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 On April 23, the House passed the Protecting the Medicaid Safety Net Act of 2008 (H.R. 5613), ANA-supported legislation that would place a moratorium on seven Medicaid regulations issued by the Department of Health and Human Services. The 349-62 vote demonstrates bipartisan concern about the effect of the regulations on providers and beneficiaries, and gives the bill more than the two-thirds majority necessary to override President Bush's veto threat. The bill has now been "fast-tracked" for a Senate vote the week of April 28th. Introduced by Reps. John Dingell (D-MI) and Tim Murphy (R-PA), H.R. 5613 would delay until Apri1 2009 implementation of seven regulations (detailed below) which together would reduce Federal Medicaid funding to the states by nearly $20 billion over the next five years. The moratorium would give Congress time to evaluate the merits of the proposed changes. The National Governors Association and the National Association of State Medicaid Directors have both issued statements decrying the regulations and the effect they are expected to have on Medicare beneficiaries. A number of the regulations covered by the bill have already been temporarily blocked by Congress; however the last of these deals will expire in June of this year. Currently, the federal government covers 57 percent of Medicaid's costs - an estimated $204 billion in fiscal 2008. Tension between the federal government and the states over the funding balance is not new. The Administration argues that the regulations close loopholes that allow states to receive extra federal funding to cover costs that the administration asserts are not Medicaid-related. The National Governor's Association counters that the regulations "effectively end the federal government" participation in many crucial components of the Medicaid program and inappropriately shift those costs to states." Given the current budget difficulties already facing most states, a cost shift of this magnitude will force states to either pare back on Medicaid services or compensate for the lost funding with reductions to other state budget items. For this reason, the rules stand to threaten access to health care for millions of our most vulnerable citizens. Medicaid is a key component of the United States health care system. One out of every three births, one out of every four children, eight million disabled citizens, and seventy percent of all nursing home care is funded by this program. Medicaid rolls have expanded over the last five years due to a dramatic increase in the number of Americans lacking health insurance, and in a time of economic downturn, the safety net that Medicaid provides is even more vital. While the bill received overwhelming bipartisan support in the House, the Senate appears much more divided. Senate Leadership unexpectedly announced on April 25 that H.R. 5613 would be "fast tracked" for a vote the week of April 29th, but key Senate Republicans including Finance Committee Ranking member Charles Grassley (R-IA), and Minority Leader Mitch McConnell (R-KY) have argued that the regulations should be allowed to take effect. This opposition will make it difficult to secure a veto proof majority. Changes that jeopardize Medicaid have real implications, not just for beneficiaries, but for all members of the community. It is vital that the implementation of these regulations be postponed until their implications can be thoroughly weighed. For this reason ANA stands strongly behind H.R. 5613. With the level of support unclear, calls from constituents will be vital when the bill comes before the Senate for a vote. You can help. Call your senators today-use our talking points to urge them to vote for H.R. 5613 when it comes before the Senate for a vote. You can reach your Senators by calling the Capitol Switchboard at 202-224-3121. ANA will continue to keep you informed about the timing of the vote through N-STAT and the Government Affairs website. The regulations targeted for a moratorium by H.R. 5613 include: Coverage of Rehabilitation Services (Rule status: proposed rule issued Aug 13 2007; current moratorium through June 2008) This rule amends the definition of Medicaid rehabilitative services and explicitly excludes from coverage services provided under foster care programs, child care, education, vocational services, and certain other social services. The rule contains a number of new definitions including the qualification of providers of rehabilitation services, more narrow definition of rehabilitative services, a requirement for a written plan of care, documentation requirements, and non-coverage for services that are covered under other programs to which the individual is eligible. This rule would affect services delivered by those nurses and other practitioners involved with patients with significant health or mental health impairments. Coverage for these services would be reduced and responsibility shifted to other social service or educational programs. Most reviewers of the regulation believe that it would result in a significant reduction in Medicaid coverage or rehabilitation services. Targeted Case Management (Rule status: interim final rule issued December 4, 2007; effective March 3, 2009; no current moratorium) The intent of the case