January 2020 Download this Case Study I. Background – The Jimmo Settlement In 2013, a U.S. District Court approved the settlement agreement in Jimmo v. Sebelius,[1] requiring the Centers for Medicare & Medicaid Services (CMS) to confirm that Medicare coverage of home health, skilled nursing facility (SNF), and outpatient therapy services is determined by a … Read more

On January 21, 2020, the Chairmen and Ranking Members of the House Ways & Means, Energy & Commerce, and Education & Labor Committees sent a letter to the Secretaries of Health and Human Services (HHS) and Department of Labor (DOL) asking the “agencies to address the confusion and financial risks that often confront Americans who … Read more

Starting January 1, 2020 Medicare Part B began covering a new Opioid Treatment Program (OTP) benefit. The Centers for Medicare & Medicaid Services (CMS) pay OTPs through bundled payments for opioid use disorder (OUD) treatment services in an episode of care provided to people with Medicare Part B. Under the new OTP benefit, Medicare covers: U.S. Food and … Read more

A study of beneficiaries in traditional Medicare who were hospitalized between January 1, 2011 and September 30, 2015 with certain primary diagnoses (stroke, hip or femur fracture without joint replacement, chronic obstructive pulmonary disease, congestive heart failure, or pneumonia) finds that beneficiaries in rural communities fared differently than those from urban areas. Beneficiaries from rural … Read more

On January 21, 2020, the Supreme Court declined to grant expedited review of the lawsuit that seeks to strike down the entire Affordable Care Act (ACA). Texas and several other states are pursuing the case (now called California v. Texas) with the support of the Trump administration. Even though an expedited schedule was denied, the … Read more

The Center has joined other organizations that advocate for older adults in filing amicus briefs in several lawsuits challenging the Department of Homeland Security’s “public charge” rule. The regulation, finalized last year, represents a drastic change in how applicants for lawful permanent residency (green cards) will be evaluated, and it will have a particularly negative … Read more

On January 15, 2020, the Center for Medicare Advocacy joined AARP and Justice in Aging in filing an amicus brief that urges the U.S. Supreme Court to grant immediate review of the health care repeal lawsuit, Texas v. U.S. The case, which seeks to dismantle the entire Affordable Care Act (ACA), is being pursued by … Read more

The Annual Coordinated Election Period (ACEP) – the period during which individuals with Medicare can make coverage elections for the following year – ended on December 7, 2019.  As discussed in previous CMA Alerts, there were a number of factors impacting the 2019 ACEP that made enrollment decisions even more challenging this past fall. Complicating … Read more

On January 15, 2020, Steve Gleason was awarded a Congressional Gold Medal, the highest civilian honor bestowed by Congress. Mr. Gleason was honored for his work on behalf of individuals with ALS and other debilitating conditions, including through his organization Team Gleason. Center for Medicare Advocacy Executive Director Judy Stein and Associate Director Kathy Holt, … Read more

Mr. G, a retired professional, is a Medicare beneficiary in his 80s with advanced Parkinson’s disease who experienced a bad fall at home. He was hospitalized and then went to a skilled nursing facility for rehabilitation. Mr. G has always had original Medicare along with a stand-alone Part D plan and a Medicare supplemental (“Medigap”) … Read more

On January 2, 2020, the Center for Medicare Advocacy and the Long Term Community Care Coalition issued a joint statement condemning proposed legislation that would weaken nurse aide training requirements. The two bills would weaken current law. Each would allow for a shorter period of prohibition of facility-conducted nurse aide training programs, and for lifting … Read more

Elder Justice: What “No Harm” Really Means for Residents is a 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 and what it means for nursing home … Read more

In October 2019, the Centers for Medicare & Medicaid Services implemented a new federal nursing home payment system, the Patient Driven Payment Model (PDPM). PDPM changed the reimbursement rules and financial incentives for skilled nursing facilities (SNFs). As a result, advocates are already seeing changes in SNF admission practices, and in the provision of therapy and other … Read more

Skilled nursing facilities (SNFs) do not like the prior authorization requirements, limited lengths of stay for residents, and lower Medicare reimbursement rates that are associated with Medicare Advantage (MA) plans. Some SNFs are responding to these concerns by starting their own special type of MA plan called an Institutional Special Needs Plan (I-SNP). I-SNPs are … Read more

Medicare Home Health Coverage and Care Is Jeopardized By the New Payment Model – The Center for Medicare Advocacy May Be Able to Help Actual Recent Case Study Mrs. Green has advanced multiple sclerosis. She spends her time either in bed or in a tilting wheelchair. After receiving Medicare-covered home health care for two years, … Read more

The Center for Medicare Advocacy submitted comments in response to the Centers for Medicare & Medicaid Services (CMS) public comment period regarding Tennessee’s section 1115 waiver application. Regrettably the Tennessee waiver proposal seeks to transform the State’s Medicaid program (TennCare) into a block grant. The Center expressed opposition to this proposal, as it would fundamentally … Read more

