16. What is a critical access hospital (CAH)? Why was this designation created?17. What are some of the main difference between teaching and nonteaching Since 1997, several key pieces of legislation have resulted in the creation and modification of the critical access hospital (CAH) program. They include:
The BBA created the program, outlining the criteria, plan development, quality assurance, and network requirements. BBRA established a length of stay of an average of 96 hours; established an optional payment methodology at 115% of the fee schedule for hospital-based physicians; and permitted participation of rural areas of metropolitan counties. BIPA established interim payments for CAHs and cost-based reimbursement for swing-bed stays and for on-call physicians. MMA expanded inpatient capacity from 15 to 25 beds; established distinct-part units for psych and rehab of up to 10 beds; increased Medicare payments to 101% of cost for inpatient, outpatient, and swing-bed services, and reauthorized the rural hospital flexibility grant program. MIPPA expanded sites for cost-based lab payments. The ARA jump started HIT and established meaningful use incentives. The Consolidated Appropriations Act included CAHs for guaranteed mortgages. The PPACA reiterated cost-based reimbursement for outpatient and included eligible ambulance services and included CAHs as an eligible provider for 340B. The Balanced Budget Act (BBA) of 1997 Section 402 of the BBA describes the critical access hospital program and the application process for CAH designation. Specifically, the BBA discusses inpatient and outpatient payments, program criteria, network development, agreements, credentialing and quality assurance, certification, grants, rural emergency medical services, the grandfathering of certain facilities that had previously been part of the Essential Access Community Hospital/Rural Primary Care Hospital (EACH/RPCH) program and the Medical Assistance Facilities (MAFs) demonstration in Montana. Below are the original criteria set forth in the BBA that hospitals had to meet in order to apply for CAH status:
The Balance Budget Refinement Act (BBRA) of 1999 The BBA contained a number of payment provisions that adversely affected hospitals. Responding to grassroots advocacy pressures, Congress and the Administration recognized that aspects of the BBA had gone too far, hurt many hospitals, and they acknowledged the need for legislative and regulatory relief. The Balanced Budget Refinement Act of 1999 (BBRA) was the first of such relief measures, and it included several changes aimed at increasing the flexibility of the critical access hospital program. The BBRA changes to the program criteria include the following:
The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) On December 21, 2000, President Clinton signed into law the second relief measure, H.R. 5661, the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA). This measure provided further improvement to the CAH program. The Congressional Budget Office estimated that CAH provisions in the new legislation represented a restoration to hospitals of $350 million over five years. The following provisions were included in the legislation: Clarification of No Beneficiary Cost-Sharing for Clinical Diagnostic Laboratory Tests Furnished by Critical Access Hospitals. Effective for services furnished on or after the enactment of BBRA, Medicare beneficiaries would not be liable for any coinsurance, deductible, copayment, or other cost sharing amount with respect to clinical diagnostic laboratory services furnished as an outpatient critical access hospital service. Conforming changes that clarify that CAHs are reimbursed on a reasonable cost basis for outpatient clinical diagnostic laboratory services were also included. Assistance with Fee Schedule Payment for Professional Services Under All-Inclusive Rate. Effective for items and services furnished on or after July 1, 2001, Medicare would pay a CAH for outpatient services based on reasonable costs or, at the election of an entity, would pay the CAH a facility fee based on reasonable costs plus an amount based on 115 percent of Medicare's fee schedule for professional services. Exemption of Critical Access Hospital Swing Beds from SNF PPS. Swing beds in critical access hospitals (CAHs) would be exempt from the SNF prospective payment system. CAHs would be paid for covered SNF services on a reasonable cost basis. Payment in Critical Access Hospitals for Emergency Room On-Call Physicians. When determining the allowable, reasonable cost of outpatient CAH services, the Secretary would recognize amounts for the compensation and related costs for on-call emergency room physicians who are not present on the premises, are not otherwise furnishing