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Introduction

On December 18, 2008, the Center for Medicare Advocacy (the Center) released a new report recommending changes to the Medicare program for consideration by the Obama Administration and the 111^th Congress. While paying particular attention to the needs of people with chronic conditions, the Center's recommendations strengthen the overall Medicare program for current and future beneficiaries.  The Center's recommendations can be found in .pdf format at http://www.medicareadvocacy.org/Reform_08_12.18.OptionsforRealReform.pdf.  

In developing its recommendations, the Center relied on its decades of experience helping clients obtain necessary Medicare coverage.  This experience with real Medicare beneficiaries is enhanced by the Center's long-standing participation in health policy discussions before the Medicare agency and in the Congress. Underlying all of the Center's recommendations are three guiding principles: what is best for Medicare beneficiaries, what is most cost-effective for taxpayers, and what will provide the greatest security for the future of Medicare.

The Center for Medicare Advocacy's Weekly Alert for December 4, 2008, "Presidential Executive Orders: a Tool of Health Policy Reform," included the Center's recommendations for Medicare improvements that could be made by Executive Order. What follows is a bulleted list of the recommendations that could be achieved through administrative, regulatory, and legislative action.

1.      Overarching Recommendations

Through Administrative and Regulatory Action, The Centers for Medicare & Medicaid Services (CMS) should:

• More effectively use its monitoring and enforcement authority.

• Broaden its approaches to informing beneficiaries about the quality of care provided by Medicare-contracted health care providers.

• Involve beneficiary advocates in developing and testing information that is disseminated through 1-800-MEDICARE.

• Make available more detailed data about the Medicare program.

• Increase accountability to beneficiaries by extending public comment periods for notices of public rule-making and providing beneficiary advocates longer comment periods on informal guidance and notices and letters to beneficiaries.

Through Legislative Action, Congress should:

• Restore equity in payment between traditional Medicare and Medicare Advantage. 

• Repeal the "45% trigger" that will otherwise lead to severe cuts to Medicare.

• Repeal the 2010 Premium Support Demonstration that will require traditional Medicare to "compete' with the better paid private Medicare plans.

• Eliminate the Part B Income-Related Premium.

• Protect against high out-of-pocket expenses in traditional Medicare.

• Increase resources for CMS for oversight, monitoring, and enforcement.

2.      Improving and Expanding Medicare Coverage

Through Administrative and Regulatory Action, CMS should:

• Prohibit the use of general "rules of thumb" to deny or limit coverage. 

Through Legislative Action - Congress could:

• Repeal the 24-month waiting period for Medicare for people under 65 with disabilities.

• Remove the statutory exclusion of routine dental services, vision care, and hearing aids and devices from Medicare.

• Add a coordinated care benefit in the traditional Medicare program.

• Add a prescription drug benefit to the traditional Medicare program.

3.      Improving Medicare for Beneficiaries with Disabilities and Chronic Conditions

Through Administrative and Regulatory Action, CMS should:

• Clarify that all Medicare beneficiaries, including those with chronic conditions are entitled to necessary services to maintain, or slow deterioration of a health condition or injury, even if their underlying condition will not improve.

• Clarify that the "primarily for use in the home" requirement for power operated vehicles (POVs) includes using the POV primarily outside the home.

• Clarify Medicare coverage of computer-assisted technologies for augmenting speech, hearing, and thought integration, including establishing a study panel to facilitate coverage policy development.

Through Legislative Action, Congress should:

• Eliminate the "homebound" requirement for accessing the Medicare home health benefit.

4.      Improving Access for Beneficiaries Who Need Post-Acute Care

Through Administrative and Regulatory Action, CMS should;

• Count time in hospital emergency rooms and in observation status toward meeting the three-day prior hospitalization requirement for access to Medicare-covered Skilled Nursing Facilities (SNFs).

• Rescind the notion of hospital observation status and services and delete all references to observation status and services in hospitals from the CMS manuals. 

• Clarify for purposes of Durable Medical Equipment (DME) that non-skilled parts of nursing homes or convalescence homes are considered the individual's home.

• Protect Medicare home health coverage recipients who require short hospitalizations by prohibiting home health providers from discharging these individuals from home care.

Through Legislative Action, Congress should:

• Repeal the Medicare statutory three-day prior hospitalization requirement for accessing the skilled nursing facility benefit. Alternatively, decrease the three-day requirement and count all time in the hospital.

5.      Improving Medicare for Beneficiaries in Part C and Part D

Through Administrative and Regulatory Action, CMS should:

• Improve protections against misleading marketing practices.

• Award amnesty to waive the late enrollment penalty.

• Clarify definition of Part D drug.

• Clarify utilization management practices.

Through Legislative Action, Congress should:

• Repeal Part D and replace it with a prescription drug benefit in traditional Medicare. Alternatively, add a drug benefit in traditional Medicare.

