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CMS Issues New Hospital Discharge Planning Guidance 

On May 17, 2013, the Centers for Medicare & Medicaid Services (CMS) released an update of Appendix A of the State Operations Manual (SOM) revising its interpretive guidelines for hospital Discharge Planning.  Medicare discharge planning is a Condition of Participation for hospitals. CMS has stated in its regulations that Medicare-participating hospitals must make their discharge planning process available to all patients upon request, even those who are not Medicare patients.

CMS' new guidance to surveyors provides additional detail about the role and functions of hospitals in the transition of patients from the hospital setting to other care settings, including the home.  Unfortunately, the new guidance is provided only in the context of hospitals that are not identified as psychiatric hospitals.  Guidance for the psychiatric hospital setting is set forth elsewhere and is not extensive.  The Center for Medicare Advocacy (the Center) has long advocated that Medicare's discharge planning requirements for all hospital settings should to be more comprehensive.  Effective discharge planning is a key element of successful post-hospital care.


Medicare Trustees Report – released May 31, 2013

2013 Revised Budget Timeline: the budget debt/deficit reduction debate will likely continue throughout the year:

  • House and Senate have released and passed their respective budgets
    • No conference committee has met to work out differences
  • Sequestration went into effect, including 2% provider cut in Medicare, effective April
  • President released proposed FY 2014 budget on April 10, 2013
  • FY2013 Continuing Resolution (CR) expires September 30, 2013
  • Debt ceiling will need to be raised by September 2013 or later
  • Medicare physician’s payment (sustainable growth rate, or SGR) – current “fix” expires Dec 31, 2013 (leading to approx. 25% cut in payment in 2014 if no Congressional action)

Proposals to Fix Medicare Physician Payment (Sustainable Growth Rate, or SGR) Projected price to fix is approx. $138 billion over 10 years


The over seven million people dually eligible for both Medicare and Medicaid represent some of the poorest and most vulnerable health care consumers in the nation. In an effort to improve care coordination and reduce unnecessary costs, CMS and states are moving forward with demonstrations to integrate care for dual eligible beneficiaries.   Six states- Massachusetts, Ohio, Washington, Illinois, California and Virginia have entered into Memorandum of Understanding (MOU) with CMS. All but one of these states (Washington) will be moving large numbers of their dually eligible residents into capitated managed care. The first waves of enrollment in several states will begin in late 2013.

State and national advocates have continually stressed the importance of consumer protections in these demonstrations. Last July, advocates sent a letter to the Medicare Medicaid Coordination Office (also known as The Duals Office) outlining the top ten priorities for beneficiary engagement and protection.  That letter has been updated based on the events of the past year and we will be resubmitting it to the duals office on June 14th 2013. We are currently seeking state and national organizations who work on behalf of dually eligible individuals to sign-on to the letter.

This years recommendations for consumer protections include suggestions for plan contract and rate transparency, the creation and funding of an independent ombudsman, quality measures for long term services and supports as well as state and plan readiness evaluation, among other issues. Please contact Andrea Callow at for a copy of the full letter and information on how to add your organization’s support to the national advocacy effort on behalf of dual eligible beneficiaries. 

For more information about the dual eligible demonstrations see:


Jimmo v. Sebelius (Improvement Standard) No. 11-cv-17 (D.Vt., filed 1/18/11).

As reported during the last Alliance call, the Settlement in this case was approved on January 24, 2013 during a scheduled fairness hearing.  With the settlement now officially approved, the Centers for Medicare & Medicaid Services (CMS) is tasked with revising its Medicare Benefit Policy Manual and numerous other policies, guidelines and instructions to ensure that Medicare coverage is available for skilled maintenance services in the home health, nursing home and outpatient settings.  CMS must also develop and implement a nationwide education campaign for all who make Medicare determinations to ensure that beneficiaries with chronic conditions are not denied coverage for critical services because their underlying conditions will not improve. A new CMS Factsheet on Jimmo was recently made available online and will be discussed on the call. 

The Factsheet is available at:

For more information, see the Center’s website at:

Bagnall v. Sebelius (Observation Status) No. 3:11-cv-01703 (D. Conn., filed 11/3/2011).

On November 3rd, the Center for Medicare Advocacy filed a class action lawsuit on behalf of individuals who have been denied Medicare Part A coverage of hospital and nursing home stays because their care in the hospital was considered "outpatient observation" rather than an inpatient admission. Here is a link to the Press Release announcing the suit: 

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