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  1. State of the Union Speech Touches on Health Care Issues
  2. Outpatient Therapy Caps: What Now?
  3. Observation Status Update Webinar Now Available
  4. Nursing Home Resident’s Rights Newsletter – January Edition
  5. Kaiser Family Foundation Issues Report on Medicare Beneficiaries’ Out-of-Pocket Spending
  6. Center for Medicare Advocacy Comments on HHS Request for Information

State of the Union Speech Touches on Health Care Issues 

Early-Bird Registration Ends Feb. 5th

5th Annual National Voices of Medicare Summit &
Sen. Jay Rockefeller Lecture

This year's Summit will focus on health care activism, civic engagement, and efforts to preserve (and enhance) the Affordable Care Act, Medicare, and Medicaid. Senators Chris Murphy and Jay Rockefeller will be present to help participants think about building a healthy future for all Americans.

In anticipation of last night’s State of the Union address, the Center issued a guide entitledHow to Listen to Tonight’s State of the Union Address that included some suggestions for how to listen to, and translate, key statements related to health care that may be in the speech.  Sometimes policymakers, including presidents, speak in code – they say one thing, but mean something else.

While the bulk of the speech focused on issues unrelated to health care, the President did touch on a few health care issues.  Here is how we responded on our Twitter feed (@CMAorg) during the speech:

  • The President touted the repeal of the core of "Obamacare," the so-called "individual mandate." Translation: Millions more people will be uninsured and premiums will increase for families all over the country. #ProtectOurCare #SOTU
  • Despite removal of the individual mandate and other #ACA sabotage, Americans still signed up in record numbers because we need #AffordableHealthcare. #ProtectOurCare #SOTU
  • President: We are giving "choice" in their #healthcare coverage. Translation: Privatize the VA and other public health care programs. #ProtectOurCare #SOTU
  • "Religious liberty" and "choice in their #healthcare decisions." #SOTU –  which translates to letting providers refuse to provide care (overall health care, abortions), or insisting on providing care (end-of-life), and/or refusing care to groups of people they find offensive. This could lead to a form of legalized discrimination and could harm older and disabled people
  • The President says one of his greatest priorities is to reduce the cost of prescription drugs. Says he will instruct his administration to do so this year. So – can we finally expect #Medicare to negotiate drug prices, @SecAzar? #SOTU

While the State of the Union did not focus on health care, we need to be informed, careful listeners as proposals are discussed in the months ahead in order to know what is really meant, and how to respond.


Outpatient Therapy Caps: What Now?

Since the Balanced Budget Act of 1997, outpatient therapy under Medicare Part B has been subject to dollar limits, or caps.[1]  During most of these 20 years, an “exceptions” process has allowed beneficiaries and providers to seek coverage above the caps.  The exceptions process expired December 31, 2017.  Although legislation to repeal the therapy caps and replace them with a process of targeted medical review has bipartisan and bicameral support, it was not included in the budget bill that Congress passed in January 2018.

Effective January 1, 2018, there are hard, unavoidable caps on therapy – a $2010 cap for physical and speech therapy combined, and a separate $2010 cap for occupational therapy. 

The Centers for Medicare & Medicaid Services (CMS) has announced that it will change its method for processing therapy claims.[2]  Just after January 1, 2018, when the caps went into effect, “CMS took steps to limit the impact on Medicare beneficiaries by holding claims affected by the therapy caps exceptions process expiration.”  It paid claims without the KX modifier (which signals that therapy was provided above the cap and that the provider considered the therapy medically necessary) as long as the beneficiary had not exceeded the cap.  Claims exceeding the cap were denied.

Beginning January 25, however, CMS “will immediately release for processing held therapy claims with the KX modifier” for claims beginning January 1-10, 2018.  Beginning January 31, “CMS will release for processing the held claims one day at a time based on the date the claim was received, i.e., on a first-in, first-out basis.”  CMS will use a “rolling hold” of 20 days “to help minimize the number of claims requiring reprocessing and minimize the impact on beneficiaries if legislation regarding therapy caps is enacted.”

As time goes by, the number of beneficiaries reaching the arbitrary caps will continue to increase.  This issue requires resolution immediately to assure that beneficiaries receive the therapy services they need to improve and, as guaranteed by the Jimmo v. Sebelius Settlement,[3] to maintain, prevent or slow decline of their condition.

