Feds Release New Quality Data Online

McKnight's Long Term Care News reports that the federal government has released new data on the quality of care delivered in skilled nursing facilities.  Centers for Medicare & Medicaid (CMS)  added five brand new quality-related measures to Nursing Home Compare. 

Transparency of outcomes “continues to intensify,” with this posting of the inaugural SNF Quality Reporting Program (QRP) measures, said Amy Stewart, RN, curriculum development specialist with the American Association of Directors of Nursing Services.  She encouraged nursing homes to check their scores on the five newly published SNF measures as soon as possible to know what the potential clients are seeing, and be ready to discuss the results. Scores will be of more interest than ever before to hospitals and other healthcare entities looking to partner with SNFs.

The five quality measures included in this latest release include:

• Percent of residents that developed new or worsening pressure ulcers during their stay in an SNF (1.7% is the nationwide rate in SNFs according to CMS);
• Percentage of patients whose activities of daily living and thinking skills were assessed and related goals were included in treatment plan (95.8% nationally according to CMS);
• Percentage of patients that experienced a fall resulting in a major injury during their stay in a SNF (0.9% nationally according to CMS);
• Medicare spending per beneficiary for patients in SNFs (showing whether Medicare spends more, less or about the same, per episode of care for a patient treated in a SNF compared to how much Medicare spends on an episode of care across all SNFs nationally);
• Rate of successful return to home or community from a SNF (48.57% nationally according to CMS).

CMS decided not to include a sixth quality measure it had previously planned to employ: Potentially preventable 30-day post-discharge readmission. Instead, the agency will allow for additional time to test and determine if there are modifications needed to better display this measure.

CMS has posted a FAQ (Frequently Asked Questions) on its website to answer some of the most common questions related to this release.

While some measures may seem duplicative of those used in the Five-Star Rating System, which includes all residents, these SNF QRP measures are specific to Medicare Part A residents only.

2019 Medicare Advantage Plans Incorporate Long Term Care, Aging in Place Benefits

Some Medicare Advantage Plan (hereafter simply "Plan") issuers are quietly and carefully adding home-based and community-based long-term care (LTC) benefits for 2019, according to Allison Bell, ThinkAdvisor's insurance editor. According to an excellent ThinkAdvisor article, officials at the Centers for Medicare and Medicaid Services (CMS). estimate that about 1.5 million of the 2019 enrollees, or 7.5% of Medicare Advantage plan enrollees, may have access either to support services in the home or community, or to extra benefits designed to help enrollees cope with the burden of diabetes or other chronic conditions. CMS officials have not, however, estimated how many enrollees might have access solely to the new home- or community-based services.  

A previous blog article discussed these changes; see the article entitled, "Trump Administration Embraces Aging In Place- 2019 Advantage Plans Permitted to Incorporate Long Term Care," available by clicking here. 

In Arizona and California, for example, units of Anthem Inc. are openly stating that they will use the new flexibility to beef up the benefits offered by some plans.  Enrollees in certain Anthem plans will have access to what amount to LTC benefits provided for a short period of time:

• Three meals delivered per day for up to 42 days.
• Four four-hour shifts of in-home assistance with daily living activities, such as laundry.
• 40 hours of respite care for caregivers per year.
• One visit per week for adult day care center services, for older adults who need supervision.
• Health care appointment transportation services.

Traditionally, commercial insurers have referred to benefits for small amounts of LTC-type services with terms such as “convalescent care benefits,” or “short-term care benefits.”  SCAN Health Plans of Long Beach, California, says it will offer new in-home benefits through most plans in Southern California, but it’s not easy to tell which new benefits will be related to the new rules.

UnitedHealth Group Inc.’s UnitedHealthcare unit says it will make telemedicine services available to 1.7 million enrollees through phones and computers, and health-related transportation services available to 1.7 million enrollees. The company is also offering a care management and care planning service for caregivers to most of its Medicare Advantage plans. It’s not clear from the company’s 2019 plan announcement whether those beneits are related to the new CMS rules.

Lack of clarity is a real problem. Unfortunately, for someone looking at the CMS 2019 Plan Information or even the plan issuers’ own benefits summary sheets, it is not easy to tell which plans will take advantage of the new CMS benefits flexibility.  Moreover, the value of these additional services, and possible resulting costs are difficult for a lay person to evaluate.  For these reasons, we strongly urge clients to establish a relationship with a trusted advisor.  Locally, many of our clients use the advisors at Harding, Harding & Associates. 

Traditionally, Medicaid has been the government health program that pays for nursing home care.  Federal rules have blocked Medicare from paying for long-term care.  Medicare has paid for skilled nursing care for people recovering from serious acute health care problems, and promised to pay for limited home health care services.

But Medicare has not paid for nursing home care for people who are in a nursing home simply because they are frail or have trouble with the activities of daily living, such as bathing or eating.  Medicare has also avoided paying for other types of in-home services, such as help with cleaning or laundry, that might help keep older people in their homes.

In May, CMS said it would change Medicare Advantage benefits rules, to give issuers ways to offer new benefits for the “social determinants of care” that might help reduce overall medical spending.  Officials suggested, for example, that, in some cases, spending a little money on transportation services or meal delivery for someone with serious health problems might be a good way to avoid spending a lot of money on hospital care. 

