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On Friday, October 23, 2015, the Centers for Medicare & Medicaid Services (CMS) announced an expansion of the 3-year Medicare Prior Authorization Model for Repetitive Scheduled Non-Emergent Ambulance Transport in accordance with section 515(a) of the Medicare Access and CHIP Reauthorization Act of 2015. The model is being expanded to the states of Maryland, Delaware, … Read more

On November 3, 2015, the Centers for Medicare & Medicaid Services (CMS), published in the Federal Register (80 Fed. Reg. 68126), proposed revisions to requirements for discharge planning for hospitals, CAHs, and HHAs. The proposed rule is also available at http://www.gpo.gov/fdsys/pkg/FR-2015-11-03/pdf/2015-27840.pdf.  Comments on the proposed rule must be submitted to CMS by 5 p.m. on … Read more

This week the Centers for Medicare & Medicaid Services released the Medicare premium, deductible and co-pay amounts for 2016.  As the Center for Medicare Advocacy has extensively reported, the Part B Premium, which was feared to spike outrageously for many beneficiaries, will instead remain the same for most, and increase far less for the rest.  … Read more

On Monday November 2, 2015, President Obama signed into law the Bipartisan Budget Act of 2015. As reported in last week’s CMA Alert, this wide-ranging budget agreement includes provisions that will mitigate, but not eliminate, Part B premium increases for some and Part B deductible increases for all. In short, the Budget Act will keep … Read more

Today, the U.S. House of Representatives passed the Bipartisan Budget Act of 2015.  Broadly speaking, this agreement avoids a pending government default by raising the nation’s debt ceiling, and prevents relief from budgetary “sequester” spending limits that have constrained social service programs.  The bill also provides temporary stability to the Social Security Disability Insurance fund. … Read more

Individuals in traditional Medicare who require intravenous or injectable medications are often stunned to learn they have to leave home to obtain this necessary care. This is true even when they are receiving other Medicare-covered home health services.    Obtaining coverage for both the medication and the professional services necessary for the infusion or injections … Read more

On July 16, 2015, the Centers for Medicare & Medicaid Services (CMS) published proposed rules to revise the Requirements of Participation (RoPs) for nursing facilities that participate in Medicare or Medicaid, or both.[1]  Since most nursing facilities participate in both programs, the federal regulations set the standards of care for facilities.  The current RoPs, which … Read more

The Kaiser Family Foundation recently released an issue brief that describes the income and assets of Medicare beneficiaries in 2014. It is essential to place proposals making changes to the Medicare program within the context of this data in order to understand the impact on beneficiaries. This is particularly true for proposals that shift costs … Read more

If Congress and the Administration truly seek ways to limit Medicare premiums and deductibles, they ought to look at CMS's hospital Observation Status policy. A major cause of the Part B increase is likely the parallel increase in so-called "outpatient" Observation Status, the use of which has more than doubled since 1999. The result of this … Read more

Today the Social Security Administration announced that, based on Bureau of Labor Statistics inflation numbers released today, there will be no Cost of Living Adjustment (COLA) for 2016. The announcement makes official the assumption underlying the 2015 Medicare Trustees Report premium and deductible projections for 2016. According to the 2015 Medicare Trustees Report, Part B … Read more

In a report entitled “Medicare Part D: A First Look at Plan Offerings in 2016” (October 2015), the Kaiser Family Foundation analyzed the Part D market in 2016 and found, among other things, that: In 2016, beneficiaries in each region will have a choice of 26 PDPs, on average, down by 4 from 2015. The … 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

The Chair of the Leadership Council of Aging Organizations (LCAO), Max Richtman, sent a letter to Senators today urging support of the “Protecting Medicare Beneficiaries Act of 2015” S. 2148. This legislation would keep the 2016 premiums and deductible stable for all Medicare beneficiaries, by protecting the premiums of the 30% of beneficiaries who will … Read more

On October 8, 2015 the Center for Medicare Advocacy filed a complaint with the Office of Civil Rights regarding Proposed Local Coverage Determination (LCD) DL 33787.  This proposed LCD would unfairly and illegally restrict Medicare coverage for beneficiaries in need of lower limb prostheses. The complaint was filed on behalf of Dr. Roger Catlin, an … Read more

Based on recent experience, the Center for Medicare Advocacy provides this Practice Tip for providers and advocates for patients who need to change from an improvement mode to maintenance mode for nursing or therapy. The Center is seeing decisions from Medicare Contractors requiring that providers obtain new orders when a patient’s goals change to maintenance … Read more

