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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

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.

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

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

Effective September 6, 2016, and as required by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (§701 of the Bipartisan Budget Act of 2015, Pub. L. 114-74),[1] the Centers for Medicare & Medicaid Services (CMS) published interim final rules updating, to account for inflation, civil money penalties (CMPs) that are imposed for … Read more

Pursuant to the settlement agreement in Exley v. Burwell, a class action brought by the Center to address delays in appeals at the Administrative Law Judge (ALJ ) level, the Office of Medicare Hearings and Appeals (OMHA) has established a new help line to troubleshoot beneficiary appeals.  In a September 1, 2016 announcement, OMHA introduced … Read more

When: Thursday, September 15, 2016 2 – 3 p.m. EST Costly mistakes and service disruptions are common for people under 65 transitioning onto or off of Medicare from Marketplace plans, Medicaid, or other insurance. Join Justice in Aging’s Directing Attorney Georgia Burke and the Center for Medicare Advocacy’s Associate Director Kathleen Holt to explore common … Read more

Prescription Drug Pricing An excellent and well-timed (given #Epi-gate) article appeared in this week’s Journal of the American Medical Association discussing the reason drug costs are so high in the U.S. According to the article, the major cause is the “granting of government-protected monopolies to drug manufacturers, combined with restriction of price negotiation at a … Read more

The Center recently submitted comments to the Centers for Medicare & Medicaid Services (CMS) regarding the following proposed rules. Appeals Since 1986, the Center has represented thousands of Medicare beneficiaries seeking coverage of health care and services through the Medicare administrative appeals process.  As discussed in previous CMA Alerts, the Center has advocated for our … Read more

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The Center for Medicare Advocacy has been hearing about people who clearly meet Medicare criteria but are unable to access home health care ordered by their physicians. In particular, people living with long-term and debilitating conditions find themselves without necessary home care. For example, they have been told Medicare will only cover 1 to 5 … Read more

In an Opinion and Order released on August 18, 2016, Chief Judge Christina Reiss, the judge in Jimmo v. Burwell – the “Improvement Standard case” – ordered the federal government, through its Centers for Medicare & Medicaid Services (CMS), to comply with the Settlement Agreement that she approved in January 2013. The Order requires CMS to remedy … Read more

On Friday August 19, 2016, the Center for Medicare Advocacy submitted comments in response to a June 30 request from the Centers for Medicare & Medicaid Services (CMS) for information regarding Durable Medical Equipment (DME) access issues faced by individuals who are dually eligible for Medicare and Medicaid.[1] The letter, signed by almost 80 organizations, … Read more

Under the federal Nursing Home Reform Law, the Centers for Medicare & Medicaid Services (CMS) has authority and the “responsibility”[1] to impose Civil Money Penalties (CMPs) and other enforcement actions at nursing homes that are found to violate federal standards of care (which are called Requirements of Participation).[2]  For the first time in more than … Read more

On August 8, a federal judge in Connecticut largely denied the government’s motion to dismiss and granted plaintiff’s motion for certification of a nationwide class. Sherman v. Burwell, No. 3:15-cv-1468 (JAM) (D. Conn.). The case challenges the fact that, for the last several years, decisions at the earliest two levels of appeal in the Medicare administrative process … Read more

The Center for Medicare Advocacy was pleased to attend, exhibit and present at this year's national SHIP and SMP conference. Pursuant to a Target Population Grant from the Administration for Community Living (ACL), the Center is working to enhance outreach and education for younger Medicare beneficiaries.  At the conference, we discussed progress and next-steps in … Read more

Justice in Aging, one of the Center's longtime partners, recently released an issue brief, Oral Health in California: What About Older Adults? The Issue Brief includes a summary of the state of oral health for older adults in California. It cites disparities in oral health based on income level, education and race. The Brief also outlines the … Read more

An August 7, 2016 New York Times article once again highlighted the problem of hospital Observation Status, including issues with the NOTICE Act, which is supposed to help Medicare beneficiaries understand their status. The article, New Medicare Law to Notify Patients of Loophole in Nursing Home Coverage, featured a Center For Medicare Advocacy client's story. In the piece, Center Executive Director Judith … Read more

Beginning August 6, 2016, the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act)[1] requires hospitals to provide written and oral notice, within 36 hours, to patients who are in observation or other outpatient status for more than 24 hours.  The notice must explain the reason that the patient is an outpatient … Read more

