Author Archives: mshepard

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

Medicare is a wonderful program.  It provides important health insurance for millions of older and disabled people. But, contrary to common belief, Medicare does not cover long-term care in skilled nursing facilities (often referred to as nursing homes).  In fact, at best, Medicare only covers up to 100 days of skilled nursing facility care per … Read more

The Medicare appeals system is not working. The success rate at the first two levels of appeal is staggeringly low for beneficiaries. It can take years to get an ALJ hearing decision – the third level of appeal, and the first real opportunity to get a coverage denial reversed. As we’ve previously reported, the Senate … Read more

By Steve Gleason I was diagnosed with ALS four years ago.  Now I am unable to move my body, except for my eyes.  I communicate through technology called a Speech Generating Device (SGD).  The SGD allows me to maintain contact with the world around me – to express my thoughts, feelings and needs.  It allows … Read more

On April 28, 2015, the Senate Finance Committee held a hearing entitled “Creating a More Efficient and Level Playing Field: Audit and Appeals Issues in Medicare.”[1] As noted by Chairman Hatch in his opening statement, Medicare’s hiring of contractors to conduct audits of claims submitted to Medicare “has led to a seemingly insurmountable increase in appeals, with … Read more

Beneficiaries who seek Medicare coverage for expanded types and features of Speech Generating Devices (SGDs) have reason to be optimistic.  Electronic devices that meet the definition of a Speech Generating Device will be coverable.  This could include a tablet, computer, or smart phone. On April 29, 2015 the Centers for Medicare and Medicaid Services (CMS) … Read more

Thank you again for taking action today to support the rights of Medicare beneficiaries, and for spreading the word!

New York Times, June 1965 By David Lipschutz, Center for Medicare Advocacy Senior Policy Attorney In the run-up to the passage of a major expansion of health insurance coverage, a prominent and rising political figure urged people to oppose such expansion, and contact their members of Congress to express their opposition: "Write those letters now; … Read more

Observation Status – hospital patients’ classification as outpatients, which makes them ineligible for Medicare Part A coverage of their subsequent stay in a skilled nursing facility (SNF) when they do not have “inpatient” status for at least three consecutive midnights – is an ongoing issue that the Center for Medicare Advocacy has discussed many times.[1]  … Read more

By Terry Berthelot, JD, MSW Somewhere in our history, it became unacceptable to die. Elizabeth Kubler-Ross described in her seminal work, On Death and Dying, dying patients forced to endure fruitless procedures and then left in their dark hospital rooms, alone, to face the inevitable.  Each death was treated as a failure. Then in the 1970’s, the … Read more

On April 14, 2015, the Senate overwhelmingly (92 to 8) passed H.R. 2 – the Medicare and CHIP Reauthorization Act (MACRA) – which repeals and replaces the flawed Medicare physician reimbursement system known as the sustainable growth rate or SGR.  The House of Representatives passed its own bill, H.R. 2 (392 to 37), on March … Read more

By Frank Miata, Medicare Beneficiary I wonder if "celebrating" is the appropriate stance to take towards 50 years of avoiding the obvious need for a single payer, national health care system. I am old enough to remember what life was like before Medicare and Medicaid. I remember people dying outside hospitals, denied care because they … Read more

In the spirit of aiding the discussion concerning the budget and the SGR “Doc Fix,” we raise many of the myths surrounding Medicare and answer them with facts. Congress is working to repeal and replace the Sustainable Growth Rate (SGR) — also known as the “Doc Fix.”  The House version of the SGR bill asked too … Read more

Every year, the Centers for Medicare and Medicaid Services (CMS) issues payment, performance and other rules that apply to Medicare Advantage (MA) and Part D plans that choose to participate in the Medicare program in the following calendar year. Commonly referred to as the “Call Letter,” this document is first released in draft form, subject … Read more

At the Center for Medicare Advocacy's National Voices of Medicare Summit (March 20, 2015), three Medicare leaders presented their perspectives on Medicare's promise and challenges. All spoke to the value of Medicare for its intended beneficiaries: older and disabled people. They also noted the resources and funds Medicare spends on providers and private industries.    Current … Read more

Thank you for your interest in the Jimmo Implemenation Council. We look forward to your insight as we move forward with Implementation of the Jimmo v. Sebelius settlement. Stay tuned for updates and further activities. More information on the Improvement Standard and Jimmo v. Sebelius.

