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Since 2011 the Center for Medicare Advocacy has been pursuing a nationwide class action lawsuit seeking an appeal for Medicare beneficiaries who are classified as hospital outpatients in observation status. (Alexander v. Azar, 3:11-cv-1703, U.S. District Court, Connecticut.) Co-counsels in the case are Wilson, Sonsini, Goodrich & Rosati and Justice in Aging. The Alexander trial … Read more

CMA Alert – Tax Cuts will Hurt, Not Help; Sherman Fairness Hearing Set; “Homebound” Settlement Objections Due; More

Words Matter. Tax Cuts Will Hurt, Not Help America Final Week in Health Care Sabotage – 2017 ACA Open Enrollment Over in Most States Social Isolation Among Older Medicare Beneficiaries Reminder: Objections to "Homebound" Settlement Due December 28, 2017 Settlement on Lower-Level Home Health Appeals Preliminarily Approved – Fairness Hearing Set for February 26, 2018 … Read more

CMA Alert – It’s Enrollment Season; CMS Reissues HH Booklet; “Homebound” Case Settlement; More

It's Health Care Enrollment Season NEW! CMS Again Reissues Improved Medicare Home Health Booklet THIS Week In ACA Sabotage… Happy Anniversary SSI Medicare "Homebound" Class Action Settled – Fairness Hearing Set for January 11, 2018 It's Health Care Enrollment Season Free Webinar Series Next Webinar: Social Security Disability Insurance (SSDI) Part 2 – Overview of Benefits for … Read more

No. 3:15-cv-1468-JAM, filed October 9, 2015 Issue: Whether the extremely high denial rates (98% and higher) at the redetermination and reconsideration stages of administrative review for home health care claims violate the Medicare statute and the Due Process Clause.  Relief sought: Declaratory and injunctive relief requiring the Secretary to correct the existing system of lower … Read more

No. 3:15-cv-01397 (DJS), filed September 22, 2015 Issue: Whether the Secretary violated the Medicare statute and the Due Process Clause by not recognizing that Vitamin B-12 injections represent a per se skilled nursing service and therefore the service should have been covered, and, in general, by failing to recognize the right to coverage for per se … Read more

No. 3:15-cv-00390-JBA (D.Conn.), filed March 17, 2015 Issue: Whether extraordinary dental care should be covered because the exclusion for coverage of dental care should be limited to routine dental care. Relief Sought: Reversal of the Secretary’s decision denying coverage to the plaintiff and enjoining the Secretary from relying on a regulation that does not define … Read more

No. 5:14-cv-269 (D.Vt.), filed Dec. 19, 2014 Issue: Whether the failure of the Secretary to apply the “prior favorable homebound decision” rule, which accords “great weight” to previous administrative decisions establishing homebound status, violates the Medicare regulations, as implemented by the Medicare Program Integrity Manual, and the Due Process Clause. Relief Sought: Declaratory and injunctive … Read more

No. 3:14-cv-01230 (D.Conn.), filed August 26, 2014 Issue: Whether the consistent failure of administrative law judges (ALJs) to issue decisions within 90 days of the request for ALJ review (with an average delay now approaching 500 days) violates the Medicare statute and the Due Process Clause. Relief sought: Declaratory and injunctive relief prohibiting the Secretary from … Read more

No. 11-cv-17 (D.Vt.), filed January 18, 2011 Issue: Whether the "Improvement Standard", which operates as a rule of thumb to terminate or deny Medicare coverage to beneficiaries who are not improving, violates substantive and procedural requirements of the Medicare statute, the Administrative Procedure Act, and the Freedom of Information Act, and the Due Process Clause of … Read more

No. 09-cv-134-TUC-DCB (D.Ariz.), filed March 10, 2009.  Appeal filed June 30, 2011 (No. 11-16606, 9th Cir.). Issue: Whether the Secretary's aggressive methods for attempting to collect payments under his Medicare Secondary Payer (MSP) program, directed at beneficiaries and their attorneys, violates the Medicare statute and the Due Process Clause. Relief sought: Declaratory and injunctive relief … Read more

No. 14-801 (D.Conn.), filed June 4, 2014 Issue: Whether the Secretary of Health & Human Services’ denial rate of about 98% at the lowest two levels of appeal in Medicare’s system of administrative review (redetermination and reconsideration) violates the Medicare statute and the Due Process Clause. Relief sought: Declaratory and injunctive relief for a Connecticut … Read more

No. 11-1703 (D.Conn.), filed November 3, 2011 Issue: Whether the Secretary's policy of allowing hospitalized Medicare beneficiaries to be placed in "observation status," rather than formally admitting them, deprives them of their Part A coverage in violation of the Medicare statute, the Administrative Procedure Act, the Freedom of Information Act, and the Due Process Clause. … Read more

