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1. MEDICARE EDUCATION & OUTREACH At a February 8, 2019 meeting of the Center for Medicare & Medicaid Services’ (CMS) National Medicare Education Program (NMEP), the agency released information about the 2018 Annual Coordinated Election Period (ACEP), sometimes referred to as “Open Enrollment” or “OP.” (Note: this is a downloadable “zip” file containing several items. … Read more

Disclaimer: the views expressed in this Issue Brief and during the Alliance call are solely those of the Center for Medicare Advocacy. ACCESS TO CARE    Home Health Between April 2017 and October 2018, the Center completed the “CMA Issue Brief Series: Medicare Home Health Crisis” – a ten-part series examining the growing crisis in … Read more

Disclaimer: the views expressed in this Issue Brief and during the Alliance call are solely those of the Center for Medicare Advocacy. BETTER ADVANCE CARE LEGAL COUNSELING   Presented by American Bar Association Commission on Law and Aging Director Charles Sabatino See separate PowerPoint slide presentation and ABA Commission on Law and Aging publication “Advance … Read more

Disclaimer: the views expressed in this Issue Brief and during the Alliance call are solely those of the Center for Medicare Advocacy. RECENT CHANGES IN LAW, REGULATIONS AND GUIDANCE RELATING TO MEDICARE ADVANTAGE AND PART D CMA Special Report (September 2018): http://www.medicareadvocacy.org/special-report-recent-changes-in-law-regulations-and-guidance-relating-to-medicare-advantage-and-the-prescription-drug-benefit-program/ Overview The first half of 2018 has seen a number of changes in … Read more

MEDICARE HOT TOPICS[1] ORAL HEALTH UPDATE On July 19, 2018 the Center issued the following press release: July 19, 2018 – Washington, DC – The Center for Medicare Advocacy, along with a diverse group of partners, released a white paper, An Oral Health Benefit in Medicare Part B: It’s Time to Include Oral Health in Health Care. … Read more

RECENT POLICY CHANGES RELATING TO MEDICARE ADVANTAGE The first few months of 2018 have seen a number of changes in law, regulations and sub-regulatory guidance that impact the Medicare program, particularly Part C, known as Medicare Advantage (MA), and Part D, the prescription drug benefit.  The section below highlights some, but not all, of these … Read more

FEDERAL UPDATE Federal Budget & Omnibus Bill On February 9, 2018, the Bipartisan Budget Act of 2018 was signed into law.  While the Budget Act included a number of permanent provisions, including those discussed below, it only extended spending on the federal budget through another short-term continuing resolution (CR), which expires March 23rd.  The remainder … Read more

MEDICARE APPEALS Expedited v. Standard Appeals – Not Knowing the Difference Can Cost You Your Appeal Rights 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 … Read more

ENROLLMENT IN MEDICARE CMS Steering to Medicare Advantage? The Medicare Annual Coordinated Election Period (ACEP), from October 15th through December 7th, allows Medicare beneficiaries to make certain changes to their Medicare coverage, effective the following January 1st.  Official Center for Medicare & Medicaid Services (CMS) Medicare Open Enrollment materials for 2018 tip the scales to … Read more

I. JIMMO IMPLEMENTATION UPDATE Background – Jimmo Settlement The settlement in Jimmo v. Sebelius, No. 5:11-cv-17 (D. Vt.) was approved on January 24, 2013.  CMS issued revisions to its Medicare Benefit Policy Manual to clarify that Medicare coverage is available for skilled maintenance services in the home health, nursing home and outpatient settings.  CMS also implemented … Read more

I. HEALTH REFORM: UPDATE Overview On May 4, 2017, the U.S. House of Representatives passed the American Health Care Act (AHCA) by a vote of 217-213.  The bill then moved on the Senate, and was reintroduced, with some minor changes, as the Better Care Reconciliation Act of 2017 (BCRA). Both AHCA and BCRA would cause substantial … Read more

HEALTH REFORM: HOUSE PASSES AMERICAN HEALTH CARE ACT (AHCA) On May 4, 2017, the U.S. House of Representatives passed the American Health Care Act (AHCA) by a vote of 217-213.  The bill will now be taken up by the Senate. American Health Care Act (AHCA): Impact on the Affordable Care Act, Medicare and Medicaid The … Read more

LITIGATION UPDATE Barrows v. Price (formerly Bagnall v. Sebelius, Barrows v. Burwell), No. 3:11-cv-1703 (D. Conn.) (Observation Status). In November 2011, the Center for Medicare Advocacy and Justice in Aging filed a proposed class action lawsuit on behalf of individuals who have been denied Medicare Part A coverage of hospital and nursing home stays because … Read more

THE FIGHT TO PROTECT THE ACA, MEDICARE AND MEDICAID The President-Elect and Republican leaders in Congress have promised to repeal, and at some point, “replace” the Affordable Care Act.  They also plan to gut the Medicaid program by imposing block granting or per-capita caps.  Speaker Ryan, Trump’s nominee for HHS Secretary Rep. Price, and many … Read more

