Author Archives: mshepard

No. 3:15-cv-00390-JBA (D.Conn.), filed March 17, 2015 Issue: Whether extraordinary dental care should be covered because the exclusion for coverage of dental care should be limited to routine dental care. Relief Sought: Reversal of the Secretary’s decision denying coverage to the plaintiff and enjoining the Secretary from relying on a regulation that does not define … Read more

No. 5:14-cv-269 (D.Vt.), filed Dec. 19, 2014 Issue: Whether the failure of the Secretary to apply the “prior favorable homebound decision” rule, which accords “great weight” to previous administrative decisions establishing homebound status, violates the Medicare regulations, as implemented by the Medicare Program Integrity Manual, and the Due Process Clause. Relief Sought: Declaratory and injunctive … Read more

By C.G., California My younger sister who has now passed became very ill at the age of 12 years old with kidney disease. She eventually had both of her kidneys removed, and Medicare was there for the long haul. She also came down with a severe case of Rheumatoid Arthritis, and Lupus. My sister still … Read more

One of Medicare’s key strengths, compared with most other types of health insurance, is that its benefits are “defined.” The Medicare law, regulations and rules set out the minimum scope of benefits that the program must cover and outlines the out-of-pocket costs for which beneficiaries are responsible. For example, as long as certain requirements are met, … Read more

On Tuesday, July 14, 2015, at a news conference on adding Medicare coverage of hearing aids, Rep. Debbie Dingell (D-MI) discussed H.R. 1653, the “Medicare Hearing Aid Coverage Act of 2015,” the first bill she introduced as a member of Congress, which would allow Medicare to provide coverage for hearing aids. She was joined by … Read more

On July 13, 2015, the Centers for Medicare & Medicaid Services (CMS) posted proposed regulations to revise the Requirements of Participation for nursing homes (called Skilled Nursing Facilities under Medicare and Nursing Facilities under Medicaid).  The proposed rules were published in the Federal Register on July 16,[1] with a 60-day comment period.  The public announcement … Read more

July 16, 2015 WASHINGTON, DC – Steve Gleason, former NFL standout athlete for the New Orleans Saints, has redefined what it means to be a hero. Diagnosed with ALS (Amyotrophic Lateral Sclerosis, or Lou Gehrig’s disease) in 2011, Steve’s mind is unaffected by the disease, but he can no longer move any part of his … Read more

By Jenny Gore Dwyer, Washington State In 2005 my husband was diagnosed with ALS. ALS is also known as Lou Gehrig's disease…or "the Ice Bucket Challenge" disease…remember last August when everyone was dumping ice over their heads? That was for ALS. ALS is a horrible disease where the nerve cells that tell the muscles to … Read more

By V.W., a Medicare Beneficiary from Colorado I am a 77 year old woman. I only used Medicare back in the earlier part of this decade, in 2002 and 2005, when I had accidents that required surgery to repair broken bones. The “out of pocket” costs for those surgeries were in the $10,000+ range each. Thanks … Read more

Once a decade, the White House convenes experts, seniors, legislators and advocates to examine issue facing older Americans and plan for the future. This year’s White House Conference on Aging was held on Monday, July 13, 2015.  The Center’s Executive Director, Judith Stein was honored to attend. The day focused on the power of our … Read more

Today, in concert with the White House Conference on Aging, the Administration announced the results of a concerted effort on the part of the Centers for Medicare and Medicaid Services (CMS) and the Social Security Administration (SSA) to improve the information available to individuals becoming eligible for Medicare.  The Medicare program has complicated rules about how … Read more

By an Anonymous Beneficiary from Iowa   In the last year I lost both of my parents.  They were 92 and 94 years old when they passed away.  They had been married for 69 years and died within less than 10 months of each other. In the last decade of their lives, due to their … Read more

Many healthcare institutions are required to provide discharge planning for their Medicare patients as part of their “Conditions of Participation” in the Medicare program.  Under the Medicare program, discharge planning services are required for hospital inpatients, long-term care hospital and rehabilitation inpatients, skilled nursing facility residents, patients in swing-beds, and hospice patients.  Discharge planning services … Read more

In the annual update to Medicare reimbursement of acute care hospitals for outpatient care (July 8, 2015)[1] the Centers for Medicare & Medicaid Services (CMS) includes proposed revisions to the “Two-Midnight Rule” and its enforcement. If the proposed changes lead to an increased number of patients being formally admitted as inpatients (rather than, as now, … Read more

Effective July 1, 2015, Virginia has become the fifth state to enact legislation requiring hospitals to inform patients when they are in Observation or other outpatient status, and the consequences of not being admitted as inpatients.  Senate Bill 750[1] requires hospitals to provide oral and written notice to patients who are receiving “onsite services” (including … Read more