The Centers for Medicare and Medicaid Services (CMS) recently rolled out a web-based resource for employers to help them assist employees with obtaining information about transitioning to Medicare coverage.  This resource is part of a broader, concerted effort on the part of CMS and the Social Security Administration (SSA) to improve the information available to … Read more

This week, the General Accounting Office (GAO) issued a report entitled “Medicare Advantage: Actions Needed to Enhance CMS Oversight of Provider Network Adequacy” (August 2015, publicly released September 28, 2015).  This report reviews how the Centers for Medicare and Medicaid Services (CMS) ensures adequate access to care for Medicare Advantage (MA) enrollees. The report was … Read more

According to the 2015 Medicare Trustees Report, Part B premiums are expected to increase for 30% of beneficiaries by 52% – from $104.90 to $159.30 per month. The trustees also predict that this increase will be accompanied by an increase in the Part B deductible—up to $223 from $147. These are projections; the final numbers … Read more

On July 16, 2015, the Centers for Medicare & Medicaid Services (CMS) published proposed rules to revise the nursing home Requirements of Participation (RoPs) – the federal rules that govern the standards of care that facilities must meet in order to participate in the Medicare or Medicaid programs, or both.[1]  At the request of many … Read more

On September 1, 2015, the Centers for Medicare and Medicaid Services (CMS) issued an announcement concerning a demonstration called the Medicare Advantage (MA) Value-Based Insurance Design (VBID) model. (See: http://innovation.cms.gov/Files/x/mavbid-announcement.pdf.)  As described by CMS, Value-Based Insurance Design (VBID) “generally refers to health insurers’ efforts to structure enrollee cost-sharing and other health plan design elements to … Read more

Social Security now offers a convenient online service for Medicare beneficiaries who have lost, damaged, or otherwise need to replace their Medicare cards. Through his or her my Social Security account, a beneficiary can now easily order a replacement Medicare card. A my Social Security account only takes a few minutes to set up, and offers several … Read more

In collaboration with a number of other advocacy organizations, this week the Center for Medicare Advocacy submitted comments to CMS about two sets of proposed rules: Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016 (CMS-1631-P) The Center’s comments primarily focus on expressing strong support for … Read more

On September 8, 2015, the Centers for Medicare & Medicaid Services (CMS) Office of Minority Health (CMS OMH) introduced an Equity Plan for Improving Quality in Medicare.  Aimed at eliminating health disparities experienced by underserved populations, the plan focuses on six priority areas and seeks to reduce health disparities in four years. A Press Release … Read more

Harmful Changes to Lower Limb Prostheses Coverage Too Much Reliance on “Improvement” in the Proposed Home Health Value-Based Purchasing (HHVBP) Model Proposed Revisions to the 2-Midnight Rule Won’t Make Any Significant Change 1. Harmful Changes to Lower Limb Prostheses Coverage The Center recently called for the elimination of a proposed local coverage determination (LCD) that … Read more

August 31, 2015 Stacey Brennan, M.D. DME MAC Medical Director National Government Services 8115 Knue Road Indianapolis, Indiana  46250 Submitted Electronically to: DMAC_DRAFT_LCD_Comments@anthem.com Re: Proposed Draft LCD on Lower Limb Prostheses (DL33787) Dear Dr. Brennan: The Center for Medicare Advocacy (Center) appreciates the opportunity to provide the following comments regarding the proposed draft LCD on … Read more

The Center for Medicare Advocacy is concerned that Medicare beneficiaries are being denied Medicare coverage for skilled services that are specifically listed as covered by Medicare in federal regulations. Medicare covers various skilled therapies (physical, speech–language pathology and occupational) and skilled nursing services, including observation and assessment, management and evaluation of a care plan, or … Read more

A recent Centers for Medicare & Medicaid Services (CMS) report, Access to Care Issues Among Qualified Medicare Beneficiaries (QMB), revealed several access to care problems for low-income Medicare beneficiaries enrolled in the QMB program. The report analyzed two studies focused on access to care for low-income beneficiaries. The first study utilized qualitative interviews with beneficiaries … Read more

Hospitals often classify hospitalized Medicare patients as outpatients, even though their hospital care may be indistinguishable from the care they would receive if they were formally admitted as inpatients.  This issue – called Observation Status – has been a serious problem for Medicare beneficiaries for many years,[1] chiefly because patients who do not have at … Read more

9 Facts About Social Security, a recent blog post by Jason Furman, Chairman of the Council of Economic Advisers, and Jeff Zients, Director of the National Economic Council, identifies nine important accomplishments for our aging society and for persons with disabilities. Social Security forms the foundation for retirement security through universal, guaranteed benefits. Social Security … Read more