[1] For a history of therapy caps, see CMA, “Medicare Therapy Caps: A Call for Repeal” (CMA Alert, ), also CMA, “Remember People with Medicare in Renewed Spending Bill Debates” (Alert, Jan. 24, 2018),
[2] CMS, “Expired Medicare Legislative Provisions and Therapy Cap Claims with the KX Modifier Rolling Hold” (Jan. 25, 2018),
[3] See the Center’s materials on Jimmo at  





Observation Status Update Webinar Now Available

On January 24, 2018, the Center for Medicare Advocacy presented the latest in our ongoing webinar series: Hospital Observation Status Update. Center Litigation Director Alice Bers and Center Senior Policy Attorney Toby S. Edelman, presented an overview of the problem of Observation Status, including an update on the Barrows case seeking appeal rights for those placed in Observation, and a discussion of options for those trapped by this ongoing problem.


Nursing Home Resident’s Rights Newsletter – January Edition

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, how prevalent "no harm" deficiencies are, and what "no harm" actually means to residents.

This issue provides real stories of resident harm from California, Illinois, Iowa, Florida, and Michigan. Some of the examples of resident harm include an avoidable accident that resulted in a resident’s shinbone breaking, inadequate housekeeping and maintenance that resulted in a maggot infestation on a resident’s scrotum, and staff intentionally choosing not to assess a resident’s sudden physical and emotional decline. 

Kaiser Family Foundation Issues Report on Medicare Beneficiaries’ Out-of-Pocket Spending

The Kaiser Family Foundation (KFF) just released a report entitled “Medicare Beneficiaries’ Out-of-Pocket Health Care Spending as a Share of Income Now and Projections for the Future” (January 2018).  As noted in the report, “[w]ith half of all Medicare beneficiaries living on annual per capita income of less than $26,200, out-of-pocket health care costs can pose a challenge, particularly for beneficiaries with modest incomes and those with significant medical needs.”
Using a broad definition of health care expenses beyond beneficiary out-of-pocket expenses projected in the annual Medicare Trustees’ report, KFF notes that “rising health care costs post significant affordability challenges for many people on Medicare today, particularly those with relatively low incomes who derive most of their income from Social Security, and […] this burden can be expected to grow in the future.” 

The Report’s key findings, as stated in the Executive Summary, are:

  • In 2013, Medicare beneficiaries’ average out-of-pocket health care spending was 41 percent of average per capita Social Security income; the share increased with age and was higher for women than men, especially among people ages 85 and over.
  • Medicare beneficiaries’ average out-of-pocket health care spending is projected to rise as a share of average per capita Social Security income, from 41 percent in 2013 to 50 percent in 2030.
  • Half of beneficiaries in traditional Medicare spent at least 14 percent of their per capita total income on out-of-pocket health care costs in 2013. The spending burden was higher for people ages 85 and over, in poor health, and with modest incomes.
  • More than one-third (36 percent) of beneficiaries in traditional Medicare, and half of those with incomes below $20,000, spent at least 20 percent of their per capita total income on out-of-pocket health care costs in 2013. By 2030, more than 4 in 10 (42 percent) traditional Medicare beneficiaries are projected to spend at least 20 percent of their total income on health-related out-of-pocket costs.


Center for Medicare Advocacy Comments on HHS Request for Information

Last week, the Center, collaborating with other advocates, provided comments to the U.S. Department of Health and Human Services’ (HHS) Request for Information (RFI): Promoting Healthcare Choice and Competition Across the United States. Our comments called on the Administration to be more transparent when issuing RFIs, to ensure broad feedback from stakeholders and the general public. HHS chose to release this RFI as “informal” and bypass publication in the Federal Register, an action that suppresses important feedback from critical stakeholders and limits public awareness. 

Some of the objectives of HHS as stated in the RFI are to “lower barriers to entry and improve access to and the quality of information that Americans need to make informed healthcare decisions.” In our comments we indicate that these objectives will not be accomplished unless the Affordable Care Act (ACA) is fully implemented. The ACA is the law of the land, and HHS is legally obligated to implement the law. The RFI describes ACA insurance as “expensive” and “mandate laden.” Such negative language is further evidence of the Administration’s goal to let the ACA fail. The American people deserve access to affordable, quality health coverage. Any attempt to weaken the ACA or its essential benefits through regulation is unacceptable and must be rejected. 

Concerning Medicare, we agreed that people with Medicare and other health care consumers must be given all the information, tools, assistance, guidance, and protection from unscrupulous actors they need in order to make the best choices for their particular, unique, circumstances. We provided suggestions to help people with Medicare benefit from changes within the program that would increase their ability to make informed choices, get the care they want and need, and hold plans accountable for failing to meet their obligations. 


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