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Final rules published in August 2013 by the Centers for Medicare & Medicaid Services (CMS) created time-based rules for determining inpatient status in an acute-care hospital.[1]  Under the rules' two-midnight presumption, a physician should order an inpatient admission if the physician expects that the patient's stay in the acute care hospital will be at least … Read more

On February 18, 2014, CMS’s Financial Services Group announced in an Alert an important change in the reporting threshold for certain liability settlements, judgments awards or other payments required by Section 202 of the Strengthening Medicare and Repaying Tax Payers Act of 2012 (SMART Act). CMS is increasing its current reporting threshold from $300 to $1000. … Read more

More than half a million Medicare beneficiaries rely on the Qualified Individual (QI) program to pay their Part B premium – a critical benefit afforded to older adults and people with disabilities with very low incomes and few assets. Reauthorization for the QI program is attached to the Medicare physician payment formula, known as the … Read more

Programs that help low-income people afford their Medicare, including the Medicare Savings Programs and the Part D Low Income Subsidy (also called LIS or Extra Help) have income and resource eligibility guidelines that change yearly. The Federal poverty level (FPL) guidelines for 2014 were published in the Federal Register on January 22, 2014.[1]  These guidelines … Read more

If you are covered by Medicare and you have a long-term or chronic condition, you may be eligible to have Medicare re-review your claims that were denied in prior years.  Please read carefully. In addition to revising Medicare manual provisions to now allow Medicare coverage for skilled maintenance care, the Settlement Agreement in Jimmo v. … Read more

As required by the 1987 federal Nursing Home Reform Law,[1] CMS has developed, tested, and periodically revised a survey protocol that state surveyors, who are generally employed by the state health departments, must use to determine nursing facilities' compliance with federal standards of care.  The survey protocol, which is composed of two Appendices to the … Read more

Medicare-covered outpatient physical, speech and occupational therapy services are subject to an annual dollar-amount payment cap.  As a result, many Medicare beneficiaries have their therapy terminate prematurely when they reach the cap.  While there is an Exceptions process in place that allows beneficiaries to receive therapy in excess of the caps, it is set to … Read more

Hospice is a program of care and support for people who are terminally ill.  To qualify for Medicare hospice coverage, a doctor certifies that a person is terminally ill, with an expectation of six months or less to live.  Once a person enters hospice, all their medical needs related to the terminal illness for pain … Read more

As of December 6, 2013, Centers for Medicare & Medicaid Services (CMS) Policy manuals have been updated to reflect the settlement in Jimmo vs. Sebelius, No.11-cv-17 (D.VT, January 24, 2013).  The manuals now make it clear that improvement is not necessary for coverage of skilled nursing and therapy services. For example, the home health section … Read more

The Center for Medicare Advocacy (the Center) has reported on the misuse of antipsychotic drugs by nursing homes for many years, discussing Congressional hearings and federal reports and the high personal and financial cost of the misuse of the drugs.[1]  In December 2013, we reported on a study that the Center undertook with Dean Lerner … Read more