RSS

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

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

On September 1, 2015, the Centers for Medicare and Medicaid Services (CMS) issued an announcement concerning a demonstration called the Medicare Advantage (MA) Value-Based Insurance Design (VBID) model. (See: http://innovation.cms.gov/Files/x/mavbid-announcement.pdf.)  As described by CMS, Value-Based Insurance Design (VBID) “generally refers to health insurers’ efforts to structure enrollee cost-sharing and other health plan design elements to … Read more

Social Security now offers a convenient online service for Medicare beneficiaries who have lost, damaged, or otherwise need to replace their Medicare cards. Through his or her my Social Security account, a beneficiary can now easily order a replacement Medicare card. A my Social Security account only takes a few minutes to set up, and offers several … Read more

In collaboration with a number of other advocacy organizations, this week the Center for Medicare Advocacy submitted comments to CMS about two sets of proposed rules: Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016 (CMS-1631-P) The Center’s comments primarily focus on expressing strong support for … Read more

On September 8, 2015, the Centers for Medicare & Medicaid Services (CMS) Office of Minority Health (CMS OMH) introduced an Equity Plan for Improving Quality in Medicare.  Aimed at eliminating health disparities experienced by underserved populations, the plan focuses on six priority areas and seeks to reduce health disparities in four years. A Press Release … Read more

Harmful Changes to Lower Limb Prostheses Coverage Too Much Reliance on “Improvement” in the Proposed Home Health Value-Based Purchasing (HHVBP) Model Proposed Revisions to the 2-Midnight Rule Won’t Make Any Significant Change 1. Harmful Changes to Lower Limb Prostheses Coverage The Center recently called for the elimination of a proposed local coverage determination (LCD) that … Read more

The Center for Medicare Advocacy is concerned that Medicare beneficiaries are being denied Medicare coverage for skilled services that are specifically listed as covered by Medicare in federal regulations. Medicare covers various skilled therapies (physical, speech–language pathology and occupational) and skilled nursing services, including observation and assessment, management and evaluation of a care plan, or … Read more

A recent Centers for Medicare & Medicaid Services (CMS) report, Access to Care Issues Among Qualified Medicare Beneficiaries (QMB), revealed several access to care problems for low-income Medicare beneficiaries enrolled in the QMB program. The report analyzed two studies focused on access to care for low-income beneficiaries. The first study utilized qualitative interviews with beneficiaries … Read more

Hospitals often classify hospitalized Medicare patients as outpatients, even though their hospital care may be indistinguishable from the care they would receive if they were formally admitted as inpatients.  This issue – called Observation Status – has been a serious problem for Medicare beneficiaries for many years,[1] chiefly because patients who do not have at … Read more

9 Facts About Social Security, a recent blog post by Jason Furman, Chairman of the Council of Economic Advisers, and Jeff Zients, Director of the National Economic Council, identifies nine important accomplishments for our aging society and for persons with disabilities. Social Security forms the foundation for retirement security through universal, guaranteed benefits. Social Security … Read more

This photo of the signing of the Social Security Act was sent to us by a friend of the Center whose father received it, signed, from President Roosevelt’s son. When President Franklin Roosevelt signed the Social Security Act into law on August 14, 1935, older people and their families entered a new era of financial … Read more

The Center for Medicare Advocacy received an e-mail inquiry from an individual requesting assistance advocating for her sister, Mrs. B.  Mrs. B is a Medicare beneficiary enrolled in a Medicare Advantage plan and in need of home health services.  The questions raised demonstrate several important issues that often arise with both the home health benefit … Read more

Medicare pays for a limited number of Part B services furnished by a physician or practitioner to an eligible beneficiary via a telecommunications system. For eligible telehealth services, the use of a telecommunications system substitutes for an in-person encounter. Cognitive Behavioral Therapy (CBT) as psychotherapy via telemental health is covered by Medicare for certain eligible … Read more

An increasing number of patients in hospitals are not formally admitted as inpatients, but as “outpatients” on “observation status.”  Although they receive whatever medical and nursing care, diagnostic tests, medications, and food they need, their status as “outpatients” means that they do not satisfy the three-day inpatient hospital prerequisite for Medicare coverage of post-acute care … Read more

Over the past week, problems with Medicare coverage of Speech Generating Devices (SGDs) have been favorably addressed through both final Administrative and Congressional action. Prior to these actions, Medicare only covered SGDs to generate face-to-face speech, excluding other forms of communication such as by email, phone or text.  Medicare had also changed the payment category … Read more