Pursuant to the settlement agreement in Exley v. Burwell, a class action brought by the Center to address delays in appeals at the Administrative Law Judge (ALJ ) level, the Office of Medicare Hearings and Appeals (OMHA) has established a new help line to troubleshoot beneficiary appeals.  In a September 1, 2016 announcement, OMHA introduced … Read more

On August 1, 2016, Judge Jeffrey Meyer of U.S. District Court in Connecticut granted final approval to a settlement agreement that will ensure timely decisions for Medicare beneficiaries who appeal denials of coverage to Administrative Law Judges (ALJs). The nationwide class action, Exley v. Burwell, 3:14-CV-1230, was brought by six individuals who waited longer than … Read more

The Medicare Advocacy Project of Greater Boston Legal Services recently received a favorable decision from the U.S. District Court in Massachusetts for “off-label” coverage of the drug Dronabinol.  This is a welcome development given how difficult it has been to obtain coverage for medications that prescribing doctors agree are necessary, but that are not FDA-approved … Read more

No. 14-1519 (APM) (D.D.C.), filed Sept. 5, 2014 Amicus information: Amici are the Center and the National Health Law Program.  They are supporting the claim of Medicare beneficiaries that they should be covered for a form of testing that would assist in the diagnosis of patients suffering from dementia. Issues: Whether a diagnostic test (PET … Read more

No. 5:14-cv-128 (D.Vt.), filed June 23, 2014 Issue: Whether the denial of coverage for named plaintiff Glenda Jimmo by the Medicare Appeals Council on re-review of her claim under the revised manual provisions pursuant to the Jimmo settlement agreement was correct. Relief Sought: Reversal of the Secretary’s decision denying coverage and granting the claim for … Read more

No. 3:08-CV-1148 (AHN) (D.Conn.), filed July 31, 2008 Issue: Whether the use of a "stability" test to terminate home health coverage on the ground that the patient no longer needs skilled nursing care violates the Medicare statute and regulations. Relief Sought: Declaratory judgment, and temporary and permanent injunctive relief on behalf of an individual Medicare … Read more

 No. CV 08-2309-PHX-ROS (D.Ariz.), filed December 18, 2008. Appeal filed March 6, 2012 (No. 12-15478, 9th Cir.). Issue: Whether the Secretary's exclusion of coverage for dental care in extraordinary circumstances where the care is necessary to treat a medical condition violates the Medicare statute and policy provisions, and the Equal Protection Clause. Relief Sought: Declaratory judgment … Read more

 No. 13-cv-55-JAW (D.Me.), filed February 20, 2013 Issue: Whether the Secretary of Health and Human Services violated the Administrative Procedure Act when she approved a proposed state plan amendment to Maine's Medicaid program that will allow Maine to cut back the eligibility standards in the QMB, SLMB, and QI programs  for disabled Mainers, beginning March … Read more

No. 09-1706 (C.D.Cal.), filed September 8, 2009.  Appeal filed January 28, 2011 (No. 11-55175, 9th Cir.) Issue: Whether the absence of an administrative appeals process for the denial of services by a hospice violates the Medicare statute and the Due Process Clause. Relief Sought: Declaratory and injunctive relief requiring an administrative appeals process. Updated: October 22, … Read more

  Attorneys from the Center for Medicare Advocacy, Vermont Legal Aid and the Centers for Medicare & Medicaid Services (CMS) have agreed to settle the "Improvement Standard" case, Jimmo v. Sebelius, No. 11-cv-17 (D.VT), filed January 18, 2011.  A proposed settlement agreement was filed in federal District Court on October 16, 2012.  When the judge approves … Read more

Attorneys from the Center for Medicare Advocacy, Vermont Legal Aid and the Centers for Medicare & Medicaid Services (CMS) have agreed to settle the "Improvement Standard" case, Jimmo v. Sebelius.[1] A proposed settlement agreement[2] was filed in federal District Court on October 16, 2012.  When the judge approves the proposed agreement, a process that may … Read more

No. C06-02841-TEH (N.D.Cal.), filed April 26, 2006 Issue: Whether CMS' failure to correctly implement the Part D prescription benefit for hundreds of thousands of dual eligibles violates the Medicare statute and the Due Process Clause. Relief sought: A nationwide class of dual eligibles has been alleged.  Plaintiffs seek declaratory and injunctive relief to ensure that dual eligibles … Read more

