In September 2014, the Centers for Medicare & Medicaid Services (CMS)[1] reported that the National Partnership to Improve Dementia Care had reduced the use of antipsychotic drugs with nursing home residents by 15.1%, “exceeding” the Partnership’s 15% drug reduction goal for long-stay residents.  That claim of success was overstated.  When CMS originally announced the initial … Read more

Two-Thirds of Nursing Facilities Nationwide Will See Decline In their Quality Measures; One-Third of Facilities Will See Decline in Their Overall Score As promised in October 2014,[1] the Centers for Medicare & Medicaid Services (CMS) has made significant changes to Nursing Home Compare, effective February 20, 2015.  The changes recalibrate the Quality Measures (QMs), add … Read more

On February 12, 2015, the Centers for Medicare and Medicaid Services (CMS) published final rules entitled “Medicare Program; Contract Year 2016 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs” [CMS-4159-F2], otherwise known as the final 2016 rules for Medicare Parts C and D.[1] Applicable to the 2016 plan … Read more

As originally enacted, the Affordable Care Act (ACA) required each state to expand Medicaid eligibility to 138 % of the Federal Poverty Level.  However, the 2012 U.S. Supreme Court’s decision National Federation of Independent Business v. Sebelius, changed that.  The National Federation decision gives states the option to accept federal funds, reject the funds altogether and … Read more

On Monday, February 2nd, President Obama unveiled his Fiscal Year 2016 Budget.[1]  For an overview of the budget’s Medicare-related provisions, including both projected costs and savings to the Medicare program, see the Kaiser Family Foundation’s summary.[2] With respect to Medicare, this year’s proposed budget is very similar to last year’s, both good and bad, with … Read more

(Steve Gleason, on living with ALS and utilizing a speech generating device.) The Steve Gleason Act of 2015, recently introduced in the House and the Senate, is a good first step toward ensuring continuous Medicare coverage for individuals who qualify for Durable Medical Equipment (DME) serving as speech generating devices (SGD) and for accessories that … Read more

Civil Money Penalties for nursing facilities have historically been too low to provide meaningful incentive for most facilities to comply with federal standards of care implemented to ensure patient safety and well-being.  The new Civil Money Penalty Analytic Tool from the Centers for Medicare & Medicaid Services (CMS) does not solve this problem. Background Every … Read more

At its January 16, 2015 public meeting, the Medicare Payment Advisory Commission (MedPAC), the government agency that advises Congress on Medicare payment policy, addressed observation status as part of its discussion of hospital short stay policy issues.[1]  MedPAC Commissioners preliminarily, but unanimously, voted to move forward on a recommendation to count time in observation status … Read more

Medicare patients considered hospital outpatients on Observation Status may be helped by a decision issued on January 22, 2015 by a federal appeals court.  A three-judge panel of the U.S. Court of Appeals for the Second Circuit decided that Medicare patients who are placed on “Observation Status” in hospitals may have an interest, protected by … Read more

By Connie Cherba, Iowa In early 2000, Edward, who was then 60 years old, applied for Social Security Disability.  Despite having suffered from bipolar disorder for nearly 40 years, Edward had earned a PhD, but was not able to hold a job.  While the Social Security Disability was economically important, becoming eligible for Medicare allowed … Read more

Medicare has not only provided access to care for people who could not get private insurance, it has also significantly reduced poverty.  As Nancy-Ann Min DeParle, former administrator of HCFA (Now CMS) stated in the preface to A Profile of Medicare in 1998: Few programs in the history of the United States have brought as … Read more

Inadequate nurse staffing is the most significant predictor of poor care in nursing facilities.  Despite the fact that understaffing is a pervasive and nationwide problem,[1] understaffing is rarely cited by state survey agencies.[2]  One reason for the lack of deficiencies and enforcement actions is that the federal standard for nurse staffing is vague.  Aside from … Read more

Most people know Medicare as one of the most successful social programs in our country’s history for its impact on the health of our older citizens and those with disabilities. But did you know that the Medicare program was key to integrating hospitals? The Civil Rights Act of 1964, stated that “No person in the … Read more

While the Center for MEdicare Advocacy continues to press for systemic improvements to the Medicare program, both big and small, there has been some good news for beneficiaries in the health care arena.  As calendar year 2014 draws to a close, the Center highlights positive changes in Medicare and health care that occurred this year, … Read more

The Medicare Payment Advisory Commission (MedPAC), the nonpartisan government agency that advises Congress on Medicare policy, indicated at its November 7, 2014 public meeting that, at its next public meeting in December, it would recommend (1) phasing-in site-neutral payments for inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) for 17 conditions, which it has … Read more

Over 9.6 million older people and people with significant disabilities are dually eligible for both Medicare and Medicaid. Dual eligible beneficiaries are among the poorest and sickest beneficiaries covered by either program. The dual eligible demonstration projects, developed pursuant to the Affordable Care Act (ACA), aim to improve coordination of services between Medicare and Medicaid, … Read more

The Centers for Medicare & Medicaid Services (CMS) announced plans to expand its focused surveys on resident assessments and nurse staffing for nursing facilities nationwide (but not in all facilities), beginning in early fiscal year 2015.  Expanded surveys should lead to more accurate reporting of quality measures and staffing data on the federal website Nursing … Read more

