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Many Americans are greatly concerned that repeal of the Affordable Care Act (ACA) will once again leave people with pre-existing conditions without health insurance. The ACA replacement proposal released by Speaker Ryan on February 16 would move coverage from the general ACA marketplace to specific High Risk Insurance Pools. These High Risk Pools would separate … Read more

According to a recent report from Vox, Congressional plans to repeal key provisions of the Affordable Care Act (ACA) will have devastating consequences for thousands of Americans each year. Vox’s Julia Belluz cites evidence to estimate that 24,000 Americans would die annually if Congress repeals vital provisions of the ACA without simultaneously enacting an appropriate … Read more

Beginning no later than March 8, 2017, and as required by the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act),[1] hospitals and critical access hospitals (CAHs) are required to give patients both oral and written notice when they are outpatients and not admitted as inpatients.[2]  Hospitals must use the written notice … Read more

The Administration and the Republican Congress threaten to repeal the Affordable Care Act (ACA), and have suggested various ideas about what a replacement to ACA would include. To better understand these proposals we’ve compiled a list of ACA replacement materials available from colleagues and partnering organizations. Though there is no consensus about what an ACA … Read more

CMS recently finalized significant changes affecting Medicare appeals, particularly at the Administrative Law Judge (ALJ) level of review.  These changes apply to appeals of payment and coverage determinations for items and services furnished to Medicare beneficiaries, enrollees in Medicare Advantage (MA) and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as … Read more

On January 24, 2017 the Task Force on America’s Health and Retirement Security, chaired by Marilyn Moon, Ph.D. and led by Principal Investigator Peter Arno, Ph.D., released a new study showing the dramatic negative impact of raising Medicare’s eligibility age to 67 – assessing results on uninsured rates if the ACA stays in place and, what we … Read more

If Medicaid becomes a block grant program, nearly one million nursing home residents who rely on Medicaid could immediately lose coverage for their nursing home care.  In addition, all of the federal standards that govern nursing home care today could be in jeopardy.  The United States does not have a comprehensive program to pay for … Read more

On January 23, 2017, Senators Susan Collins (R- ME) and Bill Cassidy (R- LA) introduced the Patient Freedom Act of 2017 (S. 191) billed as a “comprehensive replacement plan for Obamacare.” [1] According to a summary of the bill outlined on Sen. Collins’ website, it “repeals burdensome federal mandates” but “keeps essential consumer protections.”  The … Read more

“My name is JC and I live [in Speaker Paul Ryan’s Congressional District] in Wisconsin with my husband and two college-aged children.  I would like to tell you why the Affordable Care Act has been key to my husband’s recent success starting up his own business.  My husband had been employed as Vice President of … Read more

Today U.S. Rep. Tom Price (R – Ga.) faced a hearing before the Senate Health, Education, Labor and Pensions (HELP) Committee to determine his qualification to become Secretary of Health and Human Services.  Next week, on January 24th, he will face an additional hearing before the Senate Finance Committee, which will vote on his nomination. … Read more

On January 13, 2017 the Centers for Medicare & Medicaid Services (CMS) posted a State Informational Bulletin encouraging states to adopt strategies to improve dual eligible beneficiaries’ access to Durable Medical Equipment (DME). The Bulletin addresses a serious and persistent obstacle to obtaining DME faced by people dually eligible for Medicare and Medicaid in many states … Read more

“Medicare saved my life. Without this program, I would be dead. I'm not exaggerating; it's no hyperbole when I say Medicare saved my life. I have a life threatening illness and if I had no access to doctors or medicines, I wouldn't be here. A few years ago, I had been prescribed Bactrim, which caused … Read more

Protect our Health Care – Join National Call-In Day Today to #ProtectOurCare! Congress will soon vote on measures that will significantly affect access to health care for tens of millions of people insured through the Affordable Care Act (ACA), Medicare, and Medicaid. A vote that affects one of these programs will affect access to care … Read more

HHS Inspector General: Observation Status is a Growing Problem for Patients In a new report, Vulnerabilities Remain Under Medicare’s 2-Midnight Hospital Policy,[1] the HHS Inspector General documents and confirms what Medicare beneficiaries and their advocates have seen: long outpatient stays in hospitals are increasing. How hospitals bill the Medicare program – Part A for inpatient … Read more

On December 13, 2016, President Obama signed into law the 21st Century Cures Act (Public Law No: 114-255, also known as “Cures”, H.R. 34[1]).  The bill, which passed with overwhelming bipartisan support, addresses a wide range of issues, including medical research, the drug approval process, and, added in the final days leading up to passage, … Read more

1.The Problem The Center for Medicare Advocacy has been hearing from people who meet Medicare coverage criteria but are unable to access Medicare-covered home health care, or the appropriate amount of care. These problems have been escalating in 2016. Care provided often falls short of care that is covered under the law and ordered by … Read more

As we approach a new year, a new Administration and a new session of Congress, the catastrophic risks to health care coverage include threats to repeal the Affordable Care Act – without an agreed-upon replacement, turning Medicaid into a block grant or per capita cap program, and further privatizing Medicare. Several recently-issued/updated reports underscore some … Read more

