August 19, 2013 Senate Finance Committee House of Representatives, Committee on Ways and Means United States Congress Submitted electronically to: postacutecarereform@finance.senate.gov and postacutecarereform@mail.house.gov Re: Comments on Post Acute Care (PAC) Reform Proposals Dear Committee Members: The undersigned organizations, the Center for Medicare Advocacy, the National Senior Citizens Law Center, the National Committee to Preserve Social Security and Medicare, … Read more

Joining the discussion about hospitals' extended use of observation status, the Department of Health and Human Services' Office of Inspector General (OIG) has issued a memorandum report that describes the nationwide use of observation and outpatient stays in calendar year 2012.  OIG reports that more than 600,000 Medicare beneficiaries had hospital stays lasting at least … Read more

Although a large and increasing number of Senators and Representatives now support bipartisan legislation to solve the problem of Observation Status, many beneficiaries and their families continue to face this outpatient status as a barrier to Medicare coverage of care in a skilled nursing facility.  This Alert describes the continuing problem, Congressional legislation, a survey … Read more

PROGRAM INTEGRITY: OVERSIGHT OF RECOVERY AUDIT CONTRACTORS United States Senate Committee on Finance Hearing June 25, 2013 Statement Submitted by the Center for Medicare Advocacy, Inc. The Senate Finance Committee’s June 25 hearing on the Recovery Audit Contractors (RACs) program highlights the high financial costs that the RAC program has imposed on acute care hospitals … Read more

As part of the annual update to inpatient hospital reimbursement under the Medicare program, the Centers for Medicare & Medicaid Services (CMS) is again considering observation status.  This time CMS is proposing "a time-based presumption of medical necessity for hospital inpatient services based on the beneficiary's length of stay."  78 Fed. Reg. 27486, 47644 (May … Read more

Yesterday, President Obama unveiled his Fiscal Year 2014 Budget.[1]   It contains significant changes to the Medicare program – including some that would strengthen the program's fiscal stability, and some that would weaken the program and shift costs to beneficiaries.  On the one hand, it offers serious improvements to strengthen Medicare's financial footing: proposals that allow … Read more

The Center for Medicare & Medicaid Services (CMS) recently issued proposed rules and an interim CMS Ruling to allow  hospitals to bill Medicare Part B after a Part A claim is denied. 78 Fed. Reg. 16,632 (March 18, 2013).[1]  These actions address some financial concerns of hospitals about “observation status;” but they do not help … Read more

Introduction Checklist for Skilled Nursing Facility (SNF) Appeals Quick Screen: Should My SNF Care Be Covered By Medicare? Skilled Nursing Facility Appeal Details Additional Information The “Improvement Standard” Myth and Skilled Nursing Facility Care Glossary of Terms Federal Regulations – SNF Coverage Federal Regulations – Expedited Appeals Centers for Medicare & Medicaid Services (CMS) Manual Provisions 1. Introduction … Read more

Based on an article by Judith A. Stein, Executive Director, Center for Medicare Advocacy, Copyright © 2013 Bloomberg BNA (2/2013). Mrs. “P” was 68 years old and living with Amyotrophic Lateral Sclerosis (ALS, commonly known as Lou Gehrig's disease) when she contacted the Center for Medicare Advocacy. She needed a wheelchair, was unable to stand … Read more

Here’s the Issue  Expedited Medicare appeals and standard Medicare appeals are designed to address different things and there are situations where a Medicare beneficiary must pursue both types of appeals. Expedited Appeals – Address whether the provider’s termination of Medicare-covered services was proper. Standard Appeals – Address whether any subsequent services the beneficiary chose to … Read more

August 16, 2012 On June 1, 2012, the Centers for Medicare & Medicaid Services (CMS) issued Transmittal No.R2480CP, which updates its instructions on the issuance of the Advance Beneficiary Notice (ABN), Form CMS-R-131.[1]  The changes are effective on September 4, 2012.[2]  The new transmittal is part of an ongoing effort by CMS to provide additional … Read more

1. MEDICARE AND ACA MESSAGING: FIGHTING FICTION WITH FACT As pundits and politicians continue to discuss the deficit, misinformation and confusion about Medicare abound.  Fiction seems to flourish more than fact. Particularly since the passage of the Affordable care Act (ACA), we are hearing a lot of misinformation about the law and its impact on … Read more

Save Medicare

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Mr. Blake* is an 86-year old grandfather who fell and was taken to the emergency room with a broken back and internal bleeding.  After being treated for eight days, the hospital still denies that he is an inpatient. Instead, they claim Mr. Blake is simply an "outpatient under observation status." Because he is not considered … Read more

National Medicare Advocates Alliance ISSUE BRIEF #15                                                                                          FEBRUARY, 2012 __________________________________________________________________ EXTENDER … Read more

I. LEGISLATIVE UPDATE Failure of the Super-Committee On November 21, 2011, members of the Joint Select Committee on Deficit Reduction ("Super-Committee") announced that they had failed to put together a legislative package to cut the deficit by approximately $1.2 trillion, as outlined by the Budget Control Act of 2011.  Without further Congressional action, automatic cuts … Read more

What does Medicare cover for an inpatient psychiatric hospital stay?  Are outpatient psychiatric services covered by Medicare? How much will Medicare pay for mental health and substance use services, and what out-of-pocket costs will beneficiaries be responsible for? Is there information from Medicare.gov on mental health and substance abuse services? For further information, follow one … Read more

Part B

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What items or services are covered by Medicare Part B? Are routine physical exams covered under the Medicare Part B benefit? What does it mean if my doctor "accepts assignment?" Does Medicare Part B pay for the entire cost of Part B services? Does Medicare cover dental services, eyeglasses or hearing aids? For other information, follow … Read more

New Resources! Watch: Jimmo Implementation Council Webinar, November 2019 This webinar features a panel of experienced providers discussing the documentation and provision of successful maintenance therapy.  It can be done. Checklists for “Improvement Standard” Denials Toolkit: Medicare Home Health Coverage & Jimmo v. Sebelius Toolkit: Medicare Skilled Nursing Coverage and Jimmo v. Sebelius Jimmo Corrective … Read more

What services are covered by Medicare Part A? What services are covered by Medicare Part B? What ISN’T covered by Medicare? How can I appeal a Medicare denial? What are my rights and responsibilities regarding Medicare Part D? For other information, follow one of the links below or scroll down the page. PART A COVERAGE … Read more

Glossary of Terms

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  The letters at the top of the glossary chart will act as alphabetical links. To search for a specific word or phrase on this page, use the Ctrl+F keys on your keyboard, and enter the word you are looking for. If you do not find the term you are searching for, please feel free … Read more

President Obama signed into law Pub.L.111-148, the Patient Protection and Affordability Care Act of 2010 (PPACA), on March 23, 2010, and Pub. L. 111-152, the Health Care and Education Reconciliation Act of 2010 (HCERA), on March 30, 2010. These two laws will change both the availability of health insurance and how health care is delivered … Read more

By Gill Deford, Margaret Murphy, and Judith Stein Diagnosed three years earlier with Amyotrophic Lateral Sclerosis (“ALS,” or otherwise known as “Lou Gehrig’s Disease”), 68-year-old Eileen Prendergast was suddenly informed by her home health agency that Medicare would no longer cover the home health care on which she depended.[1] Ms. Prendergast, who needed an electric … Read more