Last week the Centers for Medicare & Medicaid Services released the Medicare premium, deductible and co-pay amounts for 2019.  Below are the 2019 cost-sharing amounts. Part A Premium (For those not automatically enrolled) 0-29 qualifying quarters of employment: $437.00 30-39 quarters: $240.00 Inpatient Hospital Deductible, Per Spell of Illness: $1,364.00 Co-pay, Days 1 – 60: … Read more

The Department of Health and Human Services (DHHS) Office of Inspector General (OIG) recently issued a report entitled “Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials” (OEI-09-16-00410) (see summary and full report). Among the report’s findings are that when beneficiaries and providers appealed preauthorization and payment denials, MA plans … Read more

This is Part Ten of a ten-part CMA Issue Brief Series examining the growing crisis in access to Medicare home health coverage and necessary care – and outlining the Center for Medicare Advocacy’s work to address these issues. We invite you to follow this Issue Brief Series and submit Medicare home health stories to the … Read more

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy has produced a new Checklist to help Medicare beneficiaries and their families respond to unfair Medicare denials for home health care based on an erroneous “Improvement Standard.” The Checklist outlines the coverage criteria for home health care and emphasizes language from the … Read more

The mid-term elections are 20 days away. To help keep Medicare in the forefront of candidates’ and voters’ minds, our SaveMedicareNow project is focusing on issues relevant to the promise and future of the Medicare program.  Last week, we focused on the importance of Medicare to young people.  This week, we focus on the growing … Read more

Providing Medicare Beneficiaries with Complete, Objective Information to Help Them Make the Best Enrollment Decision The Center for Medicare Advocacy and the National Committee to Preserve Social Security and Medicare have partnered to develop an education and outreach project to support Medicare beneficiaries and those who assist them enroll and re-enroll in Medicare. The Medicare … Read more

Yesterday, USA Today published an Op-Ed by President Trump entitled “Democrats [sic] 'Medicare for All' plan will demolish promises to seniors.” In addition to the inflammatory rhetoric throughout the piece (which includes language reminiscent of the “Red Scare” fears used to oppose passage of Medicare in the 1960s), it is filled with false and misleading statements about the … Read more

As midterm elections near, young Americans will be in the spotlight. Young Americans have been integral to a number of surprising primary victories across the country. And, for the first time, they will surpass Baby Boomers as the largest generation of Americans eligible to vote.[1] Medicare is often at the forefront of national discourse. However, … Read more

Overview The Annual Coordinated Election Period (ACEP), from October 15 through December 7, 2018, is the time period during which Medicare beneficiaries can enroll in, switch, or disenroll from Medicare Advantage (MA, or Part C) plans and Part D prescription drug plans.  Elections made during this time period will be effective January 1, 2019.  Information … 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

In order to qualify for Medicare Part A coverage of a post-hospital stay in a skilled nursing facility, the traditional Medicare program requires that the beneficiary first be hospitalized as an inpatient for three consecutive days, not counting the day of discharge.  This requirement has been in place since the Medicare program was enacted more … Read more

In September 2007, The New York Times published a lengthy investigative article about private equity’s purchase of nursing facilities – “At Many Nursing Homes, More Profits, Less Nursing.”[1]  The Times reported that private equity firms purchased facilities and divided ownership into multiple companies, insulating themselves from private litigation and meaningful regulatory enforcement.  Meanwhile, the firms … Read more

Starting this week, consumers may purchase short-term, limited-duration insurance policies that will provide coverage for up to one year.  It is important to remember that these skimpy plans were never intended to be used as long-term comprehensive health insurance. At best, they should be a stopgap for consumers who experience a temporary break in coverage. … Read more

In the weeks leading up to the mid-term elections, the Center for Medicare Advocacy will work to ensure Medicare gains momentum as a top issue for voters and candidates. During an audio news conference announcing the SaveMedicareNow initiative, led by the Center, key experts discussed policy and structural changes that threaten the Medicare program. Presenters … Read more

The Administration is at it again. Last weekend, the Department of Homeland Security released the text of a proposed rule that would create hardships for certain immigrants seeking permanent residency (green cards) in the U.S. This “public charge” proposed rule would also place additional barriers in the way of immigrants seeking to enter the country. … Read more

The Center for Medicare Advocacy is pleased to announce the additions of Julia Evans-Starr and Charles P. Sabatino to our Board of Directors. Julia Evans-Starr, MSW, Senior Fellow at the Center for the Advancement of Well-Being at George Mason University, is a leading authority on issues affecting the growing and diverse population of older adults. Her … Read more

The involuntary transfer and discharge of nursing home residents is the top complaint received by nursing home ombudsman programs nationwide.  In December 2017, the Centers for Medicare & Medicaid Services (CMS) announced an initiative “to examine and mitigate facility-initiated discharges that violate federal regulations.”[1]  While recognizing the seriousness of involuntary transfer and discharge for residents … Read more

