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

Mrs. R contacted the Center for Medicare Advocacy about her husband, who has ALS, and was told his home health physical therapy was about to be terminated. While receiving physical therapy, Mr. R had reduced pain, allowing him to decrease pain medications, improved bowel function, and increased ability to clear airway secretions. Nonetheless, home health agency … Read more

Despite the Jimmo case’s confirmation that Medicare coverage of a stay in a skilled nursing facility (SNF) is appropriate to maintain a resident’s functional status, when the nursing or therapy services must be provided by a professional nurse or therapist, SNFs and managed care plans frequently continue to deny medically necessary coverage.  Expedited appeals to … Read more

Based on recent experience, the Center for Medicare Advocacy provides this Practice Tip for providers and advocates for patients who need to change from an improvement mode to maintenance mode for nursing or therapy. The Center is seeing decisions from Medicare Contractors requiring that providers obtain new orders when a patient’s goals change to maintenance … 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

December 9, 2013 – The Center for Medicare Advocacy is pleased to announce that the Medicare Policy Manuals have been revised pursuant to the Jimmo vs. Sebelius Settlement. The Manual revisions, which clarify that improvement is not required to obtain Medicare coverage, were published by the Centers for Medicare & Medicaid Services (CMS) on Friday … Read more

Potential Impacts of New Medicare Payment Models On Skilled Nursing Facility and Home Health Care  CMS Extends “Equitable Relief” from Part B Late Enrollment Penalties for People Moving from ACA Marketplace Plans to Medicare Free Webinar: Coordination of Benefits – What Pays When? Potential Impacts of New Medicare Payment Models On Skilled Nursing Facility and … Read more

The Centers for Medicare & Medicaid Services will be implementing revised payment systems for both skilled nursing facility care (effective October 2019) and home health care (effective January 2020). The Center for Medicare Advocacy has written at length and submitted comments on both the home health and skilled nursing facility payment models. Unfortunately, implementing these … Read more

[Date] [Attorney’s Name] [Address] Re: [Beneficiary’s Name], Medicare No. [XXXXX] To Whom It May Concern: I am writing on behalf of my client, [Full Name], to request an expedited reconsideration. The skilled nursing facility (SNF) terminated Mr./Ms. [Last Name]’s Medicare coverage on [Date]. The SNF told Mr./Ms. [Last Name] that his/her Medicare coverage was ending … Read more

Background The United States District Court for the District of Vermont approved a settlement agreement in Jimmo v. Sebelius[1] on January 23, 2013. The Jimmo Settlement required the Centers for Medicare & Medicaid Services (CMS) to confirm that Medicare coverage of skilled nursing facility, home health, and outpatient therapy services must be determined on the … Read more

Center for Medicare Advocacy Analysis of President’s Medicare Advantage Executive Order: Among Vague Language and Proposals, Real Harm to Medicare Beneficiaries  Nursing Home Residents and Therapy Under The New Medicare Reimbursement System Important Update to Nursing Home Compare Will Enable Public to Identify Facilities with a History of Abuse Medicare’s Annual Election Period Starts Next Week … Read more

The Centers for Medicare & Medicaid Services (CMS) implemented a new Medicare Part A reimbursement system for skilled nursing facilities (SNFs), called Patient-Driven Payment Model (PDPM), on October 1, 2019.[1] Therapists immediately began reporting that nursing homes and therapy companies were laying them off and demanding that they change their therapy practices, shifting residents from … 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

Connecticut Congressional Delegation Concerned about Medicare Advantage Network Provider Terminations in the State House Companion to Part D Extra Help Bill Introduced The Patient Driven Payment Model is Here – What Does It Mean for Residents? Connecticut Congressional Delegation Concerned about Medicare Advantage Network Provider Terminations in the State As noted in a press release … Read more

The Patient Driven Payment Model is Here What Does It Mean For Residents? On October 1, 2019, the Centers for Medicare & Medicaid Services (CMS) began implementing a new payment system for Medicare-covered nursing home care. The payment system is called the “Patient Driven Payment Model” (PDPM). PDPM creates a new set of financial incentives … Read more

The Center for Medicare Advocacy (the Center), submitted comments this week regarding the 2020 proposed rules for Medicare home health care. The Center is pleased CMS plans to allow therapist assistants to perform maintenance therapy (therapist assistants are currently allowed to perform improvement therapy), recognizing equal coverage for beneficiaries who need safe and effective therapy … Read more

Medicare & You 2020 – Better Than Draft, But Room for Improvement More People Went Without Health Insurance in United States in 2018 Administrator Verma’s Tweet Sparks Support for Addressing Observation Status Proposed Home Health Rules – Payment Shouldn’t Impede Access Register Now – Free Webinar, September 18 – Skilled Nursing Facility Updates Medicare & … Read more

September 9, 2019 Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-1711-P P.O. Box 8013 Baltimore, Maryland  21244-8013 Submitted electronically to: http://www.regulations.gov Re:  CMS-1711-P; Federal Register, Volume 84, No. 138 (July 18, 2019) The Center for Medicare Advocacy (the Center) provides these comments about CMS-1711-P and the impact of the … Read more