Former residents at 12 nursing facilities owned by Golden Living in Arkansas (or their special administrators, guardians, or attorneys-in-fact) filed a lawsuit challenging the facilities’ chronic understaffing between December 2006 and July 1, 2009.  Plaintiffs moved for class certification on three claims – breach of the facilities’ standard admission agreement, violation of the Arkansas Long-Term … Read more

By P. B., a Medicare Beneficiary from Colorado I would not have been able to have a career, care for others at work, care for my mother after my career or be able to NOT be a dependent at retirement time. All this is because of a prescription that is allowed because I have Medicare. I … Read more

Most people think Medicare is a government program. That’s only partly true. While Congress created Medicare, and continues to develop Medicare coverage and appeal rules, decisions to pay claims are actually made by private companies. The government does not make those decisions. This was one of the compromises made in order to pass Medicare in … Read more

By Marilyn Moon, Institute Fellow, American Institutes for Research (Center for Medicare Advocacy Luminary) Medicare is a successful program that is extremely popular with its beneficiaries who rank it higher than others do their private insurance plans.  And polls always show that people are willing to pay more for Medicare.  So why do politicians persist in … Read more

By Mary Ashkar, Senior Attorney, Center for Medicare Advocacy Prior to becoming eligible for Medicare, many Americans who have health insurance through employment are enrolled in some type of managed care plan. Health Maintenance Organizations (HMOs) are one of the most common types of managed care plans.  Generally, individuals enrolled in HMOs are restricted to … Read more

Advancing Access to Medicare and Necessary Care for People with Long-Term Conditions and Injuries With support from the John A. Hartford Foundation the Center for Medicare Advocacy has created a multi-disciplinary Jimmo Implementation Council. The Center convened the first meeting of the Council on June 23, 2015 at the US Capitol in Washington, DC.[1] The … Read more

Medicare has helped my husband to go to the hospital, Dr. Visits, Prescriptions. It has given my husband a fighting chance to LIVE. Thank God for Medicare.    By L.W., the Spouse of a Medicare Beneficiary from Florida

Our country has a patchwork of different types of health insurance coverage, including individual insurance policies, employer-based insurance coverage plans available through the new Affordable Care Act, Medicaid, and Medicare – the country’s flagship insurance program. While some people go without health insurance altogether, others have different types of coverage over the course of their … Read more

Thank you for honoring Medicare’s 50th Anniversary with your donation to the Center’s Medicare Advocacy Fund. Your gift will help us assist older and disabled people and fight for a full and fair Medicare program. Your generous support is key to our ability to continue this critical work. Check out the Center’s infographic showing how … Read more

Matthew Hubbard came to the Center in 2015 having recently completed his Masters from the George Washington University, where he focused on the intersection of gender and international development in an Asian context. His research and readings often dealt with questions concerning health policy. Prior to his graduation, Matthew researched international labor law and standards … Read more

"If it were not for Medicare I could not possibly afford the health care that I get." – R.B, A Medicare Beneficiary from New Mexico

Medicare is not just an acute care benefit.  It covers skilled maintenance nursing and therapy; in some cases it covers long-term home care. Also, importantly, Medicare covers many preventive services, which, when utilized, can help limit the need for more costly future care. Most Medicare beneficiaries know about the "Welcome to Medicare" physical, but Medicare covers … Read more

1. Comments to Senate Finance Committee Chronic Care Workgroup On June 22, 2015, the Center for Medicare Advocacy submitted comments to the Senate Finance Committee Chronic Care Workgroup in response to the Committee’s May 22, 2015 request for comments on reforming care for individuals with chronic conditions. The Committee identified three overarching goals to guide … Read more

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy has created a council of beneficiary advocates, providers, policy-makers and other partners to discuss, analyze and advance the implementation of the Jimmo v. Sebelius "Improvement Standard" Settlement. The Center convened the first meeting of the multi-disciplinary Council on June 23, 2015 at … Read more

June 22, 2015 The Honorable Orrin Hatch                                        The Honorable Ron Wyden Chair, Committee on Finance                                     Ranking Member, Committee on … Read more

CMS-1622-P: Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNFs) for FY 2016, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and Staffing Data Collection Submitted electronically, June 19, 2015 Dear Colleagues:         The Center for Medicare Advocacy (Center) submits the following comments on the proposed rules, 80 Fed. Reg. 22043 … Read more

June 25, 2015 Today, the U.S. Supreme Court issued a decision in King v. Burwell (No. 14-114), a case challenging one of the central pillars of health insurance coverage offered through the Marketplaces, also known as Exchanges, created through the Affordable Care Act (ACA). The case challenged whether tax credits and subsidies that make health care more affordable for … Read more

By Howard Back, a Medicare Beneficiary from California Medicare funding for hospice services is a wonderful thing. But there is a missing element in the system: there is no timely way a hospice patient can appeal failure of a hospice to provide a drug, or piece of equipment or other service that the patient’s physician … Read more