On December 29, 2019 Representative John Lewis (D-GA, 05) announced that he will be undergoing treatment for stage IV pancreatic cancer. In a press release, Rep. Lewis stated, “I have been in some kind of fight – for freedom, equality, basic human rights – for nearly my entire life. I have never faced a fight … Read more

Most Read <i>CMA Alerts</i> (Plus, Webinars) of 2019

As 2019 winds down, we took a look back at the CMA Alerts you were most interested in over the last twelve months. News about skilled nursing facilities featured highly, as did Medicare payment changes. Interest in Medicare coverage of oral health remains high, and of course, you continued to follow the ongoing issues of … Read more

The Center for Medicare Advocacy is pleased to 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 Center has long advocated for a comprehensive oral health benefit in Part B of Medicare. This poll … Read more

The Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) recently released a report entitled “Billions in Estimated Medicare Advantage Payments From Chart Reviews Raise Concerns”. The report highlights that in the current risk adjusted payment system that is meant to provide Medicare Advantage (MA) plans with higher payment for … Read more

On October 1, 2019, the Centers for Medicare & Medicaid Services (CMS) implemented a new Medicare reimbursement system for skilled nursing facilities (SNFs) called the Patient-Driven Payment Model (PDPM).[1] The prior system, called Resource Utilization Groups (RUGs), paid higher rates for residents receiving more therapy – the more minutes of therapy billed to Medicare, the … Read more

In a decision that jeopardizes the health care of millions of Americans and the entire Affordable Care Act (ACA), the Fifth Circuit Court of Appeals ruled in Texas v. United States that the ACA’s individual mandate is unconstitutional. The Court remanded the case to the district court to determine how much, if any, of the … Read more

Today the U.S. House of Representatives passed H.R. 3, The Elijah Cummings Lower Drug Costs Now Act, by a vote of 230 to 192. This bill, if enacted into law, would lead to a significant reduction in prescription drug costs. The resulting savings would be reinvested into a critical expansion of Medicare benefits (vision, hearing, … Read more

A unified Medicare payment system that pays all institutional post-acute care providers the same rates, regardless of setting, runs counter to repeated analysis showing that all post-acute providers are not the same, even when they treat patients with similar conditions. It also ignores the significant changes that Medicare made in its new reimbursement system for … Read more

Medicare generally does not cover dental care (see 42 U.S.C. § 1395y(a)(12)).  Under the law, however, if dental treatment must be performed in a hospital, either because of a patient’s underlying condition or the severity of the dental procedure, Medicare Part A covers the costs of the inpatient hospitalization, even if the procedure itself is … Read more

On December 5, 2019, Representatives Linda Sánchez (D-CA) and Jan Schakowsky (D-IL) introduced the Fairness in Nursing Home Arbitration Act (H.R. 5326). The legislation prohibits long-term care facilities from requiring or requesting residents (or their representatives) to sign pre-dispute arbitration agreements. Pre-dispute arbitration agreements, which require victims to give up their right to settle disputes … Read more

The House Ways and Means Committee held a hearing on November 14, 2019 entitled “Caring for Aging Americans.” In a Statement submitted for the record, the Center for Medicare Advocacy expressed concerns about the Patient-Driven Payment Model (PDPM), the new Medicare reimbursement system for skilled nursing facilities that went into effect on October 1, 2019. … Read more

Concerns about nursing home quality have increased over the last several years. For instance, a June 2019 report by the Government Accountability Office (GAO) found that the number of cited abuse violations more than doubled between 2013 and 2017. GAO-led stakeholder meetings identified insufficient staffing, staff training, and staff screening as risk factors. On November … Read more

The Center for Medicare Advocacy (the Center) has developed information, materials, and educational webinars to promote informed choice by beneficiaries. As the Center has written, information about Medicare coverage options produced by the Medicare agency is no longer neutral; instead it now actively promotes private Medicare Advantage (MA) enrollment, and paints MA plans in the … Read more

The Medicare Annual Coordinated Election Period (ACEP) is the period during which individuals review their Medicare coverage for the next year and consider their options. At this time, beneficiaries can return to or continue in Traditional Medicare, or can make changes to their Medicare Advantage (MA) or Part D prescription drug plan (PDP). The Period … Read more

Per a December 5, 2019 press release from Speaker Pelosi’s office, the House of Representatives will vote next week on H.R. 3, the Elijah E. Cummings Lower Drug Costs Now Act. The Act, which the Center for Medicare Advocacy has supported since its inception, would lower Medicare prescription drug costs and, importantly, reinvest the savings … Read more

Adding a Dental Benefit to Medicare Part B One of the Center for Medicare Advocacy’s top priorities is to expand Medicare coverage to include oral and dental care for all beneficiaries. The addition of a comprehensive dental/oral health benefit would go a long way to improve the overall health and well-being of older persons and … Read more

On November 20, the Center for Medicare Advocacy, with support from the John A. Hartford Foundation, convened an online gathering of members of the Jimmo Implementation Council and other stakeholders in the effort to remove barriers to care for people with longer-term, chronic, and debilitating conditions. The Council first met in 2015 in Washington, DC … Read more

Time for Medicare Enrollment – Time to Talk Turkey!

