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The Center has previously written about how legislative and regulatory policy changes are tipping the scales in favor of Medicare Advantage (MA) over traditional Medicare. For example, coverage expansions such as the ability to provide new supplemental benefits have been advanced in MA but not in traditional Medicare. In recent years, this has been exacerbated … Read more

On August 14, 2019, the Department of Homeland Security (DHS) posted a final rule to the Federal Register that amends DHS regulations regarding how an application for legal immigration into this country will be assessed, expanding the government’s ability to deny entry based on the possible future use of services like Medicaid. The “Public Charge” … Read more

On August 13, 2019 the Center for Medicare Advocacy submitted comments on the Centers for Medicare & Medicaid Services’ (“CMS”) Notice of Proposed Rulemaking on Nondiscrimination in Health and Health Education Programs or Activities. The Center expressed strong opposition to the NPRM provisions that seek to eliminate and limit the Health Care Rights Law’s protections … Read more

On August 12, 2019 the Center for Medicare Advocacy submitted comments on the Centers for Medicare & Medicaid Services’ (“CMS”) request for information (“RFI”) regarding reducing administrative burden through the Patients over Paperwork initiative. The RFI sought information on how CMS could simplify and reduce paperwork burdens, including methods to modify and streamline reporting and … Read more

In late July 2019, the General Accounting Office (GAO) issued a report entitled “Medicare Plan Finder: Usability Problems and Incomplete Information Create Challenges for Beneficiaries Comparing Coverage Options” (GAO-19-627). In short, according to the Report, “[t]he Medicare Plan Finder (MPF) website—a primary resource for comparing Medicare coverage options—is difficult for beneficiaries to use and provides … Read more

For decades, the nursing home industry has proposed relaxing the requirement for annual surveys at nursing facilities.[1]  Industry representatives argue that surveyors should excuse “good” facilities from annual surveys and focus their attention on poorly-performing facilities. The argument’s superficial appeal fails with scrutiny. First, how would we identify “good” facilities? As the Government Accountability Office … Read more

A Modern Healthcare article about the National Association of Insurance Commissioners’ 2018 Accident and Health Policy Report, reports that short-term health plans, greatly encouraged by the current administration, offer little coverage for enrollees. The article reports that the average amount spent per dollar of premium paid by the five insurers bringing in the most premiums … Read more

Medicare requires beneficiaries to have a three-day inpatient hospital stay in order to qualify for skilled nursing facility (SNF) care. Unfortunately, too many beneficiaries continue to be classified as hospital outpatients on observation status, thereby eliminating their ability to receive Medicare-covered SNF care. In a recent Tweet, Centers for Medicare & Medicaid Services (CMS) Administrator … Read more

Skilled Nursing Facility Updates Wednesday, September 18, 2019 3:00 PM – 4:00 PM EDT Presenters: Center for Medicare Advocacy Senior Policy Attorney Toby Edelman, Policy Attorney Dara Valanejad, and guest. Medicare for People with Paralysis – Sponsored by the Christopher & Dana Reeve Foundation Wednesday, October 2, 2019 3:00 PM – 4:30 PM EDT Presenters: … Read more

                      Joint statement from the Center for Medicare Advocacy and the Long Term Care Community Coalition. On July 23, 2019, the U.S. Government Accountability Office (GAO) published a report on nursing home resident abuse, Improved Oversight Needed to Better Protect Residents from Abuse. The GAO … Read more

Although the revised Requirements of Participation published in October 2016[1] have not yet been fully implemented, the Centers for Medicare & Medicaid Services (CMS) published proposed rules on July 18, 2019 to revise them and also to make changes in survey and enforcement rules.[2]  CMS contends that its proposals are intended to “promote efficiency and … 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

This week the CT Mirror published a Kaiser Health News article about overpayments to private Medicare plans. The article, originally titled “Insurers Running Medicare Advantage Plans Overbill Taxpayers By Billions As Feds Struggle To Stop It” underscores the need for improved oversight and enforcement of Medicare Advantage plans. According to the Kaiser Health News article, … Read more

On July 23, 2019, the Senate Finance Committee held its second nursing home hearing this year, “Promoting Elder Justice: A Call for Reform,”[1] following its March 6 hearing “Not Forgotten: Protecting Americans from Abuse and Neglect in Nursing Homes.”[2]  The Center for Medicare Advocacy is pleased that the July 23 hearing included a national advocate … Read more

PROMOTING ELDER JUSTICE: A CALL FOR REFORM HEARING BEFORE THE U.S. SENATE COMMITTEE ON FINANCE July 23, 2019 Statement of Toby S. Edelman Senior Policy Attorney Center for Medicare Advocacy 1025 Connecticut Avenue, N.W., Suite 709 Washington, DC  20036 I am a Senior Policy Attorney in the Washington, D.C. office of the Center for Medicare … Read more

