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Author Archives: mshepard

On March 8, 2016, the Centers for Medicare and Medicaid Services (CMS) released a memorandum entitled “Suspension of Policy Providing for Automatic Reduction of Star Ratings for Contracts Operating Under Intermediate Sanction.” Through this memo, CMS has suspended its policy of lowering the star ratings of Medicare Advantage plans that are under sanction for violations … Read more

Since its implementation in 1965, Medicare has excluded coverage for hearing aids and related audiology services despite the large numbers of older Americans that have hearing loss. It is increasingly well-documented, however, that untreated hearing loss often leads to a variety of serious health problems and injuries. This means the cost of not treating audiology … Read more

Welcome and Housekeeping  (David Lipschutz, Moderator)  Litigation Update   (Ali Bers) Jimmo (Improvement standard) CMA and Vermont Legal Aid have filed a Motion for Resolution of Non-Compliance with the Settlement Agreement Exley (formerly Lessler) (ALJ Delay Case) Settlement preliminarily approved Barrows (formerly Bagnall) (Observation) Discovery on protected property interest issue; summary judgment briefing Other cases Hull … Read more

Sign our petition to remind CMS that Medicare should cover medically necessary oral health care. Medicare was created to help older people and people with disabilities.  It should not deny clinically essential or life-saving treatments simply because those treatments occur within the mouth. The Medicare statute does not prohibit coverage for non-routine dental or oral procedures … Read more

1. Comments to CMS re: 2017 Draft Call Letter for Medicare Parts C and D Every year, the Centers for Medicare and Medicaid Services (CMS) releases a draft of payment, performance and other rules that will apply to Medicare Advantage (MA) and Part D plans that choose to participate in the Medicare program in the … Read more

LITIGATION UPDATE Barrows v. Burwell (formerly Bagnall v. Sebelius) (Observation Status) No. 3:11-cv-01703 (D. Conn., filed 11/3/2011). In November 2011, the Center for Medicare Advocacy and Justice in Aging filed a class action lawsuit on behalf of individuals who have been denied Medicare Part A coverage of hospital and nursing home stays because their care … Read more

The Center for Medicare Advocacy has an immediate opening for a paralegal in its Connecticut office. The paralegal will be a member of a team that leads the organization’s advocacy for low-income Medicare beneficiaries. The paralegal will assess Medicare denials and determine the likelihood of success on appeal in a high volume practice; provide extensive … Read more

March 4, 2016 The Honorable Ron Wyden Ranking Member, Committee on Finance United States Senate Washington, D.C. 20510 The Honorable Charles Grassley Senior Member, Committee on Finance United States Senate Washington, D.C. 20510 Submitted electronically to: Report_Feedback@finance.senate.gov Re: Comments on Prescription Drug Pricing Reform Dear Ranking Member Wyden and Senior Member Grassley: The Center for Medicare … Read more

March 4, 2016 VIA ELECTRONIC SUBMISSION AdvanceNotice2017@cms.hhs.gov Andrew Slavitt, Acting Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services P.O. Box 8016 Baltimore, MD 21244-8016 Re: Advance Notice of Methodological Changes for Calendar Year 2017 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2017 Call … Read more

1. CMS Proposes Medicare Home Health Prior Authorization Demonstration On February 5, 2016, the Centers for Medicare & Medicaid Services (CMS) published a two-page Paperwork Reduction Act notice in the Federal Register announcing their effort to seek approval from the Office of Management and Budget (OMB) to “collect information” relating to a demonstration project.  Pursuant … Read more

Beneficiaries Across the Country Still Denied Needed Coverage Due to Illegal Use of Improvement Standard March 1, 2016 – Today, Plaintiffs’ counsel, the Center for Medicare Advocacy and Vermont Legal Aid, filed a Motion for Resolution of Non-Compliance with the Settlement Agreement in the landmark case, Jimmo v. Sebelius. The filing comes after three years … Read more

March 2016 Update: CMS is now delaying enforcement of the Part D Prescriber Enrollment Requirements until February 1, 2017. Nevertheless, prescribers of Part D drugs should submit their Medicare enrollment applications or opt-out affidavits to their Part B Medicare Administrative Contractors (MACs) by January 1, 2016, or earlier, to ensure that MACs have sufficient time … Read more