services, and are not on-call at any other provider or facility. The Secretary would define the reasonable payment amounts and the meaning of the term "on-call." The provision would be effective for cost reporting periods beginning on or after October 1, 2001. Treatment of Ambulance Services Furnished by Certain Critical Access Hospitals. Ambulance services provided by a CAH or provided by an entity that is owned and operated by a CAH would be paid on a reasonable cost basis if the CAH or entity is the only provider or supplier of ambulance services that is located within a 35-mile drive of the CAH. The provision would be effective for services furnished on or after enactment. GAO Study on Certain Eligibility Requirements for Critical Access Hospitals. By December 2001, GAO would be required to conduct a study on the eligibility requirements for CAHs with respect to limitations on average length of stay and number of beds, including an analysis of the feasibility of having a distinct part unit as part of a CAH and the effect of seasonal variations in CAH eligibility requirements. The GAO also would be required to analyze the effect of seasonal variation inpatient admissions on critical access hospitals. Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) On December 8, 2003, President George W. Bush signed into law P.L. 108-173, landmark legislation that provides prescription drug benefits for approximately 40 million seniors and disabled Americans beginning in 2006 and approximately $25 billion in relief to hospitals over 10 years. Section 405 contains important provisions for CAHs that enhance reimbursement, expand bed-size flexibility, and provide continued funding of the Medicare Rural Hospital Flexibility (FLEX) Program grants. Increase in Payment Amounts Coverage of Costs for Certain Emergency Room On-Call Providers Authorization of Periodic Interim Payment (PIP) Condition for Application of Special Professional Service Payment Adjustment Revision of Bed Limitation for Hospitals Provisions Relating to FLEX Grants Authority to Establish Psychiatric and Rehabilitation Distinct Part Units Waiver Authority Medicare Improvements to Patients and Providers Act of 2008 (MIPPA) Enacted in July of 2008, the MIPPA included a number of provisions for rural hospitals, including two for critical access hospitals. Flex Grants Clinical Lab Services The American Recovery and Reinvestment Act (ARA) The Recovery Act provides for the creation of federal grant and loan programs through the states to kick-start investment in health IT for CAHs. It establishes payment incentives for eligible acute-care hospitals, including critical access hospitals. These payments build off of the current cost-based payment system that pays CAHs 101 percent of their Medicare allowed costs. Under the incentive, a CAH that is determined to be a meaningful user can fully depreciate certified EHR costs beginning in FY 2011. This allows CAHs to load multiple years of depreciation into a single year. A hospital is eligible for Medicare incentives if it demonstrates that it is a "meaningful user of certified EHR technology," which will be determined by the Secretary of the Department of Health and Human Services. Consolidated Appropriations Act of 2014 Amends the National Housing Act to extend through July 31, 2016, the exemption that authorizes the Secretary to provide mortgage insurance to critical access hospitals. Patient Protection and Affordable Care Act (PPACA) Otherwise known as the Affordable Care Act the law includes provisions unique to CAHs. Sec. 3001 Directs the Secretary to establish value-based purchasing demonstration programs for: (1) inpatient critical access hospital services; and (2) hospitals excluded from the program because of insufficient numbers of measures and cases. However this was an unfunded mandate. In Sec. 3128 the ACA allows a critical access hospital to continue to be eligible to receive 101% of reasonable costs for providing: (1) outpatient care regardless of the eligible billing method such hospital uses; and (2) qualifying ambulance services. In addition, Sec. 7101 expands the 340B drug discount program to allow participation as a covered entity by certain: (1) children's hospitals; (2) freestanding cancer hospitals; (3) critical access hospitals; (4) rural referral centers; and (5) sole community hospitals. Also it expands the program to include drugs used in connection with an inpatient or outpatient service by enrolled hospitals (currently, only outpatient drugs are covered under the program). However, the inpatient expansion was not implemented. Also, the HITECH Act requires the Secretary to integrate reporting on quality measures with reporting requirements for the meaningful use of electronic health records. |