The open enrollment period for health insurance coverage for 2015 under the Affordable Care Act (ACA) begins November 15, 2014, and ends on February 15, 2015. More information on the ACA health insurance Marketplace is available at: Plans With Automatic Enrollment Some individuals who are currently enrolled in a health plan through the Marketplace … Read more

November 13, 2014 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

Medical Equipment Suppliers' Ongoing Opposition to the Competitive Bidding Program and Consequences for Beneficiaries Report prepared by Mario Ramsey, Center for Medicare Advocacy Summer Health Policy Fellow Summary Under Medicare Part B, Medicare will pay for wheelchairs, hospital beds, some walkers; Certain customized items; prosthetic and orthotic devices; capped rental items; oxygen and oxygen equipment. … Read more

Twenty-one months after winning a national class action lawsuit that sought to overturn Medicare's practice of denying skilled maintenance care to patients who did not meet an "improvement standard," plaintiff Glenda Jimmo is finally receiving Medicare coverage for skilled home health maintenance care benefits she was denied in 2007. A federal court case in Vermont … Read more

A Brief Survey of Recent Reports, and a New Special Enrollment Period for 2015 Medicare's Annual Coordinated Election Period (ACEP) for Medicare Advantage and Part D plans began on October 15th and runs through December 7th.  During the ACEP, often referred to as "open enrollment," Medicare beneficiaries who do not have a Part D plan … Read more

The federal nursing home website, Nursing Home Compare, is about to undergo major changes that should significantly improve the accuracy of information about nursing homes that is provided to the public.  The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act of 2014), signed by President Obama on October 6, 2014, supports one of … Read more

Hospital Deductible: $1,260.00 / Benefit period Hospital Coinsurance: Days 0-60: $0 Days 61-90: $315 / Day Days 91-150: $630/ Day Skilled Nursing Facility Coinsurance: Days 1-20: $0 Days 21-100: $157.50/ Day Part A Premium (For voluntary enrollees only) With 30-39 quarters of Social Security coverage: $224.00 / Month With 29 or fewer quarters of Social … Read more

Hospice care is specialized, compassionate care for those diagnosed with a limited life expectancy.  Good hospice care should enhance quality of life for the patient and should support caregivers.  The Medicare Conditions of Participation afford hospice patients certain enumerated rights including the right to choose one's own attending physician.  A new rule promulgated in the … Read more

Fall is the time for Medicare beneficiaries to explore their options regarding Part D prescription drug plans and Part C Medicare Advantage plans.  The Annual Coordinated Election Period (ACEP) for Medicare Advantage and Medicare Part D prescription drug plans will start on October 15th and end on December 7th. This means that Medicare beneficiaries have to … Read more

The Centers for Medicare & Medicaid Services (CMS) has recently issued a Survey and Certification Tool, with an introduction by Secretary Greenlee of the Administration for Community Living (ACL) within the Department of Health and Human Services.  The focus of the video learning modules is to provide useful information to long-term care facility staff about … Read more

On August 26, 2014, the Center for Medicare Advocacy filed a nationwide class action lawsuit in United States District Court (Lessler et al. v. Burwell, 3:14-CV-1230, D. Conn.). The five named plaintiffs, from Connecticut, New York and Ohio, have all waited longer than the statutory 90-day limit for a decision on their Medicare Administrative Law … Read more

A recent study in the Journal of Health Care Finance finds that Florida nursing facilities owned by private equity firms have fewer registered nurses and more deficiencies than chain-owned for-profit facilities and that the longer the facilities are owned by private equity firms, the fewer registered nurses they employ and the more deficiencies they have.[1]  … Read more

The use of “Observation Status” – treating certain hospitalized Medicare patients as outpatients when their care is indistinguishable from that of formally admitted inpatients – continues to garner considerable public and Congressional attention. It remains an unresolved problem that has serious financial consequences for Medicare patients and their families.[1]   On July 30, 2014, the Senate … Read more

On July 11, 2014, the Centers for Medicare & Medicaid Services (CMS) released its proposed rules for the 2015 calendar year.  Among these proposed rules, CMS adds four additions to covered telehealth services: psychoanalysis and psychotherapy (including family psychotherapy with and without the patient present), prolonged outpatient services such as evaluation and management, and annual … Read more

Medicare Advantage (MA) plans are increasingly dropping doctors and other health care providers from their contracted networks, often in the middle of a plan year, when most plan enrollees are not permitted to change plans.  MA enrollees often get little advance warning, and some lose access to doctors they have seen for a long time, … Read more

A study assessing the outcomes of patients who were treated in inpatient rehabilitation facilities (IRFs) with clinically and demographically similar patients who received their post-acute rehabilitation in skilled nursing facilities (SNFs) finds that IRFs provide better care to their patients over a number of outcome measures – IRF patients live longer, spend more days at … Read more

Quick Summary When Medicare beneficiaries elect the hospice benefit, they waive Medicare coverage for all care and services related to the terminal illness that are not on the hospice plan of care and provided through the hospice provider.  This means that when a terminally ill beneficiary elects hospice, all of the medications needed to control … Read more