                      Background. Every month, the Centers for Medicare & Medicaid Services (CMS) identifies nursing homes with an extremely poor record of resident care for inclusion in the Special Focus Facility (SFF) program for enhanced oversight. Due to limited resources, CMS currently caps the SFF program … Read more

On Tuesday, July 23, the Senate Finance Committee released draft drug pricing legislation, the Prescription Drug Pricing Reduction Act (PDPRA) of 2019. This sweeping bill would make a number of changes aimed at addressing the high and rising costs of prescription drug prices. However, the legislation currently does not contain important changes to the Medicare … Read more

Medicare & Oral Health Updates (Wey-Wey Kwok and Kata Kertesz) Medically Necessary Coverage Adding a Comprehensive Benefit to Medicare Policy Updates Durable Medical Equipment (Kathy Holt) Nursing Facilities (Toby Edelman and Dara Valanejad) Prescription Drugs (David Lipschutz) Health Reform (David Lipschutz) Medicare for All Hearing, other updates Litigation Update (Ali Bers) General Medicare Q&A/Wrap Up … Read more

An article in the July 2019 issue of Health Affairs, “A National Examination Of Long-Term Care Setting, Outcomes, And Disparities Among Elderly Dual Eligibles,” relayed findings from a national study on home and community-based services (HCBS) use and outcomes among dual-eligible beneficiaries. The study found that the racial/ethnic disparities in access to high-quality institutional long-term … Read more

Many Medicare hospital patients classified as observation status “outpatients” currently forego necessary skilled nursing facility (SNF) care and head home to continue care through Medicare’s home health care benefit. This is because they lack a 3-day inpatient hospital stay, which is required for Medicare coverage of most beneficiaries’ post-acute care in a SNF.[1] Beginning January … Read more

                      In 2016, the Obama Administration promulgated regulations prohibiting pre-dispute arbitration agreements between nursing homes residents (or their representative) and facilities. On July 18, 2019, the Trump Administration published a Final Rule rolling back certain features of the 2016 resident protection. Most notably, the Final … Read more

Following up on earlier work analyzing the Medicare hospice benefit, the Department of Health and Human Services (DHSS) Office of Inspector General (OIG) issued two reports this week “which found that from 2012 through 2016, the majority of U.S. hospices that participated in Medicare had one or more deficiencies in the quality of care they … 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

The Center for Medicare Advocacy is pleased to share a new opportunity for advocates working to add a comprehensive oral health benefit to Medicare. The Oral Health Progress Equity Network (OPEN), a national network of individuals and organizations that believe oral health is essential to overall health and wellbeing, is organizing across the country to ensure that … Read more

The federal website for information about nursing homes, Nursing Home Compare,[1] reports information for each Medicare-certified and Medicaid-certified nursing facility in three categories – health inspections, staffing, and quality measures – as well as an overall score that combines the three domains. The health inspections domain reflects the findings of standard (annual) and complaint surveys … Read more

Oral argument in Texas v United States, the lawsuit seeking to dismantle the Affordable Care Act, will be held Tuesday July 9, 2019. At stake in this case is the health care of millions of Americans. The case will affect the entire health care system and every aspect of the Affordable Care Act, not just the much-discussed … 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

On June 21, 2019, the Center submitted comments to the Office of Management and Budget (OMB) on a proposal to change the method for calculating the annual adjustment of income measures such as the Official Poverty Measure (OPM). We strongly urged OMB not to make the proposed change without conducting extensive research and analysis on the … Read more

On June 25, 2019, the Center sent a letter to the House Ways and Means Committee, to thank the Committee for its work addressing important beneficiary-related issues in the Beneficiary Education Tools Telehealth Extender Reauthorization (BETTER) Act of 2019, legislation that will assist individuals in making Medicare decisions as well as support low-income beneficiaries. In particular, … Read more

Elder Justice: What “No Harm” Really Means for Residents is a newsletter published by the Center for Medicare Advocacy and the Long Term Care Community Coalition. The purpose of the newsletter is to provide residents, families, friends, and advocates information on what exactly a “no harm” deficiency is and what it means for nursing home … Read more

The Centers for Medicare & Medicaid Services (CMS) identifies about 88 nursing facilities – generally one to two facilities per state – that are among the most poorly performing facilities in the country.[1] These nursing facilities, which CMS calls Special Focus Facilities (SFFs), have “more problems” than other facilities, “more serious problems” than other facilities, … Read more

One of the core considerations of the Center for Medicare Advocacy’s Medicare Platform is to reduce ongoing barriers to care. Home health is one area in particular where the Center has seen a disturbing increase in access issues. Advocates, policy-makers and CMS must all work to ensure access to home health coverage and care is … Read more

On April 25, 2019, the Centers for Medicare & Medicaid Services (CMS) published a notice of proposed rulemaking that would revise the definition of group physical, speech and occupational therapy to allow six residents, rather than four, to participate in a group therapy session. If finalized, the rule would place even more nursing home residents … Read more