On October 5, 2015, the Centers for Medicare and Medicaid Services (CMS) announced final rules concerning its requirements for Meaningful Use Stage 3 of its health records initiative. These measures have the potential to reduce health disparities among elder lesbian, gay, bisexual, and transgender (transgendered) (LGBT) patients.  The final rules require providers to have the … Read more

Thank you very much for taking the time to reply to our invitation.  If you included a donation, we thank you for that as well, and your receipt should arrive by email shortly. Detailed directions and parking information will be sent to all attendees by email prior to the Celebration. And please do share your memories, … Read more

The 2016 Medicare Part A and B General Enrollment Period runs from January 1 through March 31, 2016. As detailed below, this enrollment period is especially important for many individuals who are not eligible for premium-free Medicare Part A. Most people do not pay a premium for Medicare Part A because they have sufficient work history. … Read more

On February 9, 2016, President Obama unveiled his Fiscal Year 2017 Budget.[1]  With respect to Medicare, this year’s proposed budget is very similar to last year’s, both good and bad, with some notable exceptions.  While not a comprehensive analysis of all of the Medicare-related provisions, the Center for Medicare Advocacy provides these comments about the … Read more

On January 4, 2016, The Centers for Medicare and Medicaid Services (CMS) awarded the administration of the Jurisdiction B Durable Medicare Equipment Administrative Contractor (DME MAC) serving Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin to CGS Administrators, LLC (CGS)—an organization that is headquartered in Nashville, Tennessee. This jurisdiction was previously contracted to National Government … Read more

The Centers for Medicare & Medicaid Services (CMS) has posted new materials for unions and employers to help employees with decisions about Medicare.  The materials are available at https://www.cms.gov/Outreach-and-Education/Find-Your-Provider-Type/Employers-and-Unions/Publications-to-share-with-employees.html.  Topics include: Medicare decisions for someone nearing age 65 Deciding whether to enroll in Medicare Part A or Part B when you turn 65 Deciding whether to enroll … Read more

In December 2015, the Senate Finance Committee’s Bipartisan Chronic Care Working Group released a Policy Options Document.  The Policy Options Document was issued as part of a process begun in May 2015 to develop legislation to address challenges facing Medicare beneficiaries with chronic conditions.   According to a press release issued by the Committee, the Options … Read more

January 29, 2016 The Honorable Orrin Hatch                                       The Honorable Ron Wyden Chair, Committee on Finance                                    Ranking Member, Committee on Finance United States Senate                                               United States Senate Washington, D.C. 20510                                           Washington, D.C. 20510 The Honorable Johnny Isakson                                 The Honorable Mark Warner United States Senate                                               United States Senate Washington, D.C. 20510                                           Washington, DC 20510 Submitted electronically to: chronic_care@finance.senate.gov Re: Comments … Read more

A December 2015 Health Affairs study of freestanding Skilled Nursing Facilities (SNFs) from 2001 thru 2011 found that registered nurses (RNs) were less likely to work at nursing homes with high concentrations of racial and ethnic minorities.[1] This study reports on significant health disparities for racial and ethnic minority SNF residents. In the Health Affairs … Read more

Welcome and Housekeeping  (David Lipschutz, Moderator)  Legislative Update (David Lipschutz) Senate Finance Committee Releases Document for Comment Bipartisan Chronic Care Working Group Policy Options Document (December 2015) Overview Comments due January 26, 2016 Medicare Appeals Bill Introduced in Senate Audit & Appeal Fairness, Integrity, and Reforms in Medicare (AFIRM) Act of 2015 (S.2368) Overview Administrative … Read more

Low income racial and ethnic minority beneficiaries are adversely affected by prescription drug pricing, a problem that has a negative impact on overall Medicare program costs.  A 2011 International Journal of Health Services study estimates that the economic costs of health disparities due to race for African Americans, Asian Americans, and Latinos from 2003 thru … Read more

Be a Resource for National Healthcare Decisions Day on April 16. There are numerous ways to participate at no cost, and the goal is simple: "To inspire, educate & empower the public & providers about the importance of advance care planning."  The easiset thing you can do is draw attention to your existing resources about advance care planning … Read more

Skilled nursing facilities (SNFs) often tell Medicare beneficiaries and their families that they intend to “discharge” a Medicare beneficiary because Medicare will not pay for the beneficiary’s stay under either Part A (traditional Medicare) or Part C (Medicare Advantage).  Such a statement unfortunately misleads many beneficiaries into incorrectly believing, not only that Medicare has decided … Read more

