With support from the John A. Hartford Foundation, the Center for Medicare Advocacy has produced a new Fact Sheet to help Medicare beneficiaries and their families respond to unfair Medicare denials for care at inpatient rehabilitation hospitals/facilities (IRH/F). The Fact Sheet outlines the coverage criteria for IRH/Fs and emphasizes language from the Jimmo Settlement Agreement. … Read more

Inpatient rehabilitation hospitals (IRHs, also known as Inpatient Rehab Facilities/IRFs) provide intensive rehabilitation services to patients on an inpatient basis.[1]  Over time, a myth developed – based on a discredited CMS Policy – that patients are appropriate for Medicare-covered IRH care only if they can participate in at least three hours a day of rehabilitative … Read more

American Heart Association/American Stroke Association Recommends That Patients Who Have Strokes Receive Rehabilitation at Inpatient Rehabilitation Hospitals, not Skilled Nursing Facilities For the first time, the American Heart Association/American Stroke Association has issued a Scientific Statement and guidelines strongly recommending that, “whenever possible,” “stroke patients be treated at an in-patient rehabilitation hospital (now often referred to … Read more

The Medicare Payment Advisory Commission (MedPAC) held a public meeting on September 6, 2018. Commissioners listened as staff presented on “Aligning Medicare’s statutory and regulatory requirements under a unified payment system for post-acute care.”[1] Specifically, the presentation discussed the need to make level-of-care requirements consistent across post-acute care (PAC) settings under a unified PAC prospective … 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

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

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

What are Long Term Care Hospitals? When is Coverage Available in the LTCH? Additional Advocacy Tips Articles and Updates Long Term Care Hospitals (LTCHs) provide care to patients with medically complex problems. These complex diagnoses include, but are not limited to – Traumatic Brain Injury, conditions requiring prolonged mechanical ventilation, paralysis, very significant wound care, and other … 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

Concerns about the threat to patients raised in a letter to MedPAC and testimony before the House Energy and Commerce Health Subcommittee Washington, D.C. – The Coalition to Preserve Rehabilitation (CPR), which represents leading consumer and clinician organizations, today raised serious concerns with proposals that would divert patients who need intensive inpatient hospital rehabilitation to … 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

NATIONAL MEDICARE ADVOCATES ALLIANCE CALL AGENDA Monday, June 11, 2012– 2:00 P.M., Eastern Time Call-in Number: 1 (888) 206-2266 Pass Code: 1050263# NOTE: We ask people calling from the same location to gather around one telephone. This frees up lines and holds down costs. _______________________________________________________________________________________________   Welcome and Housekeeping  (Alfred J. Chiplin, CMA, Moderator)   Presentation: … Read more

When does Medicare cover Rehabilitation Hospital care? How can a treating physician assist me in obtaining Medicare coverage for Rehabilitation Hospital services? For further information, follow one of the links below or scroll down the page. Quick Screen for Rehab Hospital Coverage The Inpatient Hospital Rehabilitation Benefit Coverage Criteria and Appeal Rights Rehabilitation Hospital Articles … Read more

Among Vague Language and Proposals, Real Harm to Medicare Beneficiaries On October 3, 2019, President Trump issued his “Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors” (EO).[1] Much of the language of the EO is vague, and much is unknown about what polices might emerge from it. Some of the proposals are … Read more

CMS’s Proposed Changes to Nursing Home Requirements of Participation, Survey and Enforcement: Nothing Good for Residents Federal Reports Find Incidents of Nursing Home Resident Abuse Are on the Rise but also Underreported Self-Help Resources for Improvement Standard Denials – August, 2019 CMS’s Proposed Changes to Nursing Home Requirements of Participation, Survey and Enforcement: Nothing Good … Read more

Medicare coverage of skilled nursing and/or therapy services depends on a beneficiary’s need for the skilled care, not on the individual’s potential for improvement. The Settlement Agreement in Jimmo v. Sebelius, approved by a federal district court in 2013, required the Centers for Medicare & Medicaid Services (CMS) to confirm that coverage of skilled nursing … Read more