No. 10-cv-645 (D.Conn.), filed April 27, 2010 Issue: Whether a request under the Freedom of Information Act (FOIA), 5 U.S.C. § 552, about how Medicare's Improvement Standard is explained to employees of CMS and its contractors, had to be answered in a timely fashion. Relief Sought: Full and timely responses to plaintiff's FOIA request. Updated: … Read more

No. 09-cv-16 (D.Vt.), filed January 22, 2009   Issue: Whether the Secretary's policy of terminating Medicare coverage for a home health patient on the ground that her condition is stable or is not improving violates the Medicare statute and regulations.   Relief Sought: Declaratory and permanent injunctive relief prohibiting application of the "improvement" standard, with an award of … Read more

The Center is concerned about the use of MSNs that do not reveal to beneficiaries that their service was denied based on a National Coverage Determination.  Such an MSN will instead provide a misleading explanation, such as "Medicare does not cover this service," or "information provided does not support the need for this service." If … Read more

No. 09-cv-1927-MJD-JSM (D.Minn.), filed July 23, 2009 Issue: Whether the Secretary’s coverage of enteral feeding by a Part C plan on the ground that it was a skilled nursing service was correct. Relief sought: Plaintiff seeks to reverse the decision of the Secretary.  Defendants (the Secretary and the state Commissioner of the Dept. of Social … Read more

No. 09-cv-672 (D.Conn.), filed April 24, 2009 Issue: Whether a request under the Freedom of Information Act (FOIA), 5 U.S.C. § 552, about the possible failure of Part D plans to reimburse LIS beneficiaries for premium payments for which they were not responsible, had to be answered in a timely fashion. Relief sought:  Full and timely … Read more

On Friday, April 23, 2010, Judge Juan R. Sanchez of the United States District Court for the Eastern District of Pennsylvania approved the settlement of a lawsuit brought by Pennsylvania low-income Medicare beneficiaries.  Narcisa Garcia, et al. v. Kathleen Sebelius, et al.[1] The Garcia settlement will lower the cost of Medicare and increase access to … Read more

For Immediate Release January 18, 2011 Contact: Patricia Haubner 914-833-7093; 914-275-2984 LAWSUIT FILED TO BLOCK ILLEGAL DENIALS OF SERVICES TO MEDICARE PATIENTS WITH CHRONIC ILLNESS Center for Medicare Advocacy Lead Counsel in National Class-Action Suit Burlington, VT − Today, The Center for Medicare Advocacy and co-counsel from Vermont Legal Aid filed a class action lawsuit … Read more

No. CV 03 2008FMC(PJWx) (C.D.Cal.), filed March 12, 2003  Updated: August 25, 2006 Issue: Whether the County of Los Angeles, under state law and the Medicare and Medicaid statutes, may close a rehabilitation hospital and eliminate 100 beds from another public hospital. Relief Sought: A preliminary and permanent injunction prohibiting the County from reducing the … Read more

No. CIV 93-7112 TUC ACM (D. Ariz.), filed 1993; Grijalva v. Shalala, No. 97-15877 (9th Cir.), appeal filed by defendant 1997; Shalala v. Grijalva, No. 98-1284 (S.Ct.), petition for cert. filed by defendant  Final Update: October 30, 2003 Issue: Whether the Secretary of HHS failed to ensure that HMOs provided appropriate notice and hearing rights … Read more

No. CIV01-112TUC-BPV (D. Ariz), filed March 16, 2001 Last Updated: December 15, 2004 Issue: Whether CMS's procedures for promulgating Local Coverage Determinations (LCDs) and for informing beneficiaries of the application of LCDs to their claims violates the APA, the Medicare statute and regulations, and the due process clause. Relief sought: Nationwide class alleged.  Declaratory and … Read more

Within a month of each other, two federal district courts have rejected the Center for Medicare & Medicaid Services’ (CMS) beleaguered Medicare “Improvement Standard,” thereby adding to the chorus of federal judges who have found the standard unsupportable under the Medicare statute and regulations.[1] Although CMS continues to claim formally that there exists no such … Read more

No. 06-1607 (D.D.C.), filed September 15, 2006, appeal filed May 21, 2009 (No. 09-5191, D.C.Cir.)   Last Update: October 22, 2010   Issue: Whether the Secretary's refusal to inform 230,000 Part D-enrolled beneficiaries, who mistakenly were sent money reflecting the amount of their monthly premiums, of their right to request waiver of recovery, while demanding … Read more

No. 09-cv-76-CKJ (D. Ariz.), filed February 6, 2009 Last Update: October 22, 2010 Issue: Whether the defendant's failure to respond to a request for documents about the number of attorneys against whom CMS has taken action to recover conditional payments under its MSP program violates the Freedom of Information Act. Relief Sought: Declaratory and injunctive … Read more

