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  1. CMS Changes Will Help Ensure Low Income Beneficiaries Are Not Illegally Billed
  2. CMS Reissues Improved Medicare Home Health Booklet
  3. Dispelling a Myth: Medicare Home Health Coverage is NOT a Short Term, Post-Acute Care Benefit
  4. The ACA Sabotage Continues

CMS Changes Will Help Ensure Low Income Beneficiaries Are Not Illegally Billed

The Centers for Medicare and Medicaid Services (CMS) is changing reimbursement summaries sent to beneficiaries and providers to plainly state that low income beneficiaries with Qualified Medicare Beneficiary (QMB) status are exempt from paying Medicare cost sharing.

Beginning October 3, 2017, the Medicare Summary Notice (MSN) clearly identifies when the beneficiary was enrolled in the QMB program and will show a $0 balance owed for beneficiaries.

CMS is also adding information and messages to CMS' HIPPA Eligibility Transaction System (HETS) on November 4, 2017 regarding QMB status. The HETS allows providers to check Medicare beneficiary eligibility data in real-time. Including the QMB information in this system will ensure that providers are aware of QMB status in real-time, so they do not illegally bill individuals for cost-sharing.

Beneficiaries enrolled in the QMB program are excused, by law, from paying Medicare cost-sharing for all Medicare Part A and Part B claims.  This includes deductibles, coinsurance and copays. Providers are prohibited from charging them. Beneficiaries enrolled in the QMB program are, by definition, low income. In order to be eligible for the program the individual's monthly income must be at or below 100% of the annual Federal Poverty Level and have limited resources.

Despite this prohibition, a 2015 CMS study found that providers illegally balance-billed participants for Medicare cost-sharing on a regular basis. Due to a lack of information, confusion regarding the system, or concern over outstanding bills, most QMB enrollees participating in the study paid these bills. Additionally, participants reported that unpaid bills were submitted to collection agencies. For beneficiaries with such low incomes, any cost sharing amount can be cost prohibitive and lead to difficult choices regarding paying for other necessities like food and medications, or lead them to forgo necessary medical appointments or care.

The Center for Medicare Advocacy applauds these CMS changes, aimed at ensuring that low-income beneficiaries are not illegally billed by providers. These changes should eliminate such billing from providers who are simply unaware of the program itself, or unaware of a patient’s enrollment in the program. The Center thanks CMS for addressing balance billing of low-income Medicare beneficiaries.

For more information see:

More information on QMB status see:

CMS Reissues Improved Medicare Home Health Booklet

Earlier this year, CMS released the first revision to its Medicare Home Health Booklet since 2011. The Center for Medicare Advocacy (the Center) brought several sections of the revised Booklet to CMS's attention that included confusing or inaccurate information about Medicare home health coverage. CMS accepted many of the Center’s clarifications in the new version of the Booklet – most notably that home health aides can be covered and that home health coverage is available for skilled care to maintain an individual's condition or prevent deterioration.

Although the Center hopes to work with CMS to further improve the Booklet, we are encouraged that CMS accepted many of our suggestions and appreciate efforts to ensure the Booklet more accurately describes Medicare home health care coverage.

View the booklet at:

Dispelling a Myth: Medicare Home Health Coverage is NOT a Short Term, Post-Acute Care Benefit

Few people know that Congress decided years ago to remove caps and prior institutional prerequisites for Medicare's home health benefit. As policies, practices and decision-makers increasingly insist that Medicare home health coverage is intended to be short-term and for people with recent hospital stays, it is important to know this is not true. Indeed, the Omnibus Reconciliation Act of 1980 (P.L. 96-499) expanded the Medicare home health benefit. This law eliminated the annual 100-visit cap and prior hospitalization requirement that existed at the time. The legislative history of the law demonstrates that Congress intended to "liberalize" the home health benefit.[1] Congress expressly stated that unlimited visits would be available[2] and that by eliminating the prior hospitalization requirement, more than 1.1 million beneficiaries would have access to home health care as an alternative to or postponement of hospitalization.[3]

Medicare home health care is often mistakenly referred to as a short term, post-acute care benefit. Since eliminating the annual 100-visit cap and the prior hospitalization requirement in 1980, however, Congress has not acted to reintroduce such limitations. CMS, MedPAC and others should not use payment rules, quality measures, or other vehicles and pronouncements to undermine the express Congressional intent to allow people to remain at home with Medicare-covered home health care so long as they qualify. 


[1] Conference Report – September 4, 1980 – Congressional Record – House – pg 24206.
[2] Amendments to the Medicare Program – Subcommittee on Health of the Committee on Ways and Means – June 15, 1979
[3] Id.


The ACA Sabotage Continues

Last week there were reports that the administration is refusing to have regional staff at the U.S. Department of Health and Human Services (HHS) participate in Affordable Care Act (ACA/Obamacare) outreach and enrollment events. An HHS official is even quoted as saying “As Obamacare continues to collapse, HHS is carefully evaluating how we can best serve the American people who continue to be harmed by Obamacare’s failures.” This kind of sabotage is in direct opposition to the agency’s mission and an objective in their draft strategic plan to, “Improve American’s access to health care and expand choices of care and service options.” Unfortunately, we’ve already seen other mischief making such as:  

  • Shutting down for significant periods of time almost every weekend during open enrollment.
  • Cutting the ACA enrollment period in half.
  • Slashing the outreach budget and funding for community organizations that provide enrollment assistance to people who need health coverage.
  • Creating uncertainty by refusing – at least so far – to commit to paying cost sharing reductions for the full year. Many insurers have suggested that this intentional uncertainty is causing a spike in rates, sometimes in the double digits.

We call on the administration to stop sabotaging the ACA and protect our care.

HHS must remember the words etched on the wall of its national headquarters that “the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life; the sick, the needy…”

We urge the Department of Health and Human Services to honor its pledge: Help people get affordable health coverage. Stop the Sabotage.

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