LEGISLATIVE UPDATE Senate Finance Committee Releases Document for Comment   In December 2015, the Senate Finance Committee’s Bipartisan Chronic Care Working Group released a Policy Options Document.  The following is an excerpt from a 12/18/15 Press Release by Senate Finance Committee announcing the document’s release: (available at: http://www.finance.senate.gov/release/hatch-wyden-isakson-warner-release-chronic-care-options-paper): The “Finance Committee Chronic Care Working Group, … Read more

Effective February 20, 2016, CMS has created a prior authorization process for certain identified DMEPOS before they can be approved for Medicare payment. Items subject to prior authorization will be identified on a Master List. According to CMS, there will be no new documentation requirements, but prior authorization will help ensure that applicable coverage, payment, … Read more

January 4, 2016 Centers for Medicare & Medicaid Services Comments on NOTICE Act Submitted electronically: NOTICE_Act@cms.hhs.gov The Center for Medicare Advocacy (Center) is a national, private, non-profit law organization, founded in 1986, that provides education, analysis, advocacy, and legal assistance to help people nationwide, primarily older people and people with disabilities, to obtain necessary health … Read more

(New York Times) To the Editor: Today’s story, The Hidden Financial Incentives Behind Your Shorter Hospital Stay, describes how hospital stays classified under “Observation Status” are skewing admission and readmission data. As Dr. Jha states in the article, Observation Status is driven by incentives for the hospital.  This is an ever-increasing phenomena in which Medicare … Read more

Together with other beneficiary advocacy groups, the Center for Medicare Advocacy responded to several requests for comment from the Centers for Medicare & Medicaid Services (CMS) in December.  Below, we include summaries of these comments on: Integrated Denial Notice Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017 [CMS–9937–P] … Read more

December 23, 2015 Filing code for submitting comments: CMS-3317-P.  Dear Sir or Madam: Comments on the Proposed Discharge Planning Rule as put forth by the Centers for Medicare & Medicaid Services (CMS) The Center for Medicare Advocacy (the Center) is pleased to comment on the November 3, 2015, proposed revisions to the discharge planning regulations … Read more

December 21, 2015 Acting Administrator Andy Slavitt Centers for Medicare & Medicaid Services Department of Health and Human Services 7500 Security Boulevard Baltimore, MD 21244-8016 RE: Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017 [CMS–9937–P] Submitted electronically via www.regulations.gov Dear Acting Administrator Slavitt: The Center for Medicare Advocacy … Read more

Submitted electronically via MMCOcapsmodel@cms.hhs.gov December 21, 2015 Tim Engelhardt, Director Medicare-Medicaid Coordination Office Centers for Medicare and Medicaid Services 7500 Security Boulevard Baltimore, MD 21244 Re: Medicare-Medicaid Plan Quality Ratings Strategy Dear Director Engelhardt, The Center for Medicare Advocacy (Center) greatly appreciates the opportunity to provide comments on the Medicare-Medicaid Plan Quality Ratings Strategy. The … Read more

Submitted electronically at http://www.regulations.gov December 15, 2015 CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention: CMS-10003/0938-0829, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850 Re:      Comments on CMS-10003 Notice of Denial of Medical Coverage (or Payment) To Whom It May Concern: The Center for Medicare Advocacy (the Center) greatly appreciates … Read more

The Centers for Medicare & Medicaid Services (CMS) hosted a Tele Town Hall on December 21, 2015 to solicit comments on the Notice of Observation Treatment and Implications for Care Eligibility (NOTICE) Act, Public Law 114-42.  Beginning in August 2016, the NOTICE Act requires hospitals to inform patients who are hospitalized for more than 24 … Read more

On December 18, 2015, Congress overwhelmingly passed a combined budget and tax package, which President Obama signed into law the same day.  Among other things, this $1.8 trillion agreement prevents a government shutdown and funds the government through September 2016.  While Medicare beneficiary advocates had feared the Bill would include a number of provisions that … Read more

Medicare and Medicaid payments to nursing facilities, amounting to more than $80 billion in calendar year 2013,[1] are the most visible way that government financially compensates the nursing home industry.  In addition, but generally unacknowledged, federal and state governments heavily subsidize the industry through needs-based public benefits that many of the industry’s low-paid workers receive.  … Read more