Human Rights Watch (HRW) published a devastating report in February 2018, which found that over 179,000 nursing home residents were being administered off-label antipsychotic drugs every week.[1] Antipsychotic drugs are indicated to treat specific clinical conditions, such as schizophrenia, and not the behavioral symptoms of dementia. Nevertheless, the HRW report noted that most of the … Read more

This week, CMS announced it was awarding significantly less funding for navigator organizations than in the past for the upcoming Affordable Care Act open enrollment season. Overall, the program’s funding has been reduced from 2016’s $100 million budget to $10 million for 2018. Navigator organizations are non-profits that provide critical assistance to consumers who need … Read more

As reported in FierceHealthcare, “Medicare Advantage insurers scored a significant legal victory” when a U.S. District Court judge recently “struck down a 2014 rule requiring [plans] to report and return overpayments.”  Further, according to Modern Healthcare, this ruling “leaves the federal government with fewer tools to combat upcoding practices that cost the taxpayer-funded Medicare program … 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

For the first time in many years, Congress held a hearing on nursing home quality of care on September 6, 2018.  The hearing of the Subcommittee on Oversight and Investigations of the House Energy and Commerce Committee, entitled “Examining Federal Efforts to Ensure Quality of Care and Resident Safety in Nursing Homes,” featured three witnesses: … Read more

The Center for Medicare Advocacy (the Center) submitted comments to the Centers for Medicare & Medicaid Services (CMS) regarding proposed rules affecting durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). The Center requested that CMS: Seek to maximize beneficiary access to DMEPOS; Clarify supplier responsibilities to provide beneficiaries with appropriate products and timely services; Develop … Read more

Thanks to a final rule issued by the Administration, Association Health Plans (AHPs) will be available starting this month. Expanding AHPs will make it easier for certain small employers to offer plans that don’t have Affordable Care Act (ACA) coverage protections. In previous Alerts, we highlighted how these inadequate plans would draw younger healthier people … Read more

With support from The John A. Hartford Foundation, the Center for Medicare Advocacy has produced two new Checklists to help Medicare beneficiaries and their families respond to unfair Medicare denials based on an erroneous “Improvement Standard.” Per the Jimmo Settlement, CMS revised the Medicare Benefit Policy Manual to clearly disavow any notion that residents of … Read more

The Center for Medicare Advocacy (the Center) submitted comments to the Centers for Medicare and Medicaid Services (CMS) about the devastating impact a proposed rule will have on access to Medicare home health care for vulnerable older and disabled people. The proposed rule purports “to better align payment with patient care needs and better ensure … Read more

New Legislation Dealing with Pre-existing Conditions is Not What it Seems Last week Sen. Thom Tillis (R-NC) and others introduced the Ensuring Coverage for Patients with Pre-Existing Conditions Act. This bill would amend the Health Insurance Portability and Accountability Act to supposedly guarantee the availability of health coverage. The sponsors of the legislation claim that … Read more

In January, Vermont Legal Aid and the Center for Medicare Advocacy settled a case on behalf of Medicare beneficiaries in the six New England states and New York who had had been denied coverage of home health services for not being “homebound.” The settlement in Ryan v. Price, 5:14-cv-269 (D. Vt.), calls for re-review of … Read more

In conjunction with other advocacy organizations, the Center for Medicare Advocacy submitted comments during the re-opened comment period for the Kentucky HEALTH Medicaid Section 1115 waiver demonstration application. The Center strongly believes that Kentucky HEALTH should be rejected as it will lead to substantial coverage losses. Kentucky’s proposal will take health coverage away from individuals … Read more

This is part nine of a ten-part CMA Issue Brief Series examining the growing crisis in access to Medicare home health coverage and necessary care – and outlining the Center for Medicare Advocacy’s work to address these issues. We invite you to follow this Issue Brief Series and submit Medicare home health stories to the … Read more

Effective October 1, 2019, CMS will replace the prospective payment system for skilled nursing facilities, Resource Utilization Group (RUG-IV), with a new prospective payment system called the Patient-Driven Payment Model (PDPM).[1] In all significant respects, the final rules are unchanged from proposed rules published in May.[2] The new system, which is budget-neutral, bases payment on … Read more

Last week, the Secretary of Health and Human Services was reported as claiming, in remarks to the American Legislative Exchange Council, that the Affordable Care Act (ACA) has caused 28 million Americans to be uninsured. In light of this statement, we highlight the many ways the ACA has actually expanded access to insurance coverage and … Read more

Elder Justice: What "No Harm" Really Means for Residents is a monthly 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 to nursing … Read more

