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This week CMS released, for the first time, a public use file for the Medicare Current Beneficiary Survey (MCBS).  The “MCBS 2013 Access to Care Public Use File” (MCBS PUF) provides the first publicly available MCBS file for people interested in the health, health care use, access to, and satisfaction with care for Medicare beneficiaries.  … Read more

By Cynthia Ronzio, Public Health Consultant The British Medical Journal (BMJ) recently published a highly controversial and alarming study that claims that medical errors are the third leading cause of death in the US.[1]  The authors used crude statistics (for example, they do not describe their method of extrapolation nor is there mention of weights, … Read more

Oral Health America recently released a report, A State of Decay, a state-by-state ranking of healthcare delivery and public health factors that affect the oral health of older adults. Some of the Report’s Findings 76% or 38 states earned a Composite Score of Fair (22%) or Poor (54%); Ten states received a Composite Score of … Read more

The controversial issue of Observation Status continues.[1]  The latest news is that the Centers for Medicare & Medicaid Services (CMS) told Quality Improvement Organizations (QIOs) on May 4 that they should temporarily pause their reviews of hospitals’ compliance with the two-midnight rule.  The pause was reported by Livanta, one of the two QIOs nationwide (the … Read more

The Medicare Advocacy Project of Greater Boston Legal Services recently received a favorable decision from the U.S. District Court in Massachusetts for “off-label” coverage of the drug Dronabinol.  This is a welcome development given how difficult it has been to obtain coverage for medications that prescribing doctors agree are necessary, but that are not FDA-approved … Read more

American Heart Association/American Stroke Association Recommends That Patients Who Have Strokes Receive Rehabilitation at Inpatient Rehabilitation Hospitals, not Skilled Nursing Facilities For the first time, the American Heart Association/American Stroke Association has issued a Scientific Statement and guidelines strongly recommending that, “whenever possible,” “stroke patients be treated at an in-patient rehabilitation hospital (now often referred to … Read more

On May 5, 2016 Center for Medicare Advocacy executive director Judith Stein and Senior Attorney Wey-Wey Kwok, the Dental Lifeline Network, the Medicare Rights Center, and former CMS (then HCFA) administrator Bruce Vladeck, met with CMS officials to discuss coverage of medically necessary oral health care. The group’s primary goal was to advance Medicare coverage … Read more

This week the General Accounting Office (GAO) issued a report entitled “Medicare Advantage: Fundamental Improvements Needed in CMS’s Effort to Recover Substantial Amounts of Improper Payments.  The report states that the Centers for Medicare & Medicaid Services (CMS) estimates that about 9.5% of its annual payments to Medicare Advantage (MA) organizations were improper – totaling … Read more

As discussed in previous Alerts, on March 11, 2016 CMS published a proposed rule aimed at reforming how Medicare pays for drugs covered under Part B. CMS states that its main objective is to ensure that physicians are prescribing the most effective prescription drugs in order to improve patient treatment and to rein in drug spending. … Read more

The Centers for Medicare & Medicaid Services (CMS) has recently issued a host of Medicare-related proposed rules that are currently open for comment, including the following: MACRA (Physician Payment) On April 27, 2016, CMS released a proposed rule outlining new physician payment systems created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The … Read more

1. Are you with (Pick one): Created with Highcharts 4.1.1 SHIP: 27.88%SHIP: 27.88%SHIP: 27.88%SMP: 43.27%SMP: 43.27%SMP: 43.27%Both SHIP and SMP: 28.85%Both SHIP and SMP: 28.85%Both SHIP and SMP: 28.85% SHIPPercent: 27.88%Count: 29         SHIP 27.88%   29 SMP 43.27%   45 Both SHIP and SMP 28.85%   30   Total Responses 104 … Read more

In proposed rules updating Medicare reimbursement to acute care hospitals,[1] the Centers for Medicare & Medicaid Services (CMS) announces how it intends to implement the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act).[2]  Effective August 6, 2016, the NOTICE Act requires that hospitals provide written and oral notice, within 36 hours, … Read more

Reports that 20% or more of unplanned hospital readmissions are avoidable has led to considerable interest in policymakers in reducing readmissions.[1]  Actively reducing hospital readmissions is seen as a route to lower Medicare spending and improved patient care. The Affordable Care Act (ACA) established a penalty program for preventable readmissions.  Under the Hospital Readmissions Reduction … Read more

CT Sen. Ted Kennedy, Jr. presents Center for Medicare Advocacy Executive Director Judith Stein with a citation at the Center's 30th anniversary party. On Wednesday, April 13, 2016 the Center for Medicare Advocacy held a reception at the Connecticut State Capitol to celebrate 30 years working for fair access to Medicare and health care.  The … Read more

The single factor most critical to high quality of care and quality of life for nursing home residents is the staff who provide residents with care.  Most direct care in nursing facilities is provided by nurse aides, primarily women of color, who are poorly paid and often poorly treated.  In a sobering new report, Raise … Read more

As part of the Center’s ongoing project on approaches to improve nurse staffing levels in nursing facilities, this week we are posting a paper on “Increasing Reimbursement.”  This approach increases reimbursement to nursing facilities on the assumption and expectation that nursing facilities will use some of the increased reimbursement to increase their staffing levels.  This … Read more

On April 1, 2016, the Center for Medicare Advocacy held its third annual National Voices of Medicare Summit and Senator Jay Rockefeller Lecture. The event brought together leading experts and advocates to discuss best practices, challenges, and successes in efforts to improve and expand fair access to health care for older people and people with … Read more

As discussed in our March 2, 2016 CMA Alert, the Centers for Medicare & Medicaid Services (CMS) published a notice in the Federal Register in February 2016 announcing its effort to seek approval from the Office of Management and Budget (OMB) to “collect information” pursuant to a demonstration project to identify, investigate and prosecute fraud … Read more

The Older Americans Act Reauthorization Act of 2015 is tremendously important for the protection of older people and people living with disabilities.  The Reauthorization Act Bill passed the House with an amendment on March 21, 2016.  The Senate Bill, S. 192, is entitled "An Act to Reauthorize the Older Americans Act of 1965.”  The short … Read more

A comparison of the long-term care industry in California, Ontario (Canada), England, and Norway evaluates the extent to which ownership of nursing facilities has shifted from the public sector to private for-profit and not-for-profit companies, and how this shift affects the transparency of information and accountability for public reimbursement.[1] While privatization has been a recent … Read more

Medicare Part B covers drugs that are usually not self-administered, such as many intravenous medications and chemotherapy drugs. Medicare Part D, on the other hand, generally covers self-administered outpatient prescription drugs.  On March 11, 2016, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule in the Federal Register aimed at reforming how Medicare … Read more

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

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

Fairness Hearing to be Held May 31, 2016 The proposed settlement in the case of Exley v. Burwell, 3:14-cv-1230 (JAM) (D. Conn.), addresses delays that Medicare beneficiaries have been experiencing at the Administrative Law Judge (ALJ) level of review. The class includes any Medicare beneficiary who has requested an ALJ hearing but did not have … Read more

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

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

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

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

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

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

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

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

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