The 50th anniversary of Medicare has given us an opportunity to reflect on all it has accomplished to advance the health and well-being of families throughout the country. It also reminds us what could have been better – and what could still be improved. We are thankful for the vision and fortitude of President Johnson … Read more

Medicare Trustees Report – Medicare Part A Solvency Remains Stable On July 22, 2015, the Medicare and Social Security Trustees issued the 2015 Annual Report of the Boards of Trustees of the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund. Good News: In short, the projected solvency of the Part … Read more

On Tuesday, July 14, 2015, at a news conference on adding Medicare coverage of hearing aids, Rep. Debbie Dingell (D-MI) discussed H.R. 1653, the “Medicare Hearing Aid Coverage Act of 2015,” the first bill she introduced as a member of Congress, which would allow Medicare to provide coverage for hearing aids. She was joined by … Read more

On July 13, 2015, the Centers for Medicare & Medicaid Services (CMS) posted proposed regulations to revise the Requirements of Participation for nursing homes (called Skilled Nursing Facilities under Medicare and Nursing Facilities under Medicaid).  The proposed rules were published in the Federal Register on July 16,[1] with a 60-day comment period.  The public announcement … Read more

July 16, 2015 WASHINGTON, DC – Steve Gleason, former NFL standout athlete for the New Orleans Saints, has redefined what it means to be a hero. Diagnosed with ALS (Amyotrophic Lateral Sclerosis, or Lou Gehrig’s disease) in 2011, Steve’s mind is unaffected by the disease, but he can no longer move any part of his … Read more

In the annual update to Medicare reimbursement of acute care hospitals for outpatient care (July 8, 2015)[1] the Centers for Medicare & Medicaid Services (CMS) includes proposed revisions to the “Two-Midnight Rule” and its enforcement. If the proposed changes lead to an increased number of patients being formally admitted as inpatients (rather than, as now, … Read more

Advancing Access to Medicare and Necessary Care for People with Long-Term Conditions and Injuries With support from the John A. Hartford Foundation the Center for Medicare Advocacy has created a multi-disciplinary Jimmo Implementation Council. The Center convened the first meeting of the Council on June 23, 2015 at the US Capitol in Washington, DC.[1] The … Read more

1. Comments to Senate Finance Committee Chronic Care Workgroup On June 22, 2015, the Center for Medicare Advocacy submitted comments to the Senate Finance Committee Chronic Care Workgroup in response to the Committee’s May 22, 2015 request for comments on reforming care for individuals with chronic conditions. The Committee identified three overarching goals to guide … Read more

In September 2006, the nursing home industry announced a voluntary quality improvement campaign – Advancing Excellence in America’s Nursing Homes.[1]  The campaign, now in its ninth year and third phase, describes its mission: “to make nursing homes better places to live, work, and visit.”[2]  The Center for Medicare Advocacy (Center) was skeptical about the campaign … Read more

Part B of Medicare will generally cover up to 80% of emergent and non-emergent ambulance transports when medically necessary and when transport by any other means could endanger your health.  There are also origin/destination requirements; Medicare will typically only cover transports to the nearest appropriate medical facility that can provide the level of care necessary … Read more

Fast-food workers have been demonstrating for a higher minimum wage and recently, various corporations have increased the wages of their lowest-paid workers.  Has the movement come to the health care industry? On May 22, 2015, the country’s largest Roman Catholic health system, St. Louis-based Ascension Health, announced that it would pay workers at least $11 … Read more

As we’ve previously reported, on April 28, 2015 the Senate Finance Committee held a hearing about the tremendous backlog of cases piled up at the Office of Medicare Hearings and Appeals (OMHA), the office that oversees Administrative Law Judges (ALJs), the third level of appeal in Medicare’s administrative appeals system.[1]  The Finance Committee hearing also … Read more

Government contractors administering Medicare benefits are routinely denying coverage to cancer patients for claims involving the surgical removal of decayed and infected teeth caused by an aggressive course of radiation treatment to the head and neck.[1] The decayed and infected teeth, when left untreated, place these cancer patients at increased risk for infection, thereby decreasing … Read more

This CMA Alert highlights a recent individual ALJ decision that sets out an important but often unrecognized beneficiary right to a written notice when he or she is about to use hospital “Lifetime Reserve Days.”  A hospital’s failure to provide appropriate notice in this context can lead to the waiver of a beneficiary’s liability for … Read more

The traditional Medicare program pays individual health care providers for the specific services and care they provide to beneficiaries and guarantees that patients have “freedom of choice”[1] to select their Medicare providers.  A current focus of Congress and policymakers is changing Medicare payment policy to pay, instead, for episodes of care for beneficiaries.  One issue … Read more

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