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The Problem Mr. Jones tripped and fell on his driveway, fracturing his cheek and jaw, tearing the musculature, and crushing several teeth.  He was stabilized in the emergency room on the day of the accident, but in the days that followed he required assessments and procedures to repair damage and restore function to his face … Read more

In cooperation with states, the Centers for Medicare & Medicaid Services (CMS) identifies a subset of nursing facilities, generally one to two facilities per state, that are among the most poorly performing facilities in the country.  These nursing facilities, which CMS calls Special Focus Facilities (SFFs), have “more problems” than other facilities, “more serious problems” … Read more

Most nursing facilities do not have sufficient numbers of nurses to provide the care that residents need.  The result is poor care outcomes for residents – avoidable pressure ulcers, medication errors, inappropriate use of psychotropic medications, failure to assist residents with activities of daily living, avoidable weight loss, falls, and more.   The problem of insufficient … 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

September 2018 Numerous changes were made to Medicare law, regulations and guidance during the first half of 2018.The changes are particularly noteworthy regarding Part C, governing private Medicare plans, known as Medicare Advantage (MA), and Part D, the prescription drug benefit.This report focuses on the impact to Medicare beneficiaries from changes to Parts C and … 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

The Centers for Medicare & Medicaid Services (CMS) identifies some of the worst performing nursing facilities in the country as Special Focus Facilities (SFFs).  This Report looks at one of the four categories of SFFs – those that “have not improved” – and how they game and manipulate CMS’s Five-Star Quality Rating System.[1] As discussed … Read more

Nursing facilities that are identified as among those providing the poorest quality care to their residents face limited, if any, enforcement actions.  This Report looks at these nursing facilities. Background In cooperation with states, the Centers for Medicare & Medicaid Services (CMS), identifies nursing facilities that have a history of serious noncompliance.  These facilities – … Read more

This is the eighth 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

This is Part Seven 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

Beneficiary Protections Expanded in Revised Home Health Conditions of Participation

This is Part Six 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

I. JIMMO IMPLEMENTATION UPDATE Background – Jimmo Settlement The settlement in Jimmo v. Sebelius, No. 5:11-cv-17 (D. Vt.) was approved on January 24, 2013.  CMS issued revisions to its Medicare Benefit Policy Manual to clarify that Medicare coverage is available for skilled maintenance services in the home health, nursing home and outpatient settings.  CMS also implemented … Read more

This is Part Five 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

I. HEALTH REFORM: UPDATE Overview On May 4, 2017, the U.S. House of Representatives passed the American Health Care Act (AHCA) by a vote of 217-213.  The bill then moved on the Senate, and was reintroduced, with some minor changes, as the Better Care Reconciliation Act of 2017 (BCRA). Both AHCA and BCRA would cause substantial … Read more

This is Part Four 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

This is Part Three 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 Center … Read more

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 Center at https://www.medicareadvocacy.org/submit-your-home-health-access-story/. Download the complete Brief … Read more

Proposed changes to nursing facility payment under consideration by CMS would reduce financial incentives to provide therapy, and would do so with such force – providing higher reimbursement to skilled nursing facilities (SNFs) that provide fewer types of therapy to residents over a shorter period of time or no therapy at all – that it … Read more

This is Part Two of a Ten-Part CMA Issue Brief Series to examine, and inform work to resolve, the growing crisis in access to Medicare home health coverage and necessary care.  We invite you to follow this Series and provide Medicare home health stories at https://www.medicareadvocacy.org/submit-your-home-health-access-story/. CMA Issue Brief Series: Medicare Home Health Care Crisis … Read more

Today the Center for Medicare Advocacy launches a Ten-Part Series to examine and continue work to resolve the growing crisis in access to Medicare home health coverage and necessary care. We invite you to follow this Series and provide Medicare home health stories at https://www.medicareadvocacy.org/submit-your-home-health-access-story/ Medicare Home Health Crisis Series Overview – The Crisis in … Read more

Mandating specific levels of direct care nursing staff would seem to be a straightforward method to improve staffing in nursing facilities.  If more nursing staff are needed, why not simply require facilities to employ more nurses?  The strategy is far more complex, however, than it at first appears.  This paper reviews which states have tried … Read more

This project has produced a series of short papers evaluating various state approaches to improving nurse staffing levels at nursing facilities.  The papers have addressed state-mandated nurse staffing levels, wage pass-throughs, increasing reimbursement, and public and private (non-tort) litigation.  This paper, in contrast, considers whether regulatory changes at the federal level, while not specifically directed … Read more

On October 4, 2016, the Centers for Medicare & Medicaid Services (CMS) published revised Requirements of Participation (RoP) for skilled nursing facilities (Medicare) and nursing facilities (Medicaid).[1]  Although the substantive standards for nurse staffing are unchanged, CMS’s reorganization of the RoPs included moving the nurse staffing requirements to a different section[2] and moving standards for … Read more

CMS recently finalized significant changes affecting Medicare appeals, particularly at the Administrative Law Judge (ALJ) level of review.  These changes apply to appeals of payment and coverage determinations for items and services furnished to Medicare beneficiaries, enrollees in Medicare Advantage (MA) and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as … Read more

If Medicaid becomes a block grant program, nearly one million nursing home residents who rely on Medicaid could immediately lose coverage for their nursing home care.  In addition, all of the federal standards that govern nursing home care today could be in jeopardy.  The United States does not have a comprehensive program to pay for … Read more