By LGBT Aging Advocacy (Connecticut) and CT TransAdvocacy Coalition A substantial number of physicians serving Medicare participants do not know the sexual orientation or gender identification of the LGBT elders they care for, although this can be a critical factor for their patients’ health and health care. This is particularly important to keep in mind as the current … Read more

In September 2006, the nursing home industry announced a voluntary quality improvement campaign – Advancing Excellence in America’s Nursing Homes.[1]  The campaign, now in its ninth year and third phase, describes its mission: “to make nursing homes better places to live, work, and visit.”[2]  The Center for Medicare Advocacy (Center) was skeptical about the campaign … Read more

When Medicare began to provide coverage for prescription drugs almost 10 years ago, under Part D, millions of people who previously had no drug coverage were able to access needed medications.  By any measure, the drug benefit has helped many people. While drug coverage was a key missing ingredient in Medicare coverage until then, the way … Read more

By Judith Stein, Executive Director, Center for Medicare Advocacy When Medicare was enacted in 1965, over half of people over 65 had no health insurance. The fact that Medicare provided affordable, basic health insurance was a huge boon for older Americans and their families. (People with disabilities were added to the program in 1972.)  However, … Read more

Part B of Medicare will generally cover up to 80% of emergent and non-emergent ambulance transports when medically necessary and when transport by any other means could endanger your health.  There are also origin/destination requirements; Medicare will typically only cover transports to the nearest appropriate medical facility that can provide the level of care necessary … Read more

A federal judge in Connecticut has certified a nationwide class of beneficiaries who are challenging the Medicare program’s failure to render decisions at the administrative law judge (ALJ) level within the 90 days required by law.  Earlier in the year, the judge had denied the government’s motion to dismiss in the case, Lessler v. Burwell … Read more

By Douglas Gould, President, Douglas Gould and Company Medicare has done so much good over the last 50 years, but it needs a tough watchdog to keep it effective in the years to come. Case in point would be the so called “Improvement Standard,” in which care managers and other Medicare decision-makers determined that benefits … Read more

Fast-food workers have been demonstrating for a higher minimum wage and recently, various corporations have increased the wages of their lowest-paid workers.  Has the movement come to the health care industry? On May 22, 2015, the country’s largest Roman Catholic health system, St. Louis-based Ascension Health, announced that it would pay workers at least $11 … Read more

As we’ve previously reported, on April 28, 2015 the Senate Finance Committee held a hearing about the tremendous backlog of cases piled up at the Office of Medicare Hearings and Appeals (OMHA), the office that oversees Administrative Law Judges (ALJs), the third level of appeal in Medicare’s administrative appeals system.[1]  The Finance Committee hearing also … Read more

LEGISLATIVE UPDATE 1.Senate Finance Committee Addresses Medicare Appeals System On previous Alliance calls, we have discussed that through the Center’s extensive experience with the Medicare administrative appeals process, we continue to find that: The success rates for beneficiaries at the initial levels of Medicare appeal are dismal; and The average wait for a decision at … Read more

By Gill Deford, Director of Litigation, Center for Medicare Advocacy In 1965, I had a summer job as a go’fer for the administrative head of a unit at Johns Hopkins Hospital in Baltimore.  Hopkins Hospital was and is one of the great teaching hospitals in the country, but I wasn’t particularly interested in health care.  … Read more

Government contractors administering Medicare benefits are routinely denying coverage to cancer patients for claims involving the surgical removal of decayed and infected teeth caused by an aggressive course of radiation treatment to the head and neck.[1] The decayed and infected teeth, when left untreated, place these cancer patients at increased risk for infection, thereby decreasing … Read more

By A Medicare Beneficiary Having Medicare saved my life, and I will be forever grateful.  But I never thought of it before I was in the hospital, because I’d never really been sick. You have to fight for Medicare like your life depends on it.  Because, like me, your life may depend on it.  

This CMA Alert highlights a recent individual ALJ decision that sets out an important but often unrecognized beneficiary right to a written notice when he or she is about to use hospital “Lifetime Reserve Days.”  A hospital’s failure to provide appropriate notice in this context can lead to the waiver of a beneficiary’s liability for … Read more

By Matt Shepard My father worked his entire career for a private insurance company.  When he retired before he was 65, he and my Mom were able to remain in the HMO that his company had used.  The company was located in the next state over from my parents’ home state, and so was the network.  … Read more

The traditional Medicare program pays individual health care providers for the specific services and care they provide to beneficiaries and guarantees that patients have “freedom of choice”[1] to select their Medicare providers.  A current focus of Congress and policymakers is changing Medicare payment policy to pay, instead, for episodes of care for beneficiaries.  One issue … Read more

June 10, 2015,  2:00pm – 3:00 PM EST Cost: $99.00 per site This webinar will examine proper dcumention of skilled care for the purposes of obtaining Medicare coverage.  The presentation will examine how to: Identify skilled care and document it  to avoid the need for appeals; Provide adequate documentation of the patient’s condition whether changing … Read more