No. 06-35672 (9th Cir.), case in progress for several years Updated: October 22, 2009   Issue: Whether the actions and inactions of a Medicare Part D plan, defendant Humana, in failing to enroll, and otherwise provide prescription drug coverage to, the plaintiff beneficiaries cannot be challenged under state law fraud and breach of contract causes of actions … Read more

No. 09-1747 (E.D.Pa.), filed April 24, 2009 Final Update: October 22, 2010 Issue: Whether the failure of the state and federal defendants to coordinate the exchange of information necessary to ensure that the beneficiaries of the Medicare Savings Program have their Medicare premiums timely paid by the Medicaid program violates the Medicare and Medicaid statutes … Read more

In a lengthy, detailed, and complex decision, a federal appellate court rejected the right of Part D beneficiaries to sue a plan for damages when the plan fails to enroll them in a timely manner.[1] The decision, which was issued on August 31, 2010, makes clear the Court's view that Congress did not intend beneficiaries … Read more

No. 07-30111-MAP (D. Mass.), filed June 19, 2007 Final Update: December 24, 2009 Issue: Whether the failure of the Secretary of HHS and the Commissioner of Social Security to stop withholding premium payments for Part D when requested by beneficiaries, and to repay the amounts improperly withheld, violates the Medicare statute, the anti-assignment provision of … Read more

No. 3:04CV1988JCH (D. Conn.), filed Nov. 23, 2004 Last Updated: September 22, 2009 Issue: Whether the Secretary's policy of not counting time in an emergency room or in "observation status" towards the three-day qualifying hospital stay for purposes of establishing the right to subsequent skilled nursing facility coverage violates the Medicare statute and guarantees of equal … Read more

No. 1:05CV2266 (D.D.C.), filed November 23, 2005 Updated: April 9, 2009   Issue: Whether HHS violated the Freedom of Information Act when it failed to respond to a request for documents about the videoconferencing technology to be employed in the new system for handling Medicare appeals to ALJs.   Relief sought: The production of the relevant documents.   … Read more

No. 08 CV 0432(PAC) (S.D.N.Y.), filed January 17, 2008 Updated: January 5, 2009 Issue: Whether a letter sent to state officials by CMS in August 2007, in which the agency restricted states' rights to expand eligibility in their State Children's Health Insurance Programs (SCHIP) by establishing new and onerous standards, violates the SCHIP statute (title … Read more

WEICHARDT v. LEAVITT No. C 03-05490 VRW (N.D.Cal.), filed December 5, 2003 Updated: January 3, 2008 Issue: Whether CMS’ promulgation of final rules not requiring timely advance written notice to hospitalized Medicare beneficiaries who are being discharged violates the Administrative Procedure Act and the Due Process Clause. Relief sought: Nationwide class is alleged. Declaratory and … Read more

No. 398CV00418 DJS (D.Conn.), filed March 4, 1998 Last Updated: September 21, 2007 Issue: Whether the Secretary of HHS failed to ensure that home health agencies provided sufficient notice and hearing rights to home health patients whose services were cut back or terminated. Relief sought: Nationwide class alleged.  Plaintiffs sought declaratory and injunctive relief to … Read more

Medicare patients who are hospitalized sometimes find themselves being told to leave the hospital too soon, before they can safely be cared for at home or at a nursing home.[1]    The protections provided for hospital patients in this situation have recently been improved, due to a lawsuit brought by the Center for Medicare Advocacy, Inc. … Read more

No. CV05-4219-PHX-NVW (D.Ariz.), filed December 22, 2005 Updated: April 5, 2007 Issue: Whether regulations issued by CMS on March 8, 2005, which, inter alia, establish a new cadre of ALJs to handle only Medicare claims and which make it virtually impossible to have an in-person hearing close to the claimant's residence (relying on telephone or … Read more

No. 3:05CV824(RNC) (D.Conn.), filed May 24, 2005 Updated: August 26, 2006 Issue: Whether the Secretary's regulation (42 C.F.R. ' 405.910(i)(1)), effective May 1, 2005, that prohibits Medicare contractors from sending copies of the notice of initial determination to the beneficiary's appointed representative violates the notice-and-comment requirements of the Administrative Procedure Act (APA) (5 U.S.C. ' … Read more

No. 2:05-cv-6201 (E.D.Pa.), filed November 30, 2005 Last Update: August 25, 2006 Issue: Whether CMS' implementation of so-called "passive enrollment" into a Medicare managed care plan for over 110,000 dual eligibles in Pennsylvania, without prior notice and publication, violates the Medicare statute, (especially the Medicare Modernization Act), the Administrative Procedure Act, and the Due Process Clause. … Read more