House Ways & Means Committee Issues Report on Improving Chronic Care Management Act
Excerpts of the report follow (with changes to the law omitted, and available at https://www.congress.gov/congressional-report/116th-congress/house-report/646/1?s=2&r=33)
* * *
I. SUMMARY AND BACKGROUND
A. Purpose and Summary
The bill, H.R. 3436, the "Improving Chronic Care Management Act," as amended and ordered reported by the
B. Background and Need for Legislation
Generally, beneficiaries are responsible for a coinsurance payment (20 percent in most cases) and an annual deductible (
According to the
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/1/Connected Care Toolkit: Chronic Care Management Resources for Health Care Professionals and Communities, CTRS. for Medicare & Medicaid Servs., at 2 https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/connected-hcptoolkit.pdf.
/2/
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The Committee believes that congressional action is necessary to help remove barriers to care management services.
A broad swath of stakeholder organizations have registered their support for such action. For example, the
In addition, the
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/3/AAFP Letter Supporting Bill that Removes Medicare Beneficiary Cost-Sharing Responsibilities for the CCM, Am.
/4/FAH Support Letter to Ways and Means,
/5/Joint Letter Supporting a Bill that Removes Medicare Beneficiary Cost-Sharing Responsibilities for the CCM, Am.
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C. Legislative History
Background
H.R. 3436 was introduced on
Committee Hearings
On
On
The hearing included significant discussion about social determinants of health being primary factors in poor health outcomes throughout the life cycle. Witnesses noted the role of weathering, a concept that refers to increased general health vulnerability and premature aging due to the collective impact of chronic, environmental stressors on people of color, and its role in disparities overall./6/ Chronic care management (CCM) is considered to be one of the most important ways to mitigate disparities and poor health outcomes associated with social determinants of health.
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/6/
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Committee Action
II. EXPLANATION OF THE BILL
A. The Improving Chronic Care Management Act of 2019 CURRENT LAW/7/
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/7/All discussions of Current Law in this report refer to current law as of the date of the markup (i.e.,
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Medicare beneficiaries are generally responsible for a coinsurance payment (20 percent in most cases) and an annual deductible (
The notable exception is for preventive care services, with Part B covering a number of clinical preventive services. Under the Patient Protection and Affordable Care Act of 2010 (ACA; P.L. 111-148, as amended), Part B waives any cost-sharing for almost all covered preventive services, and authorizes the Secretary of
In 2015, CCM became eligible to be separately billed under the Medicare Physician Fee Schedule. Per calendar month, CCM services include at least 20 minutes of clinical staff time directed by a physician or other qualified health professional to address (1) multiple chronic conditions that are expected to last at least 12 months or until the patient dies; and (2) chronic conditions that place the patient at a significant risk of death, acute exacerbation or decompensation, or functional decline. CCM requires a comprehensive care plan, and beneficiaries with conditions requiring complex medical decision-making are eligible for up to 60 minutes of clinical staff time per calendar month.
CCM service codes are general supervision services under Part B. Therefore, the billing practitioner's physical presence is not required in order to support claims for the services, nor is the beneficiary required to be present after initiating CCM services. The "behind the curtain" nature of CCM services leaves beneficiaries confused when they receive statements reflecting charges for CCM cost-sharing, when they have not had an actual office appointment within that time period.
REASONS FOR CHANGE
The Committee believes that legislative action is necessary to remove barriers to care management services. To improve access to and utilization of CCM services, this bill removes the cost-sharing requirement for beneficiaries to access CCM services, similar to current cost-sharing policies under Part B for preventive services. The provision would apply both to coinsurance and deductibles related to CCM services.
EXPLANATION OF PROVISIONS
Section 1. Short title
The short title for this bill is the Improving Chronic Care Management Act.
Section 2. Removing cost-sharing responsibilities for Chronic Care Management services under Part B of the Medicare program Section 2 removes the beneficiary cost-sharing requirement under Medicare Part B for CCM services.
Effective
CCM codes reflect services that are in addition to routine care coordination, behavioral health integration, or psychiatric collaborative care services that are already furnished by a
EFFECTIVE DATE
Certain named provision: Effective beginning on or after date
III. VOTES OF THE COMMITTEE
In compliance with clause 3(b) of rule XIII of the
The Chairman's amendment in the nature of a substitute was adopted by a voice vote (with a quorum being present).
H.R. 3436 was ordered favorably reported to the
Table omitted: https://www.congress.gov/congressional-report/116th-congress/house-report/646/1?s=2&r=33
IV. BUDGET EFFECTS OF THE BILL
A. Committee Estimate of Budgetary Effects
In compliance with clause 3(d) of rule XIII of the Rules of the
B.
In compliance with clause 3(c)(2) of rule XIII of the Rules of the
C. Cost Estimate Prepared by the Congressional Budget Office In compliance with clause 3(c)(3) of rule XIII of the Rules of the
U.S.
Hon.
Dear Mr. Chairman: The
If you wish further details on this estimate, we will be pleased to provide them. The CBO staff contact is
Sincerely,
Enclosure.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The bill would:
* End patient cost sharing for chronic care management (CCM) services under the Medicare fee-forservice program
Estimated budgetary effects would primarily stem from Medicare's payment of the full amount for CCM services
Areas of significant uncertainty include:
* Projecting the number of Medicare beneficiaries who would use CCM services
Bill summary: H.R. 3436 would end patients' cost-sharing responsibilities for chronic care management services under Medicare.