Effective August 6, 2016, the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act)[1] requires acute care hospitals to provide oral and written notification to patients who are classified as outpatients or observation status patients for more than 24 hours.  Notice of non-inpatient status must be provided within 36 hours.  On August … Read more

The President-Elect and Republican leaders in Congress have promised to repeal, and at some point, “replace” the Affordable Care Act.  They also plan to gut the Medicaid program by imposing block granting or per-capita caps.  Speaker Ryan, Trump’s nominee for HHS Secretary Rep. Price, and many others in Congress also want to further privatize Medicare … Read more

Center for Medicare Advocacy Executive Director Judith Stein was featured in the New York Times "Room for Debate" this week defending the traditional Medicare program against efforts to privatize and weaken it. Under Speaker Paul Ryan’s plan, individuals would be given a set amount to help pay premiums for insurance on the open market. This … Read more

Medicare is not in crisis. It is on solid financial footing, and, in fact, is stronger than was predicted before the enactment of the Affordable Care Act. Medicare Part A is mostly paid for with payroll taxes which go into a trust fund. Prior to the enactment of the ACA, the Part A trust fund … Read more

The visionaries who designed, launched and supported Medicare to help all American families. The Medicare program for its invaluable contribution to desegregating American hospitals. The Medicare program for helping to keep older Americans out of poverty. The Medicare program, for insuring people with disabilities, who, like older Americans, were left behind by private insurance. The … Read more

November 23, 2016 Late November begins a time for gatherings with family and friends – Thanksgiving, soon followed by Chanukah, 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 and … Read more

Speaker Paul Ryan is already in the news saying that because of “Obamacare” Medicare is “going broke” (Fox News, 11/13/2016). As a consequence, he says, he intends to bring back his plan to privatize Medicare and change it into a voucher system. Under his plan, individuals would be given a set amount to help pay premiums … Read more

Advancing Excellence in America’s Nursing Homes, a voluntary program promoted as an effort to improve quality of care in nursing homes, has ended after a decade.  Unfortunately, the Centers for Medicare & Medicaid Services (CMS) will continue the website (“New name, new logo, same GREAT website!”[1]), which it has funded since 2006, in a new … Read more

Part A Monthly Premium (For those not automatically enrolled) 0-29 qualifying quarters of employment: $413.00 30-39 quarters: $227.00 Inpatient Hospital Deductible, Per Spell of Illness: $1316.00 Co-pay, Days 1 – 60: $0 Co-pay, Days 61 – 90: $329.00/day Co-pay, Lifetime Reserve Days: $658.00/day Skilled Nursing Facility Co-pay, Days 1 – 20: $0 Co-pay, Days 21 – 100: … Read more

It’s no surprise that the election has left many of us worried and disoriented.  But we’ll regroup. We may not understand where we’ve landed, but we’ll acclimate and march forward – with hope. We hope the new administration will realize how today’s families are balancing – often barely – all the responsibilities they face at … Read more

In last week’s Alert, we posed 10 questions to ask before deciding between traditional Medicare and a Medicare Advantage Plan. This week we discuss what your answers may mean. Do you qualify for payment assistance or have access to other coverage through any of the following… Medicare Savings Program? Part D Low Income Subsidy? Employer/Military/Other … Read more

As a condition of payment for Medicare home health benefits, a physician must certify that a patient is confined to the home, needs skilled services, receiving the services under a plan of care established and periodically reviewed by a physician, and under the care of the physician.[1]  The Affordable Care Act (ACA) added a requirement … Read more

Mr. P. has been hospitalized after having a heart attack. He also has terminal cancer for which he wants to continue treatment. If Mr. P. is admitted as an inpatient for a total of three days while in the hospital, he can qualify for Medicare Part A coverage of subsequent Skilled Nursing Facility (SNF) stay … Read more

Do you qualify for payment assistance or have access to other coverage through any of the following… : Medicare Savings Program? Part D Low Income Subsidy? Employer/Military/Other Insurance? Medigap Plan? Which providers/facilities will you want to use? How important is it to you to continue seeing them? Do they accept Medicare? What Medicare Advantage Plan … Read more

The Center for Medicare Advocacy is grateful to CMS for responding to concerns we and others raised regarding changes to the skilled nursing facility (SNF) coverage standards in the Medicare Benefit Policy Manual. The policy changes, issued this September, misstated and limited nursing home (SNF) coverage and care available under Medicare. For example, the revisions … Read more

In a June 2016 Weekly Alert the Center wrote about a process called “seamless conversion enrollment” used by some insurance companies that offer Medicare Advantage (MA) plans to capture enrollment among their pre-Medicare plan enrollees.  As we noted, “Medicare rules allow MA plan sponsors to ‘develop processes to provide seamless enrollment in an MA plan … Read more

Medicare is commonly known for providing health insurance for older people; however, a significant portion of the program’s beneficiaries are under age 65.[1] Individuals with permanent disabilities and End Stage Renal Disease (ESRD) qualify for Medicare before turning 65. This subset of Medicare beneficiaries, who often deal with multiple chronic conditions and serious health complications, … Read more