From the Center for Medicare Advocacy and the Medicare Rights Center: Medicare Fall Open Enrollment continues through December 7 — so you still have time to make certain changes to your coverage, including switching prescription drug plans or between traditional (sometimes called Original) Medicare and Medicare Advantage (MA). As friends and families around the country … Read more

November, 2019 Late November begins a time for gatherings with family and friends – Thanksgiving, soon followed by the December holidays. Nursing home residents often want to participate in these gatherings but may worry that they will lose Medicare coverage if they leave the facility to do so. Residents and their families and friends can … Read more

The current Medicare enrollment period ends on December 7, 2019. As reported yesterday in the Minneapolis Star Tribune, while some Medicare Plan Finder (MFP) problems previously identified have been fixed, there are still significant outstanding issues.  As noted in the article, “[i]n some cases, the federal website has been showing wrong information about drug formularies, … Read more

Medicare’s annual open enrollment period (October 15 – December 7), is time for beneficiaries to take stock of their Medicare options for the upcoming calendar year – whether to choose traditional (real) Medicare or a private insurance Medicare Advantage (MA) plan. The Center for Medicare Advocacy (the Center) has developed information, materials, and educational webinars … Read more

Benefit Periods. Medicare covers up to a maximum of 100 days of skilled nursing facility (SNF/nursing home) care in each benefit period. A benefit period begins on the first day that a nursing home resident receives services and ends when the resident has not received inpatient hospital or nursing home services for at least 60 … Read more

On November 8, 2019, the Centers for Medicare & Medicaid Services (CMS) released the 2020 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs. Each year, Medicare premiums, deductibles, and copayment rates are adjusted according to the Social Security Act. For 2020, the cost-sharing amounts for both Medicare Part A … Read more

The Center for Medicare Advocacy is pleased that oral health in Medicare is gaining attention and focus, as evidenced by the number of Congressional bills introduced this year that would add dental benefits to the Medicare program. Among them are the Medicare Dental Benefit Act of 2019 (S.22/H.R. 2951), the Medicare and Medicaid Dental, Vision, … Read more

Medicare’s annual open enrollment period (October 15 – December 7), is time for beneficiaries to take stock of their Medicare options for the upcoming calendar year – whether to choose  traditional (real) Medicare or a private insurance Medicare Advantage (MA) plan. The Center for Medicare Advocacy (the Center) has developed information, materials, and educational webinars … Read more

For years, the Center for Medicare Advocacy has warned of wasteful overspending on private Medicare Advantage (MA) plans, the limitations on access to physicians and health care provided by MA, and the difficulties in obtaining the same coverage from the plans as is available in real Medicare. (See Case Study below.) Despite these efforts, Medicare … Read more

Problems with Medicare Plan Finder Persist As reported by SHIPs across the country and some of our partner organizations, problems with the new Medicare Plan Finder (MPF) persist during the current Medicare Annual Election Period, which lasts through December 7, 2019. These problems include: inaccurate information about covered drugs and costs, non-formulary drugs, dosage options, … Read more

The Centers for Medicare & Medicaid Services (CMS) identifies 88 nursing facilities nationwide that are among the most poorly performing facilities in the country. CMS calls these facilities, generally two per state, Special Focus Facilities (SFFs). SFFs have a special icon on the federal website Nursing Home Compare that identifies their SFF status. At present, … Read more

Medicare’s new reimbursement system for skilled nursing facilities (SNFs), called Patient-Driven Payment Model (PDPM),[1] changed reimbursement rules and the financial incentives for SNFs, effective October 1, 2019. Just one month since implementation, some of the problems that were predicted as a result of PDPM[2] are already being seen. The former reimbursement system, Resource Utilization Groups … Read more

CMS will continue offering “Equitable Relief” to Medicare beneficiaries who are confused about the transition from an ACA Health Insurance Exchange (Marketplace) plan to Medicare. Under Equitable Relief, people who are eligible for Medicare and have Marketplace coverage can apply to enroll in Medicare Part B without penalty. Those who have already transitioned to Medicare … Read more

The Centers for Medicare & Medicaid Services will be implementing revised payment systems for both skilled nursing facility care (effective October 2019) and home health care (effective January 2020). The Center for Medicare Advocacy has written at length and submitted comments on both the home health and skilled nursing facility payment models. Unfortunately, implementing these … Read more

Medicare coverage of nursing home care depends on a resident’s need for skilled nursing and/or therapy, not the resident’s potential for improvement. However, too many nursing home residents continue to be denied skilled services on the basis of an “Improvement Standard,” which was firmly rejected by the court-approved settlement in Jimmo v. Sebelius. In order … Read more

On October 21, 2019, The Center for Medicare Advocacy submitted comments in support of a Centers for Medicare & Medicaid Services (CMS) proposal to modify the instructions to the Advance Beneficiary Notice of Noncoverage (ABN). The change would make it clear that providers may not bill dually eligible beneficiaries before their claim has gone through … Read more

As part of the Center for Medicare Advocacy’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, Center attorneys are participating in oral health partnership meetings this week. The OPEN (Oral Health Progress & Equity Network, a national network of … Read more