management services is to assist individuals with disabilities, chronic illnesses or special needs gain access to the full spectrum of health care and support services by arranging and coordinating care. States may provide case management for adults, but must provide it for children. Under the rule, which is designed to clarify when Medicaid payment will be made for case management services, states would no longer be able to receive funding for important care coordination activities. The new restrictions on targeted case management would: impose an arbitrary limit of one case manager per child; impact efforts to integrate school-based services for children with disabilities; fragment services for children in foster care; and roll back efforts to transition people from nursing homes by limiting assistance available to people with disabilities to secure needed services in a community setting. School-based transportation and outreach (Rule status: final rule issued December 28, 2007; current moratorium through June 2008) Under current practices, schools may be reimbursed for their administrative activities associated with the Medicaid program, including outreach, assistance with enrollment and referral of children to Medicaid providers and services. Schools may also be reimbursed for limited, specialized medical transportation to get children to and from school. The rule eliminates federal Medicaid matching funds for the costs of certain school-based administration and transportation activities. Medicaid payments would not be available for activities performed by school employees or contractors, or for transportation to and from school. Medicaid would continue to cover the costs of covered Medicaid services delivered in school-based settings and for transportation to a site where the covered services are available if not offered on the school campus. Many believe that the rule would seriously disrupt services to children with critical needs. Provider taxes (Rule status: final rule issued February 22, 2008; effective April 22, 2008; no current moratorium) Under current law, states are allowed to tax providers as a way to cover Medicaid expenses. These provider taxes are used to improve provider payment rates and quality. CMS wants to make it more difficult for states to raise the non-federal share of Medicaid expenditures through a provider tax that holds the provider "harmless" for the cost of the tax. This change in the definition of provider tax will put current, long-standing state programs in jeopardy. While this rule does not directly reduce eligibility, services or provider payment rates, it's indirect effects could lead to reductions in some or all of these categories. Hospital Outpatient (Rule status: proposed rule issues September 28 2007; no current moratorium) This rule would significantly impact the types of hospital outpatient services Medicaid can cover. Medicaid would be prohibited from covering services such as dental and vision, commonly provided to Medicaid patients through outpatient clinics. It would also restrict the ability of states to cover services in outpatient clinics that are separate from hospitals-a common way states have served people in communities and reduced emergency room use. Finally the rule would lower the amount states can pay for outpatient services. The rule has the potential to severely diminish access, particularly in light of Medicaid's already low reimbursement rates. Graduate Medical Education (Rule status: proposed rule issues May 23 2007; current moratorium through May 25, 2008) The proposed rule states that costs and payments under Medicaid attributable to graduate medical education would no longer be eligible for federal matching payments. CMS believes the graduate medical education is not a "health service" that is included in the Medicaid statute. Many believe that this prohibition on payment for graduate medical programs will diminish the number of providers with the necessary skills and experience available to meet the unique needs of Medicaid beneficiaries, particularly those with disabilities. Intergovernmental transfer (Rule status: final rule issued May 29 2007; current moratorium through May 25, 2008) This rule places strict limits on Medicaid payments to critical safety net institutions such as hospitals and nursing homes. This rule imposes a new definition of "unit of government" for purposes of having their contributions count toward the non-federal share of Medicaid expenditures - whether such contributions are in the form of inter-governmental transfers (IGTs) to the state or are expenditures they make to pay for care to Medicaid eligible patients. The rule also limits Medicaid payments to public hospitals to no more than their costs of providing care, and requires public hospitals to retain the full amount of their Medicaid payments. The purpose of this rule is to limit state options for recycling funds that are paid to public providers that in turn are eligible for federal matching payments. These arrangements have allowed states to shift some of the costs of Medicaid back to the federal government. While the rule does not explicitly reduce benefits, eligibility, or provider participation, it would force states to make adjustments to their Medicaid programs that could lead to cuts in all three areas. |