Disclaimer: the views expressed in this Issue Brief and during the Alliance call are solely those of the Center for Medicare Advocacy. 1. UPCOMING ANNUAL COORDINATED ELECTION PERIOD (ACEP) Overview The Annual Coordinated Election Period (ACEP) – the period during which individuals with Medicare can make coverage elections for the following year – will start … Read more

Advocates Issue Joint Letter Raising Alarms about New Medicare Plan Finder and Revisions to MA and Part D Marketing Guidelines CMS Proposed Medicare Home Health Rules Raise Concerns for Access to Care – Comments due September 9, 2019 Stop Drugging Nursing Home Residents Without their Written Consent Advocates Issue Joint Letter Raising Alarms about New … Read more

The Center for Medicare Advocacy is concerned that proposed home health rules will further steer home health agencies away from providing care for beneficiaries who need it the most and toward beneficiaries with short-term post-acute care needs.[1] Beginning in 2020, payments to home health agencies under the new model will provide higher payments for individuals … 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

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

New Medicare Home Health Fact Sheet Special Report – “Graduates” From the Special Focus Facility Program Provide Poor Care Center for Medicare Advocacy Submits Joint Comments on Proposed Revisions to the Definition Of Group Therapy In Skilled Nursing Facilities New Medicare Home Health Fact Sheet One of the core considerations of the Center for Medicare … 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

NOT FORGOTTEN: PROTECTING AMERICANS FROM ABUSE AND NEGLECT IN NURSING HOMES Hearing held March 6, 2019 Statement for the record submitted by:  Tony Chicotel, Staff Attorney; Michael Connors, Long Term Care Advocate; Janet Wells, Public Policy Consultant California Advocates for Nursing Home Reform 650 Harrison Street, #2 San Francisco, CA  94107 www.canhr.org Toby Edelman, Senior … Read more

1. MEDICARE EDUCATION & OUTREACH At a February 8, 2019 meeting of the Center for Medicare & Medicaid Services’ (CMS) National Medicare Education Program (NMEP), the agency released information about the 2018 Annual Coordinated Election Period (ACEP), sometimes referred to as “Open Enrollment” or “OP.” (Note: this is a downloadable “zip” file containing several items. … Read more

On January 30, 2019, the Centers for Medicare & Medicaid Services (CMS) issued Part II of its draft 2020 Call Letter, an annual set of proposed rules, guidelines and clarifications for Part C Medicare Advantage (MA) and Part D plans that want to participate in Medicare in the following calendar year. In collaboration with several … Read more

March 1, 2019 Via Electronic Submission to www.regulations.gov (CMS-2018-0154)   Seema Verma, Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services 7500 Security Blvd. Baltimore, Maryland 21244 Re: Advance Notice of Methodological Changes for Calendar Year (CY) 2020 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies, … Read more

6th Annual National Voices of Medicare Summit Welcomes Congressman John Lewis as the 2019 Sen. Jay Rockefeller Lecturer – Register Now Home Health Aide Coverage Continues to Shrink: Attention Must Be Paid Case Spotlight: A Medicare Beneficiary in Need of Home Health Aides  Cathy Hurwit Joins Center for Medicare Advocacy Advisory Board The Administration for Community Living … Read more

The Problem Mrs. B contacted the Center for Medicare Advocacy seeking assistance with Medicare home health coverage. She lives with her husband who has advanced Parkinson’s disease. He receives physical therapy and speech language pathology through a Medicare-certified home health agency, but the agency told Mr. and Mrs. B they are “over Medicare’s income limit … Read more

#MedicarePlatform – Improve and Expand Medicare: Long-Term Services and Supports (LTSS) Center Submits Comments on Proposed Medicare Prescription Drug Rule Congressional Hearings Explore Rising Prescription Drug Costs Medicare’s New “What’s Covered” App Adds to Outreach but More Work Is Needed #MedicarePlatform – Improve and Expand Medicare: Long-Term Services and Supports (LTSS) Recently, the Center for … Read more

The Centers for Medicare & Medicaid Services (CMS) has released a free mobile app for iOS and Android users. The app, “What’s Covered,” is designed to provide Medicare beneficiaries and their families with a general overview of covered services, coverage requirements, costs, and additional information. While the app is geared towards beneficiaries in traditional Medicare, … Read more

Disclaimer: the views expressed in this Issue Brief and during the Alliance call are solely those of the Center for Medicare Advocacy. ACCESS TO CARE    Home Health Between April 2017 and October 2018, the Center completed the “CMA Issue Brief Series: Medicare Home Health Crisis” – a ten-part series examining the growing crisis in … Read more

– Join us for Our Medicare Home Health Webinar · January 23 at 3pm EST– Guest Speaker: Physical Therapist Cindy Krafft, PT, MS Last week, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress.  One of the core considerations to improve Medicare for all beneficiaries, now and in the future, … Read more