On August 1, 2016, Judge Jeffrey Meyer of U.S. District Court in Connecticut granted final approval to a settlement agreement that will ensure timely decisions for Medicare beneficiaries who appeal denials of coverage to Administrative Law Judges (ALJs). The nationwide class action, Exley v. Burwell, 3:14-CV-1230, was brought by six individuals who waited longer than … Read more

The Centers for Medicare & Medicaid Services (CMS) recently released research drawn from the 2013-14 National Health Interview Survey highlighting health disparities between LGBT and other older people (age 65 or older). The National Health Interview Survey is a wide-ranging survey conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics … Read more

Jul 19, 2016 by Gretchen Jacobson and Tricia Neuman This Issue Brief, available at http://kff.org/medicare/issue-brief/turning-medicare-into-a-premium-support-system-frequently-asked-questions/, is an excellent breakdown of what a "Premium Support" structure – also referred to as "Defined Contributions" or "Vouchers"  – would mean for Medicare and Medicare beneficiaries. Topics addressed include: What is premium support? How could a premium support system for Medicare affect beneficiaries’ premiums … Read more

In order for Medicare Part A to pay for a patient’s stay in a skilled nursing facility (SNF), the patient must first have spent at least three consecutive days as an inpatient in an acute care hospital.[1]  For many Medicare beneficiaries, Part A SNF coverage is denied because the hospital classifies the stay as Outpatient … Read more

Platform Side-by-Side Suggested Medicare/Healthcare Priorities Language Originally Submitted to Platform Committee The two major American political parties have released their 2016 party platforms in anticipation of their respective party conventions and the upcoming general election. Given the importance of health care in this upcoming election, the Center for Medicare Advocacy has done an initial analysis … Read more

If properly utilized, Electronic Health Records (EHR) could increase the quality of care for Medicare’s beneficiaries and lower program costs. EHRs provide the possibility of easy transfer of information between providers, and better patient access to important information. This can mean that clinicians are apprised of changes in health status, with access to information regarding … Read more

As reported this week in The Hill, President Obama is calling on Congress to add a “public option” to the Affordable Care Act (ACA) to improve his signature health law.  “Public programs like Medicare often deliver care more cost-effectively by curtailing administrative overhead and securing better prices from providers,” Obama writes in the Journal of … Read more

The New York Times reported on July 11, 2016 that a noninvasive alternative to dental fillings that could save money, while preventing future decay, has gained increased traction among dentists. The liquid – Silver Diamine Fluoride, or S.D.F. – can be brushed on certain types of cavities, removing the need for a drill or injection. … Read more

On June 30, 2016 the Centers for Medicare & Medicaid Services (CMS) published a proposed rule about the difficulties of dually eligible people (individuals eligible for both Medicare and Medicaid) to obtain Durable Medical Equipment (DME). The proposed rule seeks information about the problem, as well as potential solutions. The proposed rule is primarily focused … Read more

In 2012, the Centers for Medicare & Medicaid Services (CMS) announced expansion of Medicare’s Value-Based Purchasing (VBP) Program for acute care hospitals.  Beginning in Fiscal Year 2015, and as mandated by Congress in the Affordable Care Act,[1] CMS would incorporate a new measure for “Medicare Spending Per Beneficiary.”  CMS suggested this efficiency measure would reward … Read more

In the last 18 months, the Center for Medicare Advocacy, and other advocates around the country, have received many, many calls from older and disabled beneficiaries who can no longer obtain coverage for the Lidocaine Patch 5% from their Part D plans. Many have been using the Patch for at least a decade and are … Read more

As part of the Center for Medicare Advocacy’s commitment to improving oral health for older people and people with disabilities, Center attorneys recently attended a DentaQuest convening in Cambridge, Massachusetts aimed at unifying partners in this common mission. The convening focused on leadership strategies, shared network goals and collaborative work in social justice.  The Center’s … Read more

The Center for Medicare Advocacy submitted comments this week to the Centers for Medicare & Medicaid Services (CMS) concerning the proposed rule on the Medicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule (CMS–5571–P), two elements proposed in the Medicare Access and CHIP Reauthorization Act of … Read more

Today, June 22, 2016, the Medicare and Social Security Trustees issued the 2016 Annual Report of the Boards of Trustees of the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund. In short, according to the report, the Part A trust fund depletion date is 2028, down 2 years from 2030 as … Read more

On June 9, 2016, the Government Accountability Office (GAO) publicly released a report (dated May 2016) titled “Medicare Fee-For-Service: Opportunities Remain to Improve Appeals Process”.[1]   Among other things, the report analyzes the increased number of appeals in the system and the resulting backlog at the third level (Administrative Law Judge, or ALJ) and fourth level … Read more