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  1. Fact-Checking the State of the Union Speech Regarding Health Care
  2. Medicare Oral Health Care Update
  3. Administration Encourages States to Block Grant Medicaid
  4. Center Submits Comments Opposing Social Security Administration Proposal to Increase Frequency of Disability Benefit Reviews 
  5. Free Webinar: Medicare Home Health Coverage

Fact-Checking the State of the Union Speech Regarding Health Care

Earlier this week, President Trump delivered the annual State of the Union speech (see the transcript here). Here we provide a summary of some of the false and misleading statements concerning health care, along with the facts.

Statement 1: “I have also made an ironclad pledge to American families: We will always protect patients with pre-existing conditions.”

The New York Times appropriately labels this claim “false.” As noted by the Times:

The president has taken multiple steps to weaken or eliminate current protections for Americans with pre-existing health conditions. These efforts include legislation he championed, regulation his administration has finished, and a lawsuit the Justice Department is litigating that would declare the Affordable Care Act unconstitutional.

Similarly, a Washington Post article fact-checking the speech elaborates on the lawsuit and other efforts to undermine the Affordable Care Act (ACA):

In an ongoing court case, the Trump administration is supporting a total repeal of the Affordable Care Act — including its guarantee that patients can’t be denied coverage for preexisting conditions. Republicans in Congress tried for years to repeal the whole law. Trump has not presented a plan to cover the gaps in case the court challenge is successful. Moreover, he has promoted short-term plans (which he touted in his speech) that are not required to cover preexisting conditions.

Statement 2: “And we will always protect your Medicare and your Social Security. Always.”

According to an article in the New York Times, this statement is “misleading.”  The Times notes:

Not only has President Trump failed to strengthen Medicare and Social Security, but the financial outlook for both trusts has not improved or worsened. That is at least partly the result of Mr. Trump’s tax law, which has left the Treasury Department to collect fewer taxes from Americans and, in turn, invest less money into each program. Last April, the government projected that Medicare funds would be depleted by 2026, three years earlier than estimated in 2017. The report noted that less money will flow into the fund because of low wages and lower taxes.

Just days earlier, as noted in a different article in the Times, the President suggested that he “would be willing to consider cuts to social safety-net programs like Medicare to reduce the federal deficit if he wins a second term, an apparent shift from his 2016 campaign promise to protect funding for such entitlements.”

Statement 3: “My Administration is also taking on the big pharmaceutical companies.”

As noted in this article from CNN, “Tackling the high cost of prescription drugs was one of Trump’s key campaign promises in 2016. And it’s been a main focus of his administration, though little has actually been done.”

In NPR’s fact check of the speech, they note:

Voters care a lot about America’s high prescription drug costs, but Congress seems to have reached a standstill on passing legislation to help bring them down. The bipartisan effort on the Senate side that Trump mentions here has not won over Senate Majority Leader Mitch McConnell of Kentucky. Until it does, its prospects for passage this year are not great. During this part of the speech, Democrats chanted “HR 3,” the sweeping bill on drug prices that passed the House in December but is very unlikely to pass in the Republican-controlled Senate.

In sum, the state of the union on health care remains under threat. In order to reverse this trend, we urge the Administration to, among other things, drop support of the lawsuit seeking to strike down the Affordable Care Act. We also urge the Senate to take up H.R. 3, which would reduce prescription drug costs and use the savings to expand Medicare coverage for all beneficiaries, not just those enrolled in private Medicare Advantage plans.

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Medicare Oral Health Care Update

Addressing the problem of Medicare’s lack of meaningful oral health coverage has long been a focus of the Center for Medicare Advocacy.  Over the decades, the Center has assisted beneficiaries who require access to medically necessary oral health care, challenged Medicare’s restrictive coverage policy in litigation, and worked with broad coalitions to expand Medicare oral health coverage administratively and legislatively. Read on for updates on some of our recent work in this area:

Comprehensive Oral Health Benefit in Part B

As part of the Center’s continued commitment to improving oral health for older adults and people with disabilities, and expanding Part B to include a comprehensive oral health benefit, the Center supported, and urged passage of, H.R. 3, the The Elijah Cummings Lower Drug Costs Now Act, which reinvests savings from changes to drug pricing into filling gaps in Medicare coverage, like oral health. The legislation passed in the House on December 12, 2019.

The Center expressed support for the legislation both as an organization, and collectively with our fellow oral health advocates. While this historic legislation is an important step toward providing comprehensive oral health coverage for all Medicare beneficiaries, the Center continues to advocate for the oral health benefit to align beneficiary coinsurance with all other services covered under Part B.

The Center was pleased to recently share the results of new polling conducted by Morning Consult, which found that a large majority of respondents support including oral and dental health services as part of the traditional Medicare program. The widespread support for an oral health benefit, combined with the momentum from the passage in the House of this historic legislation, continue to propel the Center’s efforts for a comprehensive oral health benefit.