Nursing home financial arrangements are important issues of public policy. Failures by state and federal governments to ensure nursing home financial accountability and integrity have an increasingly devastating impact on nursing home residents and their families across the country. According to a recent report by The New York Times, the U.S. Department of Housing and … Read more

On May 23, 2019, Ways & Means Committee Chairman Richard E. Neal (D-MA) and Energy & Commerce Committee Chairman Frank Pallone, Jr. (D-NJ), along with Ranking Members Kevin Brady (R-TX) and Greg Walden (R-OR) announced a solicitation for comments on draft legislation to reform the Medicare Part D program that would establish an out-of-pocket cap … Read more

Medicare home health coverage plays a vital role in supporting the health, safety, and well-being of adults in need of community-based care. Unfortunately, the Center for Medicare Advocacy (the Center) regularly hears from Medicare beneficiaries and their families about their inability to access care, or the appropriate amount of care, despite meeting the necessary coverage … 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

On June 3, 2019, The Center submitted comments on the Centers for Medicare & Medicaid Services (CMS) proposed rule regarding interoperability in Medicare and Medicaid programs. In the comments, the Center expressed support for the Administration’s commitment to improving patient access to health information. However, we raised concerns about patient privacy created by increased data … Read more

The Affordable Care Act created the Centers for Medicare & Medicaid Innovations (CMMI), which is tasked with testing demonstration programs aimed at delivery system reform. As discussed in a previous Weekly Alert in May 2018, among the models being developed is a suite of “Direct Contracting Model Options” described on the CMMI website.  According to … Read more

At present, only 88 nursing facilities nationwide (0.6% of the nation’s total number of facilities) are identified as Special Focus Facilities (SFFs). The Centers for Medicare & Medicaid Services (CMS) describes SFFs as having “more problems” than other facilities, “more serious problems” than other facilities, and “[a] pattern of serious problems that has persisted over … Read more

    Background. Medicare beneficiaries are entitled to a maximum of 100 days of skilled nursing facility (SNF) care in a benefit period when they meet specific coverage criteria. However, Medicare Part A only covers the full cost of a beneficiary’s skilled care during the first 20 days of a nursing home stay. Starting on … Read more

A recent report by the Sunlight Foundation’s Web Integrity Project shows that the Administration removed 85 pages of information about the Affordable Care Act (ACA). According to the report, the removed information concerned “a wide range of information about programs offered, and rights guaranteed, under the ACA, and how the law affects coverage for a … Read more

As part of its investigative series on nursing home care in Florida, Naples Daily News (part of the USA Today Network) reports that the new Medicaid reimbursement system for Florida’s nursing homes, scheduled for full implementation in 2023, will increase reimbursement for some of the state’s most poorly performing facilities by millions of dollars while … Read more

The landmark Affordable Care Act (ACA) included an anti-discrimination provision – the Health Care Rights Law – otherwise known as Section 1557.  This provision prohibits discrimination by certain health programs or facilities on the basis of race, color, national origin, sex, age or disability. Unfortunately, the Trump Administration recently released a proposed rule (not yet … Read more

Public information about enforcement actions imposed and upheld against nursing facilities is inaccurate and limited, or missing. The Center for Medicare Advocacy (the Center) analyzed whether the federal website Nursing Home Compare to determine if it accurately reports civil money penalties (CMPs) that were imposed against nursing facilities and upheld by Administrative Law Judges (ALJs).  … Read more

Congressional Hearing on Surprise Medical Bills; Center for Medicare Advocacy Submits Statement on Observation Status Report Highlights Overpayments to Medicare Advantage Plans and Raises Important Policy Considerations Webinar: Where Does the Money Go? Insights and Consumer Perspectives on Nursing Home Profits and Losses Elder Justice Newsletter – New Issue Available Now Congressional Hearing on Surprise Medical … Read more

Elder Justice: What “No Harm” Really Means for Residents is a newsletter published by the Center for Medicare Advocacy and the Long Term Care Community Coalition. The purpose of the newsletter is to provide residents, families, friends, and advocates information on what exactly a “no harm” deficiency is and what it means for nursing home … Read more

On May 21, 2019, the Long Term Care Community Coalition (LTCCC) hosted a webinar on nursing home profits and losses. Dara Valanejad, a Policy Attorney with both the Center for Medicare Advocacy and LTCCC, participated in the webinar. Mr. Valanejad presented findings from the Medicare Payment Advisory Commission’s March 2019 report to Congress, discussed how … Read more

The Kaiser Family Foundation (KFF) recently released a report entitled “Do People Who Sign Up for Medicare Advantage Plans Have Lower Medicare Spending?” (May 2019). As summarized in the report, “Even after risk adjustment, the results indicate that beneficiaries who choose Medicare Advantage have lower Medicare spending – before they enroll in Medicare Advantage plans … Read more

“Protecting Patients from Surprise Medical Bills” – a hearing held on May 21 by the House Ways and Means’ Subcommittee on Health – considered the bills for health care services that patients get after they received care from health care providers who were not in the patients’ health insurance network.[1] Typically, patients receive these bills … Read more