In 2013, a federal district court approved a settlement agreement in Jimmo v. Sebelius, No. 5:11-CV-17 (D. VT). The Jimmo Settlement confirmed that Medicare coverage should be determined based on a beneficiary’s need for skilled care (nursing or therapy), not on the individual’s potential for improvement. The Jimmo Settlement and court decisions pertain to all … Read more

The Growing Disparity Between Medicare Advantage and Traditional Medicare: CMS Publishes Final MA Telehealth Benefit Rule How to Prevent Re-Hospitalization Of Nursing Home Residents: More Physicians and Nurses In Nursing Homes Joint Statement: Federal Report Finds That CMS Failed to Properly Oversee State’s Nursing Home Investigations Latest Issue: Elder Justice: What “No Harm” Really Means … Read more

Observation Status Deprives Medicare Beneficiaries of their Skilled Nursing Facility Benefit. Period. Nursing Home Requirements of Participation: Will the Administration Overturn 2016 Rules for Infection Control? New Fact Sheet Available – Medicare Inpatient Rehabilitation Hospital/Facility Coverage In Light of Jimmo v. Sebelius Join Us! 6th Annual National Voices of Medicare Summit & Sen. Jay Rockefeller … Read more

Joint Statement by Center for Medicare Advocacy and Medicare Rights Center: President’s Budget Targets Key Health Care Programs Members of Congress Reintroduce Legislation to Fix Outpatient Observation Status Medicare Advantage Case Spotlight Spanish Language Home Health Outreach Materials Available Join Us! 6th Annual National Voices of Medicare Summit & Sen. Jay Rockefeller Lecture Early-Bird Registration … Read more

The son of a hospitalized patient recently called the Center for Medicare Advocacy. His father was ready for discharge. Physicians at both the hospital and the inpatient rehabilitation hospital (IRH) agreed that the patient would benefit from IRH services. However, the patient’s Medicare Advantage (MA) plan refused to authorize IRH care.  The plan instead said … Read more

June , 2018 Mr. Alex M. Azar. II Secretary, Department of Health and Human Services Seema Verma Administrator, Centers for Medicare & Medicaid Services Department of Health and Human Services Room 445-G, Hubert H. Humphrey Building 200 Independence Ave., S.W. Washington, D.C.  20201 Re: CMS-1696-P.  Notice of Proposed Rulemaking with Comment.  Medicare Program; Prospective Payment … Read more

CMA Alert – Proposed Payment Rules Will Worsen Home Care Crisis; CMS Clarifies “3-Hour Rule;” Still Time to Register for Next Week’s Summit

Proposed CMS Payment Rules Will Worsen the Home Care Crisis CMS Clarifies 3-Hour “Rule” Should Not Preclude Medicare-Covered Inpatient Rehabilitation Hospital Care Register Now – One Week Left Until the National Voices of Medicare Summit & Sen. Jay Rockefeller Lecture in Washington, DC Proposed CMS Payment Rules Will Worsen the Home Care Crisis This is … Read more

UNITED STATES HOUSE OF REPRESENTATIVES COMMITTEE ON WAYS & MEANS, SUBCOMMITTEE ON HEALTH HEARING ON "THE CURRENT STATUS OF THE MEDICARE PROGRAM, PAYMENT SYSTEMS, AND EXTENDERS” WRITTEN TESTIMONY SUBMITTED BY CENTER FOR MEDICARE ADVOCACY May 18, 2017 Introduction The Center for Medicare Advocacy, founded in 1986, is a national, non-partisan education and advocacy organization that … Read more

On February 16, 2017, the Jimmo v. Sebelius court approved a Corrective Statement to be used by the Centers for Medicare and Medicaid Services (CMS) to affirmatively disavow the use of an “Improvement Standard” for Medicare coverage.  The government will use the statement as part of its Corrective Action Plan, which was ordered by the … Read more