LEGISLATIVE/BUDGET UPDATE 1.Medicare Physician Payment (SGR) In an effort to address the perennial issue of payment for Medicare physicians — the fundamentally flawed reimbursement system known as the sustainable growth rate or SGR – the House of Representatives overwhelmingly passed a “doc fix” package on March 26, 2015 that would repeal and replace the SGR.  … Read more

Reflections on the 2nd Annual National Voices of Medicare Summit A Look Back at the Summit from the Attendees' View 2015 Program and Speakers    Register Now for 2016!  Reflections on the 2nd Annual National Voices of Medicare Summit and Senator Jay Rockefeller Lecture On March 20, 2015, the Center for Medicare Advocacy, held its second … Read more

By Harry Ting, PhD, Health Economist Medicare is the major driver of innovation in health insurance reimbursement. Early examples were establishing per case rates for hospitals in the form of DRG payments and requiring three day hospital stays for coverage of skilled nursing home care.  More recently, it adopted payment reductions for hospital acquired conditions and penalties … Read more

The Kaiser Family Foundation (KFF) has published a report entitled “Comparison of Consumer Protections in Three Health Insurance Markets: Medicare Advantage, Qualified Health Plans and Medicaid Managed Care Organizations.” The report is authored by Center Senior Policy Attorney David Lipschutz, former Center Policy Attorney Andrea Callow (now at Families USA) and Karen Pollitz, MaryBeth Musumeci … Read more

For the last several years, the Center has been trying to address the problem of Observation Status in the hospital, which can affect both what Medicare beneficiaries pay for hospital stays, and their coverage of subsequent care in a nursing facility.  For the last several sessions of Congress, bills have been introduced to try to … Read more

Today, March 26, the House of Representatives passed the Medicare Access and CHIP Reauthorization Act of 2015 (H.R. 2).  While the Center for Medicare Advocacy believes it’s in the best interest of Medicare beneficiaries to find a permanent solution to the broken physician payment formula called the “Sustainable Growth Rate” (SGR), this Bill is not … Read more

 “Beneficiaries Would Pay Too Much, With Too Little in Return” March 24, 2015 – The Center for Medicare Advocacy believes it is in the best interest of Medicare beneficiaries and their doctors to find a permanent solution to the broken physician payment formula called the “Sustainable Growth Rate” (SGR). “Unfortunately, the SGR replacement package from … Read more

By Kevin Prindiville, Executive Director, Justice in Aging Of the 54 million people with Medicare, a staggering 25% have annual incomes below $14,400.  For these people living in retirement, or coping with a disability in poverty, Medicare coverage offers a lifeline, a chance to get needed health care. That precious red white and blue Medicare card means … Read more

Today the Senate releases its budget, which like the companion House budget released yesterday, appears to have significant cuts to the Medicare program.  Yet again, yesterday’s House budget includes a proposal to create a “premium support” – or voucher – option for future Medicare beneficiaries, starting in 2024. Medicare vouchers would convert much of Medicare … Read more

Unless Congress takes action by March 31, 2015, doctors who treat Medicare patients will see a 21% payment cut due to the current physician payment formula called the "sustainable growth rate" or "SGR."  Lawmakers have deferred the cuts prescribed by this 1997 reimbursement formula 17 times. These “patches” have been temporary because Congress has not … Read more

On March 11, 2015, the Diane Rehm program on National Public Radio hosted a discussion of the revisions to the Centers for Medicare & Medicaid Services’s (CMS’s) Five Star Quality Rating System for nursing homes.[1] Patrick Conway, CMS Chief Medical Officer and Deputy Administrator for Innovation and Quality began the show by describing the changes.  … Read more

Today, the House Budget Committee released “A Balanced Budget for a Stronger America.” Once again, the budget includes a proposal to create a “premium support” – or voucher – option for future Medicare beneficiaries, starting in 2024. Medicare vouchers would convert much of Medicare from a defined benefit into a defined contribution program. This would … Read more

Medicare home health coverage can mean the difference between an individual staying home or becoming a nursing home resident.  While the Medicare skilled nursing facility benefit is very limited, for beneficiaries who meet the coverage criteria, the home care benefit can be an ongoing Godsend. For people who can’t readily leave home without a major … Read more

We thank you for joining us to celebrate Judith Stein's joining the ranks of the Medicare-eligible, as well as 50 years of Medicare itself. Remember, if you wish to contribute any notes, pictures or thoughts to Judy, to include in her Memory Book of this day, please mail them to: Center for Medicare Advocacy 1025 … Read more

Last week’s Alert discussed the Centers for Medicare & Medicaid Services’ (CMS’s) National Partnership to Improve Dementia Care and the Government Accountability Office’s (GAO) recent report on antipsychotic drugs.[1]  The CMS Partnership and the GAO reported different numbers of nursing home residents receiving antipsychotic drugs.  Some of the differences appear to reflect the different databases … Read more