance Program in 1952, provision was made for the payment of drugs provided to Public Assistance Medical Care recipients. The Rhode Island Medical Assistance Pharmacy program was developed in 1952. This program was developed through the cooperation of the Rhode Island Advisory Committee on Pharmacy and the Advisory Committee on Social Welfare of the Rhode Island Medical Society. The Pharmacy phase of the Medical Assistance Program has always had the close support and cooperation of the pharmacists of Rhode Island.
It should be noted that 100 percent of the Rhode Island pharmacists are participating in the Rhode Island Medical Assistance Program (239 as of September, 1971).
3. The Pharmacy phase of the Rhode Island Medical Assistance Program is a liberal one which does not impose hardships on the recipients and impediments to utilization of pharmacy services.
There is considerable evidence to prove that the elderly and all recipients of Medical Assistance in Rhode Island are receiving those drugs and medical services and supplies which are necessary to maintain good health.
We Continue to be Concerned About High Quality Pharmacy Services
Since the inception of our program in 1952 and the Medical Assistance Program in 1966, we continue to maintain real concern for the provision of high quality pharmacy services for our eligible recipients. If we were to agree to provide anything but the same high quality services which are available to all other persons in the community, then we would be guilty of an unreasonable act of discrimination.
It is for this reason that we have not insisted upon utilization of the following so-called control devices:
(1) Insistence upon the prescription of generic drugs.
(2) The establishment of centralized dispensing units.
(3) Insistence that prescriptions for Medical Assistance recipients be filled through hospital clinics or pharmacies.
It is an established fact that the history of our program supports our position to the effect that every reasonable effort is made to insure the personal physician-patient-pharmacist relationship which does prevail for all other citizens who are not dependent upon a State-administered program of Medical Assistance. 4. During the fiscal year 1970-1971, over 1 million prescriptions were provided to recipients of Medical Assistance. Of these 1 million prescriptions, over 180,000 prescriptions were dispensed to Old Age Assistance recipients in Rhode Island and an estimated 350,000 prescriptions were dispensed to Medically Needy Recipients over 65 years of age.
5. The Department of Social and Rehabilitative Services has designed its pharmacy program to eliminate serious hardships which may be incurred on the part of the elderly.
Witness the fact that, in March 1965, a revised policy allowed refills for Medical Assistance recipients for drugs classified as vitamins, tranquilizers and anti-depressants. Prior to that time, Medical Assistance recipients were required to return to their physicians each month to obtain a new prescription.
Elderly recipients who obtain an original prescription from the attending physician which provides for up to a 30-days supply of medication may, in addition
to the original prescription, be allowed three refills when indicated by the attending physician. This provides an additional 90-days supply of medication.
The Department of Social and Rehabilitative Services is currently reviewing a proposal which would provide for a 100-days supply of certain maintenance drugs thereby further eliminating inconveniences on the part of all eligible recipients of Medical Assistance.
While it is true that the pharmacy phase does not have restrictions, such as a 30-days supply of medication and prior authorization for drugs not included in the scope of our program, it should be noted that these restrictions were designed primarily to protect the Medical Assistance recipients.
CHART VII.-EXPENDITURES FOR DRUGS DISPENSED TO ELIGIBLE RECIPIENTS OF MEDICAL ASSISTANCE BY CATEGORY OF ASSISTANCE (1969-70-1970-71)
We are concerned about the premature approval of drugs which eventually prove to be harmful drugs-responsible for adverse reactions in those who use these medications.
It is for this reason that we employ the mechanism of prior authorization as a means of employing a reasonable and desirable control as it relates to the early usage of new and clinically untried drugs which can be classified as potentially dangerous. It should also be noted that many of these new and untried drugs are extremely expensive drugs. The additional expense cannot be justified by an established certainty that the new drugs are that much more effective than the older, more well-established drugs and of equal safety.
E. DENTAL SERVICES
1. Federal Medicare does not make provision for payment of dental services for those aged individuals entitled to Federal Medicare supplementary medical insurance benefits. In addition to this, the conditions for Federal participation in our title XIX Medical Assistance Programs does not require the State to include provision for payment of dental services. Rhode Island, has always considered dental care a very important facet of total medical care and, therefore, voluntarily included payment for dental services within the scope of our Medical Care Program since 1952.
The Rhode Island State Department of Social and Rehabilitative Services expended in excess of $1,000,000 for dental services provided for all categories of assistance entitled to Medical Assistance benefits under the provisions of title XIX during the fiscal year 1970–1971. Of this expenditure, in excess of $300,000 was expended for dental services provided eligible recipients 65 years of age and over.
2. The Rhode Island Medical Assistance Program does make provision for payment of dental services for Medically Needy Only Recipients as well as Money Payment Recipients. There is a uniform scope of dental benefits for all eligible recipients of the Rhode Island Medical Assistance Program.
3. With the implementation of the Kerr-Mills Program in October 1964, the dental phase of the Medical Assistance for the Aging Program did provide for a limited scope of benefits for eligible recipients classified as Medically Needy Only. However, with the implementation of the Rhode Island Medical Assistance Program in 1966, the dental phase was expanded to include the full scope of dental
services which previously had been provided only to Money Payment Recipients. This expansion of scope of services was particularly beneficial to those persons65 years of age and over-since it included provision for payment of partial and full dentures.
4. On October 1, 1967, an upward revision of the Dental Fee Schedule was implemented with the concurrence and acceptance of the Rhode Island State Dental Society. The practicing dentists participating in our program have expressed an overall satisfaction with this fee schedule which has resulted in a more extensive participating in the program by the practicing dentists.
We are convinced that high quality dental care is available to all our eligible recipients of Medical Assistance; that these services are being utilized by our eligible caseload. We take pride in the fact that these services are provided for these recipients by the private dentist of their own choice.
CHART VIII.-DENTAL EXPENDITURES FOR OAA AND MA RECIPIENTS TOGETHER WITH THE TOTAL DENTAL EXPENDITURES FOR ALL CATEGORIES OF ASSISTANCE
1. Payment for visiting nursing services has always been included within the scope of our Medical Assistance Program. We have always looked upon the services of visiting nurses as essential services required for:
(a) the provision for medical care on a continued basis;
(c) facilitate the early discharge of patients from expensive hospital facilities.
(d) returning these hospitalized patients to their families and community at the earliest time possible in keeping with good quality of medical care. We consider these services as essential for the intelligent administration of the Medicare Program.
In planning for the implementation of the Medicaid Program, the State Agency looked upon the provision of Title XVIII (A) and (B) for the payment of socalled home health services provided by visiting nurses. We considered these as essential for the intelligent administration of the Medicare Program and, more specifically, the hospital phase of the Medicare Program. We have always felt that if expensive hospital facilities are to be utilized only for those patients requiring these services, the early return of the patient from the hospital to the community would be predicated upon the provision of adequate home health services.
2. Our State planning for the cost of Visiting Nursing Services was predicated upon the fact that these services would, for the greater part, be paid for through the Federal Medicare Program. However, an apparent re-definition of standards and Federal Medicare policy, in 1969, has created a very real and serious problem for the Visiting Nursing Associations who are providing home visits to the elderly and to the State Agency which is responsible for 23.4 percent of the population 65 years of age and over in Rhode Island.
It appears that, since 1969, a substantial number of our eligible recipients whom we considered eligible for home health services under the provisions of
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