The Centers for Medicare & Medicaid Services (CMS) identifies some of the most poorly performing nursing facilities in the country as Special Focus Facilities (SFFs).  In this Second Report on SFFs, the Center for Medicare Advocacy looks at one of four categories of SFFs – those that “have not improved” – and how they game … Read more

Last week, the U.S. Department of Health and Human Services (HHS) released the final rule expanding the use of Short-Term Limited-Duration Insurance. For months, we have been highlighting how these “Junk Plans” would adversely impact both the Affordable Care Act (ACA) Marketplace and consumers with complex care needs. Short-term insurance is meant to be a … Read more

Last week, the Office of Inspector General (“OIG”) published a report[1] of its study on the growth in hospice utilization and reimbursement since 2005.  The Report summarizes key vulnerabilities in the Medicare hospice program affecting quality of care and program integrity, and presents recommendations to the Department of Health and Human Services for protecting beneficiaries … Read more

The Center for Medicare Advocacy wanted to determine whether nursing facilities that had one-star in their health survey ratings on Nursing Home Compare were able to boost their overall ratings from one star to two stars through the designation of five stars in the self-reported quality measure domain.  The finding – that many facilities in … Read more

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy has produced a new Checklist to help Medicare beneficiaries and their families respond to unfair Medicare denials for nursing home care based on an erroneous “Improvement Standard.” The Checklist outlines the coverage criteria for care at a skilled nursing facility and emphasizes … Read more

Charlene Harrington, professor emerita at the University of California San Francisco, and Center for Medicare Advocacy Senior Policy Attorney Toby S. Edelman have written an analysis of the class action lawsuit against twelve Golden Living nursing facilities in Arkansas for insufficient nurse staffing. The case was settled for $72 million in 2017.[1]  In “Failure to … Read more

Last week, the Center for Medicare and Medicaid Services (CMS) issued a notice that beneficiaries in Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island and Vermont will begin receiving new Medicare cards. The agency also announced the completion of the mailing to beneficiaries who live in Alaska, American Samoa, California, Guam, Hawaii, … Read more

The Center for Medicare Advocacy issues this Special Report to shine a light on nursing homes throughout the country that have been identified as providing the poorest quality care to residents – while facing limited, if any, enforcement action as a consequence. Known as Special Focus Facilities, (SFFs), these facilities are identified by the Centers … Read more

The Office of the Inspector General for the Department of Health and Human Services released a report recently regarding Part D coverage of prescription drugs used by people dually eligible for Medicare and Medicaid. The June report, Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles: 2018, found that most Part D plan … Read more

This week, the Kaiser Family Foundation released a poll showing that 56% of Americans believe that the Administration is “trying to make the ACA fail.” The polling also shows that by nearly seven to one, people think this is a negative thing. Over the last few months, we’ve highlighted negative actions taken by the Administration … Read more

Kaiser Family Foundation Report A report recently issued by the Kaiser Family Foundation, “Medigap Enrollment and Consumer Protections Vary Across States” (July 2018), “provides an overview of Medigap enrollment and analyzes consumer protections under federal law and state regulations that can affect beneficiaries’ access to Medigap. In particular, [the] brief examines implications for older adults … Read more

An emerging issue of concern for advocates is nursing facilities’ increased marketing of “in-house” managed care plans – specifically, Institutional Special Needs Plans, or I-SNPs – to their residents.[1]  These Medicare Advantage plans are limited to beneficiaries who require, or are expected to need, institutional long-term care for 90 days or more. A recent article … Read more

In a previous CMA Alert we highlighted a statement reportedly made by CMS Administrator Seema Verma that she took “exception to those out there who have made claims that we have tried to sabotage the health care of the American people, particularly when it comes to the health-care exchanges…” We listed actions taken prior to … Read more

The Social Security Administration (SSA) has released revisions to the Program Operations Manual System (POMS) regarding how to process Part A enrollments that are conditional to a state’s determination of a beneficiary as a Qualified Medicare Beneficiary (QMB).  The update is intended to address inconsistencies and confusion in SSA field offices and includes important clarifications, … Read more

In the proposed rule, published in the Federal Register on July 12, 2018[1], CMS confirms that a patient’s condition does not need to improve for home health care to be covered by Medicare. CMS also acknowledges the following: There have been reports of difficulty accessing coverable home health care, especially when the patient’s condition is … Read more

On July 10, 2018, the President signed an Executive Order undermining the impartial hiring of Administrative law Judges (ALJs). The order states that “conditions of good administration make necessary an exception to the competitive hiring rules and examinations for the position of ALJ.”  What this really means is that ALJs will now be hired directly … Read more

Researchers studying patients with hip fractures found that patients with Medicare Advantage (MA) plans have shorter stays in skilled nursing facilities (SNFs) and receive less rehabilitation than patients in traditional Medicare, but are, nevertheless, less likely to be readmitted to an acute care hospital within 30 days or to become long-term care residents.[1]  These findings … Read more