MOVING FORWARD WITH HOPE It’s no surprise that the election has left many of us worried and disoriented.  But we’ll regroup. We may not understand where we’ve landed, but we’ll acclimate and march forward – with hope. We hope the new administration will realize how today’s families are balancing – often barely – all the … Read more

National Medicare Advocates Alliance Issue Brief #41, September 2016 LITIGATION UPDATE Barrows v. Burwell (formerly Bagnall v. Sebelius), No. 3:11-cv-1703 (D. Conn.) (Observation Status). In November 2011, the Center for Medicare Advocacy and Justice in Aging filed a class action lawsuit on behalf of individuals who have been denied Medicare Part A coverage of hospital … Read more

PROPOSED RULE TO REVISE MEDICARE ADMINISTRATIVE APPEALS PROCESS As discussed during previous Alliance calls, there is a significant backlog of cases at the third and fourth levels of the Medicare administrative appeals process, the administrative law judge (ALJ) stage administered by the Office of Medicare Hearings and Appeals (OMHA), and the Medicare Appeals Council (Council) … Read more

MEDICARE’S COVERAGE OF ORAL HEALTH   Current Centers for Medicare & Medicaid Services (CMS) policy[1] broadly bars Medicare coverage for practically all dental services.  The Center for Medicare Advocacy firmly believes that CMS has the legal authority under the Medicare statute to cover medically necessary oral health care – that is, treatment deemed necessary by … Read more

LITIGATION UPDATE Barrows v. Burwell (formerly Bagnall v. Sebelius) (Observation Status) No. 3:11-cv-01703 (D. Conn., filed 11/3/2011). In November 2011, the Center for Medicare Advocacy and Justice in Aging 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 … Read more

LEGISLATIVE UPDATE Senate Finance Committee Releases Document for Comment   In December 2015, the Senate Finance Committee’s Bipartisan Chronic Care Working Group released a Policy Options Document.  The following is an excerpt from a 12/18/15 Press Release by Senate Finance Committee announcing the document’s release: (available at: http://www.finance.senate.gov/release/hatch-wyden-isakson-warner-release-chronic-care-options-paper): The “Finance Committee Chronic Care Working Group, … Read more

LEGISLATIVE UPDATE: CONGRESS MITIGATES INCREASES IN 2016 PART B PREMIUM AND DEDUCTIBLE Bipartisan Budget Act of 2015 – Overview On Monday November 2, 2015, President Obama signed into law the Bipartisan Budget Act of 2015.  This wide-ranging budget agreement includes provisions that averted a pending government default by raising the nation’s debt ceiling, and prevents … Read more

ADMINISTRATIVE UPDATE 1. Proposed Requirements of Participation for Nursing Facilities On July 16, 2015, the Centers for Medicare & Medicaid Services (CMS) published proposed rules to revise the nursing home Requirements of Participation (RoPs) – the federal rules that govern the standards of care that facilities must meet in order to participate in the Medicare … Read more

LEGISLATIVE UPDATE 1.Senate Finance Committee Addresses Medicare Appeals System On previous Alliance calls, we have discussed that through the Center’s extensive experience with the Medicare administrative appeals process, we continue to find that: The success rates for beneficiaries at the initial levels of Medicare appeal are dismal; and The average wait for a decision at … Read more

LEGISLATIVE/BUDGET UPDATE 1.Medicare Physician Payment (SGR) In an effort to address the perennial issue of payment for Medicare physicians — the fundamentally flawed reimbursement system known as the sustainable growth rate or SGR – the House of Representatives overwhelmingly passed a “doc fix” package on March 26, 2015 that would repeal and replace the SGR.  … Read more

LITIGATION UPDATE Recent Litigation Victories Bagnall v. Sebelius (Observation Status) No. 3:11-cv-01703 (D. Conn., filed 11/3/2011). In November 2011, the Center for Medicare Advocacy and the National Senior Citizens Law Center filed a class action lawsuit on behalf of individuals who have been denied Medicare Part A coverage of hospital and nursing home stays because … Read more

LEGISLATIVE UPDATE The Year Ahead 1. Legislative & Budget Landscape in a New Congress In the 114th Congress staring in January 2015, Republicans will control both the House of Representatives and the Senate.  What will this mean for health care policy generally and Medicare specifically?  Here are a few different takes: American Enterprise Institute (AEI) briefing … Read more

1.  LEGISLATIVE UPDATE: THE IMPACT ACT OF 2014 On October 6, 2014, President Obama signed into law the “Improving Medicare Post-Acute Care Transformation Act of 2014” or IMPACT Act.  The bill resulted from a bipartisan, bicameral effort by the House Ways & Means and Senate Finance Committees to address various issues relating to care Medicare … Read more

1.  CHANGES TO MEDICARE’S QUALITY IMPROVEMENT ORGANIZATIONS (QIOs)     CMS has restructured its Quality Improvement Organization (QIO) Program to separate the beneficiary complaint review functions from the quality improvement functions. The change information described below is response to many years of urging CMS to separate the review of beneficiary complaints function of QIOs from … Read more