• Develop standardized benefit packages and limit the number of plan choices in Medicare Parts C and D.

• Eliminate "lock-in" for Medicare Parts C and D.  In the alternative, adopt additional special enrollment periods and conform Part C and Part D enrollment periods.

• Protect against high out-of-pocket expenses in Part C and Part D plans.

• Allow payments by ADAP programs and Indian Health Service to count towards the Part D out-of-pocket limit.

6.      Standardizing Procedures to Simplify Medicare Operations for Beneficiaries

Through Administrative and Regulatory Action, CMS should:

• Improve notices provided to beneficiaries about appeal rights.

• Issue a monthly Medicare summary notice (MSN).

• Clarify fast track review appeal rights.

• Identify services eligible for prior determination process.

• Require plans to provide a supply of on-going medication pending appeal.

• Allow tiering "Exceptions" for specialty drugs and to generic tiers

• Clarify the opportunity to present evidence to the Qualified Independent Contractor (QIC).

• Establish time frames for decisions by Administrative Law Judges (ALJs) in Part C and Part D appeals.

Through Legislative Action, Congress should:

• Eliminate the Qualified Independent Contractor level of review.

• Simplify the Part D appeals process.

7.      Assuring Quality of Care for Medicare Beneficiaries

Through Administrative and Regulatory Action, CMS should:

• Require CMS to update the requirements of participation for Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs). 

• Amend reimbursement regulation and policy to assure that they are consistent with the requirements of participation, pay for high quality care, and are enforced.

• Strengthen the nursing facility survey and enforcement systems.

• Resist industry efforts to abandon the nursing facility enforcement system and replace it with a limited oversight model that relies on self-regulation, technical assistance, quality assurance, and customer satisfaction.

Through Legislative Action, Congress should:

• Identify methods to improve oversight of nursing homes owned by private equity firms.

8.      Improving Medicare for Low-Income Beneficiaries

Through an Administrative and Regulatory Action, CMS should:

• Reduce reassignment of low-income beneficiaries to new plans each year.

• Adopt a process of intelligent assignment or beneficiary-centered assignment for dual eligible persons and State Pharmaceutical Assistance Program enrollees in Part D plans.

• Change deeming requirements for the Part D Low-Income Subsidy (LIS) to ensure that anyone eligible for Medicaid at any time during the year is also eligible for the entire following year.

• Ensure that Part D plans provide requisite reimbursements to individuals

• Direct states to use actual family size, following the interpretation used by the Social Security Administration for the Low-Income Subsidy, in assessing eligibility for Medicare Savings Programs.

• Direct states to ensure that all eligible Medicaid recipients, including those whose only income is Supplemental Security Income, are enrolled in the Qualified Medicare Beneficiary (QMB) program.

• Clarify, through amendments to regulations concerning Third Party Liability, that states should not require beneficiaries to appeal coverage denials from a primary payer – especially Medicare – before they can get Medicaid coverage for a service. 

• Clarify requirements for Medicare Advantage plans enrolling dual eligibles concerning coordinating with Medicaid benefits. 

• Expand requirements for Medicare Advantage Special Needs Plans.

Through Legislative Action, Congress should:

• Deem individuals found eligible for Supplemental Nutrition Assistance Program (SNAP, formerly food stamps) and/or Low-Income Home Energy Assistance Program (LIHEAP) to be also eligible for Medicare Savings Programs and the Part D Low-Income Subsidy.

• Eliminate asset tests for programs for low-income Medicare beneficiaries.  Alternatively, increase the assets levels.

• Make the Qualified Individual (QI) program permanent. 

• Align the Medicare Savings Programs (MSPs) and the Part D Low-Income Subsidy (LIS) to allow enrollment in one program to provide automatic access to the other. 

• Recalculate the Part D benchmark to reduce reassignment of low-income beneficiaries each year.

• Provide Internal Revenue Service (IRS) authority to share data with the Social Security Administration to identify individuals likely to be eligible for low-income assistance to allow for targeted outreach.

• Repeal the provision of the Medicare act of 2003 (MMA) that prohibits states from receiving federal financial participation for covering Part D covered drugs, so that Medicaid programs could pay for cost-sharing and non-formulary drugs.

• Repeal the provision of the Balanced Budget Act of 1997 that allows states to pay Medicare cost-sharing for Qualified Medicare Beneficiaries at the Medicaid payment rate rather than the (usually higher) Medicare payment rate.

• Repeal the provision of the Medicaid law that prohibits qualified Medicare beneficiaries from receiving retroactive Medicaid coverage, as all other Medicaid beneficiaries do.

Conclusion

If adopted, the Center for Medicare Advocacy's recommendations would go a long way to returning the focus of Medicare to the beneficiaries for whom it was created.  They would also make Medicare an efficient and economic program for the taxpayers who share in its financing and, further, would help Medicare serve as a model for broader health care reform initiatives.