On February 9, 2016, President Obama unveiled his Fiscal Year 2017 Budget.[1]  With respect to Medicare, this year’s proposed budget is very similar to last year’s, both good and bad, with some notable exceptions.  While not a comprehensive analysis of all of the Medicare-related provisions, the Center for Medicare Advocacy provides these comments about the … 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

Advancing Access to Medicare and Necessary Care for People with Long-Term Conditions and Injuries                                                                                      … Read more

June 22, 2015 The Honorable Orrin Hatch                                        The Honorable Ron Wyden Chair, Committee on Finance                                     Ranking Member, Committee on … 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

Washington, D.C. – December 19, 2014: The Center for Medicare Advocacy, and the rest of the Coalition to Preserve Rehabilitation (CPR), an alliance of leading national consumer and clinician organizations, expressed disappointment over the recommendation approved today by the Medicare Payment Advisory Commission (MedPAC) to recommend “site-neutral” payment for certain Medicare patients in need of … Read more

What is "Site Neutral Payment?" Site Neutral Payment is the concept of paying the same amount for rehabilitation regardless of whether the patient is treated in an inpatient rehabilitation hospital or nursing home. Problems with Site Neutral Payments for Rehabilitation Vulnerable Medicare beneficiaries risk being diverted into a less intensive, less appropriate rehabilitation setting simply because … Read more

Introduction How to Use This Packet Observation Status Self-Help Federal Regulations – Requirements for Medicare Coverage for Skilled Nursing Facility Care Pertinent Federal Regulations for Medicare Appeals INTRODUCTION Dear Medicare Patient: The Center for Medicare Advocacy has produced this Self-Help Packet to help you understand Observation Status and options for beneficiaries who are placed on … Read more

A Message from the Executive Director News You Can Use Legislative Watch CMA In the Community A Message from the Executive Director Since I wrote you last month, the Center for Medicare Advocacy hosted our 1st Annual National Voices of Medicare Summit in Washington, DC.  This all-day conference brought together advocates, policy-makers, economists, and scholars … Read more

General Question: Are professional therapy services available under Medicare only for patients who are improving or who are expected to improve? Answer:  No.  The Jimmo Settlement confirms that services by a physical therapist, occupational therapist, and speech and language pathologist are covered by Medicare, Parts A and B, and by Medicare Advantage Plans in skilled … Read more

This article is part of a NAELA Journal symposium edition that focuses on "The Future of Elder Law and Special Needs Planning." This article will provide an overview of the policy debate that led to the creation of the Medicare program.  It will identify key cost and quality problems facing the program and review solutions … Read more

NATIONAL MEDICARE ADVOCATES ALLIANCE CALL Monday, October 15, 2012 – 2:00 P.M., Eastern Time Call-in Number: 1(888)206-2266 Pass Code: 9874704 NOTE: We ask people calling from the same location to gather around one telephone. This frees up lines and holds down costs. _______________________________________________________________________________________________ Update on Medicare Appeals and Complaints − AGENDA − (Materials will be sent prior to … Read more

  NATIONAL MEDICARE ADVOCATES ALLIANCE CALL Monday, August 13, 2012 – 2:00 P.M., Eastern Time Call-in Number: 1 (888) 206-2266 Pass Code: 9874704 NOTE: We ask people calling from the same location to gather around one telephone. This frees up lines and holds down costs. _______________________________________________________________________________________________ − AGENDA − (Materials will be sent prior to the call) … Read more

NATIONAL MEDICARE ADVOCATES ALLIANCE CALL Monday, April 9, 2012– 2:00 P.M., Eastern Time Call-in Number: 1 (888) 206-2266 Pass Code: 1050263# NOTE: We ask people calling from the same location to gather around one telephone.  This frees up lines and holds down costs. ______________________________________________ Welcome and Housekeeping  (David Lipschutz, CMA, Moderator) Presentation: Challenging Notices of … Read more