This photo of the signing of the Social Security Act was sent to us by a friend of the Center whose father received it, signed, from President Roosevelt’s son. When President Franklin Roosevelt signed the Social Security Act into law on August 14, 1935, older people and their families entered a new era of financial … Read more

The Center for Medicare Advocacy received an e-mail inquiry from an individual requesting assistance advocating for her sister, Mrs. B.  Mrs. B is a Medicare beneficiary enrolled in a Medicare Advantage plan and in need of home health services.  The questions raised demonstrate several important issues that often arise with both the home health benefit … Read more

Medicare pays for a limited number of Part B services furnished by a physician or practitioner to an eligible beneficiary via a telecommunications system. For eligible telehealth services, the use of a telecommunications system substitutes for an in-person encounter. Cognitive Behavioral Therapy (CBT) as psychotherapy via telemental health is covered by Medicare for certain eligible … Read more

An increasing number of patients in hospitals are not formally admitted as inpatients, but as “outpatients” on “observation status.”  Although they receive whatever medical and nursing care, diagnostic tests, medications, and food they need, their status as “outpatients” means that they do not satisfy the three-day inpatient hospital prerequisite for Medicare coverage of post-acute care … Read more

Over the past week, problems with Medicare coverage of Speech Generating Devices (SGDs) have been favorably addressed through both final Administrative and Congressional action. Prior to these actions, Medicare only covered SGDs to generate face-to-face speech, excluding other forms of communication such as by email, phone or text.  Medicare had also changed the payment category … Read more

As a retired speech/language pathologist I have intimate knowledge of the benefits and need to increase eligibility for services.In my professional capacity, I would often evaluate a dementia or Alzeheimer patient who was experiencing severe difficulty eating and swallowing, which is common as these diseases progress.Many would cough or choke during a meal, thus their … Read more

The 50th anniversary of Medicare has given us an opportunity to reflect on all it has accomplished to advance the health and well-being of families throughout the country. It also reminds us what could have been better – and what could still be improved. We are thankful for the vision and fortitude of President Johnson … Read more

A.P., Washington State I have a pre-existing condition (Epilepsy) and if it wasn't for Medicare, I don't think I could afford the medications needed to control it. __________ L.F., Colorado Medicare has helped me in so many ways! It helped to pay for my pacemaker, plus doctor visits, medicine etc Us older folks that are on … Read more

While the Medicare Act covers physical, speech, and occupational therapies in various community-based and facility settings, coverage is often denied or inappropriately limited.  Most often, this is because the individual requires therapy to maintain her condition, or slow deterioration. When an individual is not going to improve, providers too often decline to provide therapy or … Read more

By T.P., PhD, a Medicare Beneficiary from Ohio I would like to express my view that it would be cheaper and more efficient for all to have drug coverage as part of Medicare itself and not as a separate plan handled by private insurance companies. In addition, if the government can negotiate drug prices for … Read more

By Max Richtman, President & CEO National Committee to Preserve Social Security and Medicare As we celebrate Medicare’s 50th anniversary, it’s important to remember that one of Medicare’s most important hallmarks is the program’s long and successful history of adapting to the changing demographic and health security needs of America’s seniors.  Ten thousand Americans turn … Read more

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 may be changed in order to assist those in need.  Below you will find specific information, if … Read more

Medicare Trustees Report – Medicare Part A Solvency Remains Stable On July 22, 2015, the Medicare and Social Security Trustees issued the 2015 Annual Report of the Boards of Trustees of the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund. Good News: In short, the projected solvency of the Part … Read more

By D.C., California Last October I awoke early one morning with a severe pain radiating from my abdomen to my back. I had never had a pain quite like this before. I had recently moved, and my new primary care physician was not available. I had had a gastroenterology evaluation for acid reflux (negative) a … Read more

By Lisa Hall, Appeals Administrator, Center for Medicare Advocacy   After beginning to work for Medicare beneficiaries, I was amazed to realize that Medicare, which is a federal health care insurance that we are all entitled to and count on being there for us one day, spends so much time, money and energy trying to … Read more

By L.S., a Medicare Beneficiary from New York Medicare has kept my family from being homeless. My husband had three different kinds of cancer, with surgery and radiation. He had three necessary replacements – hip and both knees and he had to have back surgery. Medicare took care of all the bills. There is absolutely no … Read more

One of the most fundamental rights set out in the Constitution is the right to due process of law when government action harms an individual. “Due process” means both notice and an opportunity to be heard. In other words, individuals are entitled to be informed about a government action, as well as their right to … Read more

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

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