RSS

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

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

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 the first time in 20 years, there will be an increase in the amounts of federal fines that nursing facilities may be required to pay for violating the Nursing Home Reform Law.  A little-noticed provision of the Bipartisan Budget Act of 2015, Pub.L. 114-74 (signed by President Obama on November 2, 2015), amends the … Read more

When Emily Back was dying in early 2008, her treating physician prescribed a medication to help relieve her excruciating pain.  After the hospice provider refused to furnish the medication, her husband, in desperation, purchased it from the pharmacy, spending almost $6,000 of their own funds.  Mr. Back thought there must be some way to appeal … Read more

Hospice Quick Reference Hospice care is compassionate end-of-life care that includes medical and supportive services intended to provide comfort to individuals who are terminally ill. Care is provided by a team. Hospice is often called “palliative care,” because it aims to manage a patient’s illness and pain, but does not treat the underlying terminal illness. Hospice … Read more

Medicare beneficiaries often need care in a Medicare- participating skilled nursing facility (SNF) after an inpatient hospitalization.  For these patients, hospitals are responsible for identifying skilled nursing facilities within the geographic region that can meet the patient’s medical needs.  Until such a placement is found, the beneficiary will not be responsible for her hospital stay.  … Read more

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