NATIONAL MEDICARE ADVOCATES ALLIANCE CALL Monday, December 12, 2011– 2:00 P.M., Eastern Time Call-in Number: 1(888)206-2266 Pass Code: 1050263# NOTE: We ask people calling from the same location to gather around one telephone.  This frees up lines and holds down costs. _____________________________________________________   Welcome and Housekeeping  (David Lipschutz, CMA, Moderator) Extender Bill  (re: QI, therapy caps, physician … Read more

This is the seventh in a series of Alerts by Center for Medicare Advocacy regarding the Patient Protection and Affordability Care Act of 2010 (PPACA) and the Health Care and Education Reconciliation Act of 2010 (HCERA). This Alert focuses on changes in PPACA that address measuring the quality of care that is received by Medicare … Read more

1. UPDATES on the BENES Act and PART D LEGISLATION Guest Speaker:  Lindsey Copeland from the Medicare Rights Center Beneficiary Enrollment Notification and Eligibility Simplification (BENES) Act (S. 1280/H.R. 2477) Medicare Rights Center one-pager – https://www.medicarerights.org/pdf/2019-benes-act-factsheet-long.pdf Medicare Watch article, The BENES Act Advances in the House – https://blog.medicarerights.org/benes-act-advances-in-the-house/ Medicare Watch article, MedPAC Calls for Improvements in Medicare … Read more

1. MEDICARE & ORAL HEALTH UPDATES Medically Necessary Coverage The Center for Medicare Advocacy has long advocated for coverage of medically necessary oral health care, which is currently supported by the Medicare statue, but is, unfortunately, significantly limited in practice due to CMS policy. Denying Medicare coverage to people for medically essential care, simply because … Read more

Observation Status and Surprise Medical Bills Government Watchdog Agency Issues Report Highlighting “Significant Vulnerabilities” in Medicare’s Hospice Benefit Observation Status and Surprise Medical Bills The Center for Medicare Advocacy frequently hears from Medicare beneficiaries and their families about patients who receive treatment, tests, and services for multiple days while they are in a hospital bed … Read more

The Center for Medicare Advocacy frequently hears from Medicare beneficiaries and their families about patients who receive treatment, tests, and services for multiple days while they are in a hospital bed but who are called “outpatients.” If these patients need post-hospital care in a skilled nursing facility (SNF), Medicare Part A will not pay for … Read more

June 18, 2019 Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-1718-P P.O. Box 8016 Baltimore, MD 21244-8016 Re: Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2020 Submitted electronically to: http://www.regulations.gov. … Read more

The National Association of Insurance Commissioners Recognizes Maintenance Therapy, Bolstering the Jimmo Settlement Agreement Inadequate Personal Care at Home Increases Overall Medicare Costs The New York Times Reports On HUD-Backed Nursing Homes Center for Medicare Advocacy Submits Comments to House Ways & Means and Energy & Commerce Committees on Draft Part D Legislation The National … Read more

The National Association of Insurance Commissioners (NAIC) is a standard-setting and regulatory support organization governed by chief insurance regulators from across the country. NAIC’s website indicates that organizational members and its resources, “form the national system of state-based insurance regulation in the U.S.” One such resource is NAIC’s Glossary of Health Insurance and Medical Terms, … Read more

(Due) June 18, 2019 Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-1718-P P.O. Box 8016 Baltimore, MD 21244-8016 Re: Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2020 Submitted electronically to: … Read more

More Health Care Sabotage: Inadequate Funding for Navigators Court Ruling May Lead to Even More Overpayments to Medicare Advantage MedPAC Discusses Requiring a Three-Day Hospital Stay for All Post-Acute Care, Threatening Access to Care House Committee Holds Hearing on Nursing Home Quality Issues Proposed DMEPOS Rules: Clarification and Enforcement Needed More Health Care Sabotage: Inadequate … Read more