Health Care Sabotage Continues as ACA Open Enrollment Comes to an End Center Submits Comments Opposing Proposed “Public Charge” Rule CURE High Drug Prices Act Introduced Elder Justice "No Harm" Newsletter – Issue 10 Checklist for Medicare Outpatient Therapy “Improvement Standard” Denials Health Care Sabotage Continues as ACA Open Enrollment Comes to an End There … Read more

There are only two days left to get covered! Consumers have until December 15th to obtain health insurance through the Affordable Care Act (ACA) Marketplace. Those who need coverage should visit www.healthcare.gov to shop, compare and find a plan that meets their needs. It is important to keep in mind that ACA plans prohibit annual … Read more

Important Health Policy Article Published In New England Journal of Medicine: “Medicare Advantage Checkup" ACA Open Enrollment Ends December 15th State Attorneys General Successfully Take on Nursing Home Issues Important Health Policy Article Published In New England Journal of Medicine: “Medicare Advantage Checkup” The November 2018 New England Journal of Medicine features a article by … Read more

There is not much time left to obtain health insurance from the Affordable Care Act (ACA) Marketplace during this year's Open Enrollment period. Consumers who need coverage should visit www.healthcare.gov to shop, compare and find a plan that meets their needs. Consumers should act quickly.  Not only has this year’s Open Enrollment period been shortened … Read more

Home for the Holidays: Leaving the Nursing Home During a Medicare-Covered Stay Home Health Issue Brief Checklist for Medicare Home Health “Improvement Standard” Denials Home Health Aide Coverage Continues to Shrink in Traditional Medicare While CMS Enhances it in Medicare Advantage Successful Advocacy for Home Health Beneficiary in Need of Maintenance Physical Therapy Home Health … Read more

Health Care Prominent in Mid-Term Elections – How will the New, Divided Congress React? Center for Medicare Advocacy Comments on Proposed Nursing Home Legislation and Rule Jimmo Implementation: Beneficiary Successfully Appeals Denial of Maintenance Therapy Health Care Prominent in Mid-Term Elections – How will the New, Divided Congress React? As results from this week’s mid-term … Read more

ACA Open Enrollment Begins Choosing Between Traditional Medicare and Medicare Advantage Final Medicare Home Health Payment Rule Threatens Access to Care HHS Publishes Final Rules Providing Annual Inflation-Related Increases for Civil Money Penalties in Its Programs. Better Late than Never? ACA Open Enrollment Begins #SaveMedicareNow The #SaveMedicareNow initiative seeks to educate and raise awareness about … Read more

Today is the first day of Open Enrollment for the Affordable Care Act (ACA) Marketplace. Consumers who need coverage should visit www.healthcare.gov to shop around and find an ACA plan that meets their needs. Unfortunately, due to actions taken by the Administration to undermine the Marketplace, there is not as much assistance available to help … Read more

Center for Medicare Advocacy Survey: CMS’ Jimmo v. Sebelius “Improvement Standard” Education Still Not Working Health Care Sabotage: Expanded “Short-Term, Limited-Duration Insurance” is Here Study: Three-Day Hospital Requirement for Post-Hospital Care In a Skilled Nursing Facility Increases Medicare Costs Who Owns Nursing Facilities and Why? Center for Medicare Advocacy Survey: CMS’ Jimmo v. Sebelius “Improvement … Read more

The Center for Medicare Advocacy recently completed a survey of Jimmo v. Sebelius stakeholders to analyze the effectiveness of the Centers for Medicare & Medicaid Services’ education efforts regarding the Jimmo Settlement, which clarified that Medicare must cover skilled maintenance care in the home health, skilled nursing facility and outpatient therapy settings. Unfortunately, the results … Read more

Disclaimer: the views expressed in this Issue Brief and during the Alliance call are solely those of the Center for Medicare Advocacy. RECENT CHANGES IN LAW, REGULATIONS AND GUIDANCE RELATING TO MEDICARE ADVANTAGE AND PART D CMA Special Report (September 2018): http://www.medicareadvocacy.org/special-report-recent-changes-in-law-regulations-and-guidance-relating-to-medicare-advantage-and-the-prescription-drug-benefit-program/ Overview The first half of 2018 has seen a number of changes in … Read more

September 10, 2018 Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-1691-P Mail Stop C4-26-05 7500 Security Boulevard Baltimore, Maryland  21244-1850 Submitted electronically to: http://www.regulations.gov Re:  CMS-1691-P; Federal Register, Volume 83, No. 139 (July 19, 2018) The Center for Medicare Advocacy (the Center) provides these comments regarding CMS-1691-P and the … Read more

August 27, 2018 Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-1689-P P.O. Box 8013 Baltimore, Maryland  21244-8013 Submitted electronically to: http://www.regulations.gov Re:  CMS-1689-P; Federal Register, Volume 83, No. 134 (July 12, 2018) The Center for Medicare Advocacy (the Center) provides these comments regarding CMS-1689-P and the impact of the … Read more