Election Season continues apace, so it is no surprise that we are hearing all the usual scare-tactics about Medicare – but before you take them at face value, please read this piece from Modern Healthcare: "Predicting Medicare Spending is Hard, Especially If It's In the Future." Modern Healthcare editor Merril Goozner debunks 2016 presidential debate-host Chris … Read more

Fall is the time for Medicare beneficiaries to explore their options regarding traditional Medicare, Part D prescription drug plans and Part C Medicare Advantage plans.  The Annual Coordinated Election Period (ACEP) starts on October 15th and ends on December 7th. This means that Medicare beneficiaries have to analyze their options and make choices by December … Read more

On October 18, 2016, the Social Security Administration announced that the annual cost-of-living adjustment (COLA) will increase by only 0.3% in 2017.  Although Medicare premiums won’t be announced until later this Fall, as a result of this small increase to COLA, Part B premiums are projected to increase significantly. A “hold-harmless” provision in the Medicare … Read more

Each year the Centers for Medicare & Medicaid Services publishes Medicare & You a handbook for those with Medicare and those who will become Medicare beneficiaries.  The handbook offers information on what is important in 2017, as well as a guide to Medicare coverage. A .pdf of Medicare & you is available online at https://www.medicare.gov/pubs/pdf/10050-Medicare-and-You.pdf.

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

In light of Hurricane Matthew’s disruptions to beneficiary services, equipment and supplies, we are reissuing these reminders. When a Medicare beneficiary lives in an area that has been declared an emergency or disaster by the President, a Governor, or the Secretary of Health and Human Services, the usual Medicare rules for coverage and related concerns … Read more

Abbey, Duane. “Inpatient Versus Outpatient: The Real Issue.” RAC Monitor. 06 March 2014. http://www.racmonitor.com/rac-enews/1618-inpatient-versus-outpatient-the-real-issue.html (site visited September 21, 2016). The author writes that there aren’t any well-established guidelines for Recovery Audit Contractors (RACs) when they review observation-related Medicare appeals. When there are disagreements, RACs can be directed to specific criteria. Unfortunately, Medicare RACs lack such … Read more

In 2014, The New York Times reported that nursing facilities were gaming the Five-Star Quality Rating System on Nursing Home Compare and that “even nursing homes with a history of poor care rate highly in the areas that rely on self-reported data."[1]  The Times reported that nearly two-thirds of 50 facilities on CMS's watch list … Read more

Public coverage of the new nursing home Requirements of Participation (RoPs)[1] – the standards of care that nursing facilities must meet in order to be eligible for reimbursement by the Medicare and Medicaid programs – has focused primarily on their prohibition against facilities’ use of mandatory pre-dispute arbitration agreements.[2]  While advocates for residents applaud this … Read more

Can we talk about fraud? It exists. It’s not good for Medicare. Efforts to eliminate its damage to the program are necessary.  But CMS’ war on fraud seems to be indiscriminate, full of tactical errors and collateral damage. Rather than carefully targeting the perpetrators of fraud, a wide net is cast, resulting in legitimate claims … Read more

This summer, the New York Times article “New Medicare Law to Notify Patients of Loophole in Nursing Home Coverage”* told the story of one of many people who contact the Center for Medicare Advocacy for help with hospital “outpatient” Observation Status. These patients stayed in the hospital for multiple days receiving skilled care, but were coded … Read more

Senate Finance Committee Ranking Member Ron Wyden, D-Ore, introduced the Medicare Affordability and Enrollment Act on Wednesday, September 21, 2016. The Bill would improve low-income protections for beneficiaries, eliminate the two-year waiting period for people with disabilities to enroll in Medicare, and reduce late enrollment penalties. The Center for Medicare Advocacy strongly endorses the Bill. … Read more

The Affordable Care Act (ACA), signed into law in 2010, was enacted to increase the quality and affordability of health care and lower the rate of uninsured by expanding private and public health insurance.  One mechanism the ACA established to achieve this goal was the creation of health insurance “Exchanges” – regulated online marketplaces where … Read more

Note:  The amounts in this table do not apply to beneficiaries who have the Part D Low Income Subsidy (“Extra Help”) Annual Deductible Maximum $400 Initial Coverage Period Cost sharing during this period may be a flat 25% co-insurance OR the plan may have a tiered system of co-pays and co-insurance that is actuarially equivalent … Read more

As we have reported, the Center has been hearing more and more about people who meet Medicare criteria but cannot obtain, or retain, necessary home health care ordered by their physicians. In particular, people living with long-term and debilitating conditions such as ALS, MS, paralysis and Parkinson’s disease find themselves without necessary home care. For … Read more

The Center for Medicare Advocacy has been hearing from people who meet Medicare coverage criteria but are unable to access Medicare-covered home health care, or the appropriate amount of care.   In particular, people living with long-term and debilitating conditions find themselves facing significant access problems. For example, patients have been told Medicare will only … Read more