Case Study: MA Enrollee Wins Coverage for Oral Procedures

Recently, the Center assisted “Mrs. S”, a Medicare Advantage (MA) enrollee in Oregon, who had a rapidly growing cyst in her mouth. Upon the MA plan’s advice, she got a referral from her network physician to see a Medicare-participating oral surgeon, who promptly removed and biopsied the cyst. One of her teeth had to be extracted to remove the cyst. The surgeon billed her for the total procedure, stating it was not Medicare-covered. A claim was submitted to the MA plan, only because her son requested it. The plan denied the claim despite its earlier representation that treatment would be covered.

On appeal, the Center sent a letter to the plan explaining that excision of an oral tumor or lesion is a covered procedure that does not fall within Medicare’s exclusion of payment for services “in connection with the care, treatment, filling, removal, or replacement of teeth or structures supporting teeth.” 42 U.S.C. 1395y(a)(12). The letter also explained that the extraction of Mrs. S’ tooth is also covered, as it was performed “incident to and as an integral part of a covered procedure[.]” Medicare Benefits Policy Manual, Ch. 15, § 150.  The plan reversed its decision and reimbursed Mrs. S for the treatment.

Unfortunately, this is not an isolated case. The Center knows that beneficiaries continue to be denied access to, or payment for, covered oral procedures because MA plans and participating dentists misunderstand Medicare’s oral health coverage policy.

TAKE ACTION to Support Medically Necessary Oral Health Coverage

For the past few years, a coalition of beneficiary advocates, disease organizations, industry groups, oral health and medical health professionals has been advocating for Medicare coverage of medically necessary oral health care, which is authorized under current law. The coalition recently launched a web-based platform for members of the public to express their support and urge the Administration to provide critical coverage for medically necessary oral health services.  Please consider participating and spreading the word. The platform is: https://freeroots.com/campaign/make-medicare-better.

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Administration Encourages States to Block Grant Medicaid

On January 30, 2020 The Centers for Medicare & Medicaid Services (CMS) issued new guidance, through a State Medicaid Director Letter, which encourages states to voluntarily adopt caps on their federal Medicaid funds under a Medicaid section 1115 demonstration waiver. This “block granting” of Medicaid would fundamentally change Medicaid programs by allowing states to limit benefits and services, jeopardizing the health of millions of beneficiaries and their families.

The Center for Medicare Advocacy strongly opposes block granting Medicaid, and urges CMS to rescind this harmful guidance. The Center will work to fight this guidance, and any specific waiver proposals block granting Medicaid that emerge as a result of the guidance.

Additional Resources:

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Center Submits Comments Opposing Social Security Administration Proposal to Increase Frequency of Disability Benefit Reviews

The Center for Medicare Advocacy (“Center”) and California Health Advocates (“CHA”) submitted joint comments in opposition to a proposed Social Security Administration (SSA) rule to increase the frequency of continuing disability reviews (CDRs) (see Notice of Proposed Rulemaking on Rules Regarding the Frequency and Notice of Continuing Disability Reviews, 84 Fed. Reg. 36588 (November 18, 2019), Docket No. SSA-2018-0026). If implemented, this rule will likely cause many people eligible for Medicare based upon receipt of Social Security Disability Insurance (SSDI) to unfairly lose their legitimate right to coverage.

The Center and CHA noted that “[i]ncreasing the burden on the under-65 Medicare population by requiring more frequent CDRs will negatively impact this group, who already face more challenges than the over-65 Medicare population. Not only will more frequent CDRs impose a significant and unwarranted burden on these individuals, many will lose their health insurance coverage. Those who do not lose their health insurance coverage will bear negative health consequences imposed by the strain of unnecessary and burdensome CDRs.”

If implemented, the proposed rule will lead to more people losing Medicare eligibility. This is a devastating consequence at a time when finding other avenues to obtain legitimate pre-Medicare health insurance coverage is becoming more difficult, particularly due to efforts to repeal or otherwise diminish the Affordable Care Act and restrict Medicaid eligibility.

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Free Webinar: Medicare Home Health Coverage

Wed, Feb 19, 2020 2:00 PM – 3:00 PM EST
Sponsored by the National Center on Law & Elder rights

Medicare home health coverage can be a robust benefit under the law for those who qualify. Understanding access to coverage and receiving necessary home care is challenging, and new Medicare payment systems add an additional layer of complexity. Center for Medicare Advocacy Executive Director Judith Stein and Associate Director Kathleen Holt will provide an overview of Medicare coverage law, including who should qualify, for what services, and for how long. Presenters will provide case studies and practice tips to illustrate potential challenges to obtaining and retaining home health coverage and care. 

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