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

Separating Beneficiary Complaint Review Functions from Quality Improvement Functions On May 9, 2014, the Centers for Medicare & Medicaid Services (CMS) announced the first phase of its restructuring of the QIO functions.  In the first phase, CMS has contracted with Livanta LLC (for geographic areas 1 and 5), located in Annapolis Junction, Maryland, and KePRO … Read more

The Centers for Medicare & Medicaid Services (CMS) is charged with the implementation and oversight of the DMEPOS program.[1]  Since the rollout of the DMEPOS competitive bidding program (CBP) in July, 2008, there has been confusion over what constitutes delivery and set-up of specific DMEPOS items.[2]  In some instances, beneficiaries have experienced delays in obtaining … Read more

To: Medicare Beneficiary Advocates From: Mario D. Ramsey, CMA Health Policy Fellow Subject: GAO and OIG Reports Note No Problems In Beneficiary Access to DMEPOS.  Beneficiary Advocates Disagree. Date: July 8, 2014 Advocates' Concerns about the DMEPOS Reports Advocates are concerned that some suppliers are not delivering and setting-up necessary items of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).[1] … Read more

The Supreme Court decision in Burwell, Secretary of Health and Human Services, et al. v. Hobby Lobby Stores, Inc., et al. (5-4 decision), 573 U.S. ___ (2014) is ominous. Not only is the decision, and its interpretation of the Religious Freedom Restoration Act (RFFA) a blow to a woman's access to preventive and contraceptive care, its … Read more

June 26, 2014 Medicare's Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program was enacted by Congress as a cost and fraud protection measure.  From its inception, there have been questions about the program's complexity and fairness, and whether it would hinder beneficiary access to necessary DMEPOS items and services.  Background information about … Read more

Connecticut Passes Observation Notice Law On June 12, 2014, Connecticut Governor Dannel P. Malloy signed into law a requirement that, starting October 1, 2014, Connecticut hospitals give oral and written notice to patients placed on observation status for 24 hours or more.  Similar laws already exist in New York and Maryland.  Specifically, Connecticut's law requires: … Read more

Research suggests that medications that should be covered by the Medicare Hospice Benefit are sometimes paid for by Medicare Part D plans. In March, to prevent this from happening, the Centers for Medicare & Medicaid Services (CMS) issued a memorandum to Part D Plan Sponsors and Medicare Hospice Providers entitled, "Part D Payment for Drugs for … Read more

June 12, 2014 Quality Assessment and Performance Improvement (QAPI) In Nursing Homes: Diverting CMS Attention from Enforcement In the past few years, the Centers for Medicare & Medicaid Services (CMS) has focused considerable attention on Quality Assessment and Performance Improvement (QAPI) in nursing homes.  This focus, we fear, is diverting the agency's resources from enforcing … Read more

Technology can help the most vulnerable among us live with more capabilities than we would have considered possible, even a few short years ago.  Rather than encourage technological advances that promote independence and safety, however, the Centers for Medicare & Medicaid Services (CMS) is reducing access to technology in an ill-conceived effort to control short-term … Read more

In May 2014, the Administration for Community Living (ACL), an agency within the Department of Health and Human Services,  issued guidance applicable to all ACL grantees concerning the federal government's policy on same-sex marriages following the Supreme Court Decision in  United States v. Windsor, 133 S. Ct. 2675 (2013).[1] The Court in Windsor found that … Read more

May 21, 2014 The May 20, 2014 hearing on "Current Hospital Issues in the Medicare Program," held by the Health Subcommittee of the House Committee on Ways and Means, was the first Congressional hearing to consider the impact of observation status on hospitalized Medicare patients.[1]  At the hearing, the Center for Medicare Advocacy's Senior Policy … Read more

Center for Medicare Advocacy Senior Policy Attorney Toby S. Edelman will testify before the House Ways and Means Health Subcommittee on Tuesday, May 20, 2014 at 9:30 AM regarding current hospital issues in the Medicare program, specifically the ongoing problem of observation status. The hearing, announced on May 13th, is the first Congressional hearing to … Read more

On May 8, 2014, Sen. Patty Murray (D-WA) and Sen. Mark Udall (D-CO) introduced a bill to amend the Social Security Act so that all legal marriages are appropriately recognized.  See:—one-pager-final.pdf.   The bill, called the SOCIAL SECURITY AND MARRIAGE EQUALITY (SAME) ACT OF 2014, would ensure that all same-sex spouses receive equal treatment under … Read more

The Department of Health and Human Services' Inspector General recently reported that nearly one third-of nursing home residents suffered an adverse event or other harm during a stay in a Medicare-participating nursing home in August 2011, and that most of the adverse events or other harm were preventable and the result of problems in staffing.[1] … Read more

The use of Medicare observation status in hospitals has increased dramatically over the past several years.[1] The most notable adverse consequence of Observation Status on beneficiaries is financial liability for any post-hospitalization care at a Skilled Nursing Facility.[2] However, many of the beneficiaries the Center assists also find themselves facing large hospital bills for drugs … Read more