Estimated Federal cost: The estimated budgetary effect of H.R. 3436 is shown in Table 1. The costs of the legislation fall within budget function 570 (Medicare).
TABLE 1.--ESTIMATED BUDGETARY EFFECTS OF H.R. 3436
Table omitted: https://www.congress.gov/congressional-report/116th-congress/house-report/646/1?s=2&r=33
Basis of estimate: For this estimate, CBO assumes that the bill will be enacted near the end of 2019.
Direct spending: In 2015, Medicare began to pay for CCM services for beneficiaries who have two or more chronic conditions that are expected to last at least 12 months or until the death of the patient. CCM services are electronic and provided remotely. Examples of such services include developing comprehensive care plans and management, providing access to around-the-clock care and transitional care management, and coordinating home- and community-based care. Medicare patients must consent to receiving the services and acknowledge their cost-sharing responsibilities. Under its fee-for-service program, Medicare typically pays 80 percent of the physician fee schedule amount, and beneficiaries pay the remaining 20 percent. In 2018, about 4 million CCM services were provided to Medicare beneficiaries and, on average, patient's monthly cost sharing totaled about
Beginning in 2020, H.R. 3436 would eliminate cost sharing for CCM services. CBO estimates that removing the cost sharing requirement would increase the number of CCM services provided to chronically ill individuals by about 200,000 (a five percent increase) in 2020, increasing to about I million additional services (a 25 percent increase) by 2029. Under H.R. 3436, Medicare would pay the full fee schedule amount, which would increase direct spending by
Uncertainty: CBO cannot precisely estimate the number of Medicare beneficiaries who would use CCM services once cost sharing ends. Because coverage of CCM services is relatively new to the Medicare program, it is possible that the number of beneficiaries using CCM services could be higher or lower than CBO anticipated.
Pay-As-You-Go considerations: The Statutory Pay-As-You-Go Act of 2010 establishes budget-reporting and enforcement procedures for legislation affecting direct spending or revenues. The net changes in outlays that are subject to those pay-as-you-go procedures are shown in Table 1.
Increase in long-term deficits: CBO estimates that enacting H.R. 3436 would not increase on-budget deficits by more than
Mandates: None.
Estimate prepared by: Federal Costs:
Estimate reviewed by:
V. OTHER MATTERS TO BE DISCUSSED UNDER THE RULES OF THE HOUSE
A. Committee Oversight Findings and Recommendations With respect to clause 3(c)(1) of rule XIII and clause 2(b)(1) of rule X of the Rules of the
B. Statement of General Performance Goals and Objectives With respect to clause 3(c)(4) of rule XIII of the Rules of the
C. Information Relating to Unfunded Mandates
This information is provided in accordance with section 423 of the Unfunded Mandates Reform Act of 1995 (Pub. L. No. 10494).
The Committee has determined that the bill does not contain Federal mandates on the private sector. The Committee has determined that the bill does not impose a Federal intergovernmental mandate on State, local, or tribal governments.
D. Congressional Earmarks, Limited Tax Benefits, and Limited Tariff Benefits
With respect to clause 9 of rule XXI of the Rules of the
E. Duplication of Federal Programs
In compliance with clause 3(c)(5) of rule XIII of the Rules of the
F. Hearings
In compliance with Sec. 103(i) of
(1) On
(2) On
Content omitted: https://www.congress.gov/congressional-report/116th-congress/house-report/646/1?s=2&r=33
VII. DISSENTING VIEWS
H.R. 3436, introduced by
A major contributing factor to high health care costs is that consumers have become increasingly insulated from the cost of health care services. For instance, at least 80% of Medicare beneficiaries have some type of supplemental coverage, which means the vast majority of Medicare beneficiaries currently pay little or nothing in cost sharing.
This bill exacerbates that trend by eliminating costsharing for certain beneficiaries and shifting the cost of those services onto the already struggling Medicare program. To lower health care costs overall,
Under the CCM billing code, a clinician can bill each month for up to 20 minutes of non-face-to-face time for patients with two or more chronic conditions. This could include time spent talking to a lab regarding lab results or a pharmacist who calls the physician's office because the patient reported a rash using certain medication. It is a slippery slope for the government to use taxpayer dollars to not only pay for the natural communication and care coordination between health care providers, but take the next step and pay for all cost-sharing.
This policy is consistent, however, with the
Under the CCM billing code, the patient must have two or more chronic conditions that: (1) are expected to last at least 12 months or until death, and (2) place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline. Diagnoses that may be likely to qualify include diabetes, chronic obstructive pulmonary disease, cardiovascular disease, or atrial fibrillation. These are serious, costly conditions, but there are countless serious diseases that affect the daily lives of millions of Americans, and the government should not be picking winners and losers among disease groups and patient groups.
Rather than expanding fee-for-service Medicare, we should be focused on paying for improved healthcare outcomes. Medicare is moving away from fee-for-service in order to pay for value rather than volume of services. Alternative payment models in Medicare focus on improving the coordination of care and improving the quality of care. Within the same vein, we should be focused on getting more seniors into plans that are designed around their needs. In Medicare Advantage, seniors with serious chronic conditions are able to enroll in a special needs plan tailored to their condition. These plans offer better benefits than traditional Medicare, and seniors are able to choose what type of care coordination they value the most. Moreover, these plans have the ability to reduce cost-sharing on services that will keep seniors with chronic conditions healthy. For example, a plan designed for diabetic patients would be able to offer coverage for foot and eye exams to make sure their patient is in good condition.
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