1.  MEDICARE’S COVERAGE OF CAPPED RENTAL ITEMS DURING PART A INSTITUTIONAL STAYS: LOSING ACCESS TO SPEECH GENERATING DEVICES (SGDs) CMS Changes Its Coverage of Speech Generating Devices Through a new interpretation of longstanding rules, CMS is currently leading an outright attack on coverage for Speech Generating Devices (SGDs).  SGDs are typically tablet-like units that allow … Read more

1.  LITIGATION UPDATES Jimmo v. Sebelius (Improvement Standard) No. 11-cv-17 (D.Vt. filed 1/18/11).  As reported during previous Alliance calls, the Settlement in Jimmo was approved on January 24, 2013 during a scheduled fairness hearing.  As previously discussed, CMS has issued revisions to its Medicare Benefit Policy Manual to ensure that Medicare coverage is available for skilled … Read more

1. PRESENTATION:  RE-REVIEW OF PREVIOUSLY DENIED CLAIMS PURSUANT TO THE JIMMO SETTLEMENT In addition to revising Medicare manual provisions to now allow Medicare coverage for skilled maintenance care, the Settlement Agreement in Jimmo v. Sebelius provides that Medicare beneficiaries who were previously denied Medicare coverage may have claims re-reviewed under the revised manual provisions.  The … Read more

1. PRESENTATION: CMS MANUAL PROVISIONS ISSUED PURSUANT TO THE JIMMO SETTLEMENT The Center for Medicare Advocacy is pleased to announce that the Medicare Policy Manuals have been revised pursuant to the Jimmo vs. Sebelius Settlement.  The Jimmo case ended a longstanding practice denying Medicare coverage to people who had “plateaued,” or were “chronic,” or “stable,” or “not … Read more

1. PRESENTATION:  MEDICARE ANNUAL ELECTION PERIOD & THE MARKETPLACES Medicare Annual Coordinated Election Period (ACEP) – 10/15/13 – 12/7/13  During the Annual Coordinated Election Period (ACEP) people with Medicare can change their choice of health coverage (whether they receive that coverage through a private Medicare Advantage plan or traditional Medicare), and add, drop or change Medicare … Read more

1.  PRESENTATION:  UPDATE ON HOSPITAL OBSERVATION STATUS  Observation status is getting a lot of attention from Congress, the media, and researchers.  The bipartisan federal legislation, the Improving Access to Medicare Coverage Act of 2013, has gotten more cosponsors daily.  As of August 6, the House bill, H.R. 1179, introduced by Congressman Joseph Courtney (D, CT), … Read more

1.  PRESENTATION  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 … Read more

And Proposals for the Future of Medicare 1.  PRESENTATIONS MEDICARE’S ADMINISTRATIVE REVIEW PROCESS – ONGOING DUE PROCESS CONCERNS & POSSIBLE SOLUTIONS During our October 2012 Alliance call, we discussed that through the Center’s extensive experience with the Medicare administrative appeals process, we continue to find that: 1) the success rate for beneficiaries at the initial … Read more

1.  PRESENTATIONS UPDATE ON JIMMO:  SETTLEMENT APPROVED In January 2011, the Center for Medicare Advocacy and Vermont Legal Aid filed a lawsuit in the District Court of Vermont challenging Medicare’s “Improvement Standard.” Jimmo v. Sebelius No. 11-cv-17 (D.Vt., filed 1/18/11). This case argues that the "Improvement Standard", which operates as a rule of thumb to … Read more

1.  PRESENTATIONS UPDATE ON JIMMO: THE IMPROVEMENT STANDARD CASE In January 2011, the Center for Medicare Advocacy and Vermont Legal Aid filed a lawsuit in the District Court of Vermont challenging Medicare’s “Improvement Standard.” Jimmo v. Sebelius No. 11-cv-17 (D.Vt., filed 1/18/11). This case argues that the "Improvement Standard", which operates as a rule of … Read more

National Medicare Advocates Alliance Issue brief #18 1.  PRESENTATIONS ADMINISTRATIVE REVIEW PROCESS:  LITTLE SUCCESS, LONG DELAYS Based upon the Center’s extensive experience with the Medicare administrative appeals process, we are continuing to find that: 1) the success rate for beneficiaries at the initial levels of appeal is generally very low; and 2) once appeals get … 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

HOSPITALIZATION AND REHOSPITALIZATION OF NURSING HOME RESIDENTS 1.  Concerns about hospitalization and rehospitalization of nursing home residents •         Effects on patients (hospital-acquired infections, delirium, increased use of antipsychotic drugs and physical restraints, increased morbidity and mortality) •         High costs associated with hospitalization 2.  Three distinct issues (some overlap) are involved: •         Reducing hospitalization from the community, … 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

I.                   Joint Select Committee on Deficit Reduction ("Supercommittee") The Budget Control Act of 2011 created this committee and tasked it with seeking at least $1.2 trillion in federal savings over 10 years. If this committee fails to come to an agreement by November 23, 2011, or if Congress fails to approve the Committee's recommendations by … Read more