The Medicare appeals system is not working. The success rate at the first two levels of appeal is staggeringly low for beneficiaries. It can take years to get an ALJ hearing decision – the third level of appeal, and the first real opportunity to get a coverage denial reversed. As we’ve previously reported, the Senate … Read more

On April 28, 2015, the Senate Finance Committee held a hearing entitled “Creating a More Efficient and Level Playing Field: Audit and Appeals Issues in Medicare.”[1] As noted by Chairman Hatch in his opening statement, Medicare’s hiring of contractors to conduct audits of claims submitted to Medicare “has led to a seemingly insurmountable increase in appeals, with … Read more

Beneficiaries who seek Medicare coverage for expanded types and features of Speech Generating Devices (SGDs) have reason to be optimistic.  Electronic devices that meet the definition of a Speech Generating Device will be coverable.  This could include a tablet, computer, or smart phone. On April 29, 2015 the Centers for Medicare and Medicaid Services (CMS) … Read more

Observation Status – hospital patients’ classification as outpatients, which makes them ineligible for Medicare Part A coverage of their subsequent stay in a skilled nursing facility (SNF) when they do not have “inpatient” status for at least three consecutive midnights – is an ongoing issue that the Center for Medicare Advocacy has discussed many times.[1]  … Read more

On April 14, 2015, the Senate overwhelmingly (92 to 8) passed H.R. 2 – the Medicare and CHIP Reauthorization Act (MACRA) – which repeals and replaces the flawed Medicare physician reimbursement system known as the sustainable growth rate or SGR.  The House of Representatives passed its own bill, H.R. 2 (392 to 37), on March … Read more

In the spirit of aiding the discussion concerning the budget and the SGR “Doc Fix,” we raise many of the myths surrounding Medicare and answer them with facts. Congress is working to repeal and replace the Sustainable Growth Rate (SGR) — also known as the “Doc Fix.”  The House version of the SGR bill asked too … Read more

Every year, the Centers for Medicare and Medicaid Services (CMS) issues payment, performance and other rules that apply to Medicare Advantage (MA) and Part D plans that choose to participate in the Medicare program in the following calendar year. Commonly referred to as the “Call Letter,” this document is first released in draft form, subject … Read more

Reflections on the 2nd Annual National Voices of Medicare Summit A Look Back at the Summit from the Attendees' View 2015 Program and Speakers    Register Now for 2016!  Reflections on the 2nd Annual National Voices of Medicare Summit and Senator Jay Rockefeller Lecture On March 20, 2015, the Center for Medicare Advocacy, held its second … Read more

The Kaiser Family Foundation (KFF) has published a report entitled “Comparison of Consumer Protections in Three Health Insurance Markets: Medicare Advantage, Qualified Health Plans and Medicaid Managed Care Organizations.” The report is authored by Center Senior Policy Attorney David Lipschutz, former Center Policy Attorney Andrea Callow (now at Families USA) and Karen Pollitz, MaryBeth Musumeci … Read more

For the last several years, the Center has been trying to address the problem of Observation Status in the hospital, which can affect both what Medicare beneficiaries pay for hospital stays, and their coverage of subsequent care in a nursing facility.  For the last several sessions of Congress, bills have been introduced to try to … Read more

Today, March 26, the House of Representatives passed the Medicare Access and CHIP Reauthorization Act of 2015 (H.R. 2).  While the Center for Medicare Advocacy believes it’s in the best interest of Medicare beneficiaries to find a permanent solution to the broken physician payment formula called the “Sustainable Growth Rate” (SGR), this Bill is not … Read more

Today the Senate releases its budget, which like the companion House budget released yesterday, appears to have significant cuts to the Medicare program.  Yet again, yesterday’s House budget includes a proposal to create a “premium support” – or voucher – option for future Medicare beneficiaries, starting in 2024. Medicare vouchers would convert much of Medicare … Read more

Unless Congress takes action by March 31, 2015, doctors who treat Medicare patients will see a 21% payment cut due to the current physician payment formula called the "sustainable growth rate" or "SGR."  Lawmakers have deferred the cuts prescribed by this 1997 reimbursement formula 17 times. These “patches” have been temporary because Congress has not … Read more

On March 11, 2015, the Diane Rehm program on National Public Radio hosted a discussion of the revisions to the Centers for Medicare & Medicaid Services’s (CMS’s) Five Star Quality Rating System for nursing homes.[1] Patrick Conway, CMS Chief Medical Officer and Deputy Administrator for Innovation and Quality began the show by describing the changes.  … Read more

Last week’s Alert discussed the Centers for Medicare & Medicaid Services’ (CMS’s) National Partnership to Improve Dementia Care and the Government Accountability Office’s (GAO) recent report on antipsychotic drugs.[1]  The CMS Partnership and the GAO reported different numbers of nursing home residents receiving antipsychotic drugs.  Some of the differences appear to reflect the different databases … Read more

Every year, the Centers for Medicare and Medicaid Services (CMS) releases a draft of payment, performance and other rules that apply to Medicare Advantage (MA) and Part D plans that choose to participate in the Medicare program in the following calendar year. Commonly referred to as the “Call Letter,” this document is first released in … Read more

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

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