CMS Announces 2019 Medicare Premiums and Deductibles

On October 12, 2018, the Centers for Medicare & Medicaid Services (CMS) released the 2019 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs.

Medicare Part B Premiums/Deductibles

Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered by Medicare Part A.  

The standard monthly premium for Medicare Part B enrollees will be $135.50 for 2019, an increase of $1.50 from $134 in 2018. An estimated 2 million Medicare beneficiaries (about 3.5%) will pay less than the full Part B standard monthly premium amount in 2019 due to the statutory hold harmless provision, which limits certain beneficiaries’ increase in their Part B premium to be no greater than the increase in their Social Security benefits. The annual deductible for all Medicare Part B beneficiaries is $185 in 2019, an increase of $2 from the annual deductible $183 in 2018. Premiums and deductibles for Medicare Advantage and Medicare Prescription Drug plans are already finalized and are unaffected by this announcement.

Since 2007, a beneficiary’s Part B monthly premium is based on his or her income. These income-related monthly adjustment amounts (IRMAA) affect roughly 5 percent of people with Medicare Part B.  The total premiums for high income beneficiaries for 2019 are shown in the following table:

Premiums for high-income beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:

Medicare Part A Premiums/Deductibles

Medicare Part A covers inpatient hospital, skilled nursing facility, and some home health care services. About 99 percent of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment.

The Medicare Part A inpatient hospital deductible that beneficiaries will pay when admitted to the hospital will be $1,364 in 2019, an increase of $24 from $1,340 in 2018. The Part A inpatient hospital deductible covers beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. In 2019, beneficiaries must pay a coinsurance amount of $341 per day for the 61st through 90th day of a hospitalization ($335 in 2018) in a benefit period and $682 per day for lifetime reserve days ($670 in 2018). For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 of extended care services in a benefit period will be $170.50 in 2019 ($167.50 in 2018).

Enrollees age 65 and over who have fewer than 40 quarters of coverage and certain persons with disabilities pay a monthly premium in order to voluntarily enroll in Medicare Part A. Individuals who had at least 30 quarters of coverage or were married to someone with at least 30 quarters of coverage may buy into Part A at a reduced monthly premium rate, which will be $240 in 2019, an $8 increase from 2018. Certain uninsured aged individuals who have less than 30 quarters of coverage and certain individuals with disabilities who have exhausted other entitlement will pay the full premium, which will be $437 a month, a $15 increase from 2018.

For more information on the 2019 Medicare Parts A and B premiums and deductibles (CMS-8068-N, CMS-8069-N, CMS-8070-N), please visit https://www.federalregister.gov/public-inspection.

Social Security Announces 2019 Changes

The Social Security Administration (SSA) has released the 2019 benefit changes.   Based on the increase in the Consumer Price Index (CPI-W) from the third quarter of 2017 through the third quarter of 2018, Social Security and Supplemental Security Income (SSI) beneficiaries will receive a 2.8 percent increase or COLA for the year 2019. 

SSA also announced an increase in the SSA taxable maximum amount to $132,900. The indivdiual's amount for SSI for 2019 will increase to $771 per month. 

The tax rate for most people is 7.65%, the combined rate for Social Security and Medicare. The Social Security portion (OASDI) is 6.20% on earnings up to the applicable taxable maximum amount. The Medicare portion (HI) is 1.45% on all earnings. Also, as of January 2013, individuals with earned income of more than $200,000 ($250,000 for married couples filing jointly) pay an additional 0.9 percent in Medicare taxes (not reflected in the 7.65% combined rate reported above). 

The detailed fact sheet is available here.

Declining SNF Utilization

There is increasing evidence that either (1) utilization of nursing homes is rapidly diminishing, or (2) utilization of nursing homes has reached saturation, and competition is closing less competitive operations.  One would like to think that seniors and their families are implementing "Aging in Place" planning in order to avoid institutionalization. The issue is complicated, however, and although what is occurring is demonstrable, the underlying causes are unclear. 

The New York Times recently published an article discussing the phenomenon entitled "In the Nursing Home, Empty Beds and Quiet Halls,"explaining that a once vibrant facility now stands closed due to a drop in demand.  According to the article, "[t]he most recent quarterly survey from the National Investment Center for Seniors Housing and Care reported that nearly one nursing home bed in five now goes unused. ... Occupancy has reached 81.7 percent, the lowest level since the research organization began tracking this data in 2011, when it was nearly 87 percent."  

The occupancy rate for skilled care nursing homes has been trending downward, and as a result facilities close.  According to the article, somewhere between 200-300  close annually.  The article  offers some possible explanations for the phenomenon given the number of baby boomers that one might think would cause an increase in demand.  The article suggests the decreasing utilization is caused by:  

• Increased regulations and more financial belt-tightening;
• Hospitals' use of observation status,which affects Medicare coverage for subsequent SNF care;
• More surgeries on an out-patient basis;
• Increasing number of Medicare Advantage plans;
• Increased competition through other housing options;
• The shift to Medicaid covering care in the community, with "Money Follows the Person [having] moved more than 75,000 residents out of nursing homes and back into community settings."

The article speculates whether this trend will reverse itself once the boomers start reaching age 80 and beyond. The article also discusses whether the lower demand provides more options for those in need of nursing home care.