Now is the time to support the Center's activities to preserve a full and fair Medicare program for today – and tomorrow. Gifts to the Medicare Advocacy Fund support the broad range of programming that has been the Center for Medicare Advocacy's hallmark: from keeping people informed about Medicare laws and regulations, to advocating for equitable … Read more

The federal government’s funding of a value-based purchasing (VBP) demonstration project in the Medicare Advantage (MA) program did not improve quality of care, as measured by the plans’ five-star quality ratings. The findings from this demonstration are the most recent evidence that paying health care providers more to provide better care, or to improve their … Read more

The Senate Finance Committee recently passed the Audit & Appeal Fairness, Integrity, and Reforms in Medicare (AFIRM) Act of 2015 (S. 2368).  The Act, intended to improve the Medicare audit and appeals process, would not, in fact, improve the appeals process for beneficiaries and leaves key beneficiary concerns unaddressed. The Bill does not address the … Read more

The Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS) released a statement on October 30, 2015 that advises hospitals that it will not administratively sanction them if they discount or waive charges for an outpatient’s self-administered drugs. Thus, hospitals now have the option, and a greater incentive, not … Read more

In 2013, the Centers for Medicare & Medicaid Services (CMS) promulgated the Two-Midnight Rule, which, for the first time in the Medicare program’s 50-year history, determined patient status in a hospital by reference to time.[1]  Specifically, CMS’s new rule provided that a patient would be considered an inpatient, and the hospital stay would be covered … Read more

The Center for Medicare Advocacy has been hearing more often from persons nearing retirement who work in small businesses, many of which have fewer than 20 employees.  Questions include whether COBRA benefits[1] will be available to them after they close their businesses and whether they have to keep some form of health care coverage to … Read more

This page focuses on programs that help Medicare beneficiaries acquire necessary medications, although many of the programs discussed are not limited to that population.  Many Americans who are still feeling the effects of the recession are struggling to find ways to save money and pay for their medications. Unfortunately, some have been forced to make … Read more

Continued health care coverage authorized by the Consolidated Omnibus Budget Reconciliation Act of 1985, commonly referred to as COBRA, provides a great step forwarded in reducing gaps in insurance for people between jobs or losing coverage due to the death of the covered worker in a family.  The rules for COBRA coverage are, nonetheless, complicated.  … Read more

Welcome and Housekeeping  (David Lipschutz, Moderator)  Legislative Update: Congress Mitigates Increases in 2016 Part B Premium and Deductible (David Lipschutz) Bipartisan Budget Act of 2015 – Overview 2016 Part B premiums increases for some, and deductible increases for all, mitigated “Loan” is to be repaid by Medicare beneficiaries over time Underlying cause(s) of increase in … Read more

Caution Advocates have seen an increase in the number of Medicare beneficiaries who have delayed enrolling in Medicare Part B, thinking, erroneously, that because they are paying for and receiving continued health coverage under COBRA, they do not have to enroll in Medicare Part B.[1]  COBRA-qualified beneficiaries who have delayed enrollment in Medicare Part B … Read more

On November 20, 2015, Center staff attended a one day symposium hosted by the federal Department of Health and Human Services (HHS) entitled “HHS Pharmaceutical Forum: Innovation, Access, Affordability & Better Health.”  The forum featured HHS Secretary Burwell, Acting Administrator for the Centers for Medicare and Medicaid Services (CMS), Andy Slavitt, consumer advocates, pharmaceutical company … Read more

November 24, 2015 Late November begins a time for gatherings with family and friends – Thanksgiving and Chanukah, soon followed by Christmas and New Years. Nursing home residents often want to participate in these gatherings but may worry they will lose Medicare coverage if they leave the facility to do so. Residents and their families … Read more

For Immediate Release November 18, 2015 Contact: Maria Myotte, mmyotte@douglasgould.com, 720 352 6153 Find the Department of Health and Human Services Departmental Appeal Board Decision of Medicare Appeals Council here: http://www.medicareadvocacy.org/wp-content/uploads/2015/11/Back-MAC-decision.pdf   In October, the Medicare Appeals Council (MAC), Medicare’s top appeal unit, reversed years of earlier decisions that thwarted an appeal of a hospice … Read more