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

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

Medicare typically covers genetic tests only when a beneficiary has signs or symptoms that can be further clarified by diagnostic testing. Medicare also covers some genetic tests that assess an individual’s ability to metabolize certain drugs. The only screening test Medicare will cover (once every three years) is to determine if a beneficiary has colorectal … Read more

(The Content below is taken from the Centers for Medicare & medicaid Services: Home infusion therapy involves the intravenous or subcutaneous administration of drugs or biologicals to an individual at home. Certain drugs can be infused in the home, but the nature of the home setting presents different challenges than [other settings]. The components … Read more

All Competitive Bid Program Contracts Ended on December 31, 2018. What Beneficiaries Should Know: Equipment in process under the 13 month capped rental program should continue “business as usual”. While providers who do not accept Medicare assignment cannot charge more than 15% higher than Medicare’s allowed charge. There is no such restriction (no limiting charge) … Read more

With the mid-term elections just days away, the President unveiled a minimal drug proposal in yet another effort to suggest minor changes at a politically opportune time. This is a distraction from the fact that the Administration is not “strengthening” Medicare as claimed, but fragmenting it and putting it on a path to privatization. Don’t fall for the … Read more

The Bipartisan Budget Act of 2018 became law on February 9, 2018. The Act repealed the Medicare outpatient therapy caps, which functioned as a barrier to care for those receiving outpatient therapy services. Section 50202 of the Act, “Repeal of Medicare Payment Cap for Therapy Services; Limitation to Ensure Appropriate Therapy,” states that the repeal … Read more

On February 9, 2018, the Bipartisan Budget Act of 2018 was signed into law by the President. The budget act includes a “health extenders” package that, among other changes, permanently repeals annual Medicare payment limits (or caps) on outpatient physical, speech, and occupational therapy services.[1] Pursuant to the Balanced Budget Act of 1997, Medicare Part … Read more

Since the Balanced Budget Act of 1997, outpatient therapy under Medicare Part B has been subject to dollar limits, or caps.[1]  During most of these 20 years, an “exceptions” process has allowed beneficiaries and providers to seek coverage above the caps.  The exceptions process expired December 31, 2017.  Although legislation to repeal the therapy caps … Read more

On October 18, 2016, the Social Security Administration announced that the annual cost-of-living adjustment (COLA) will increase by only 0.3% in 2017.  Although Medicare premiums won’t be announced until later this Fall, as a result of this small increase to COLA, Part B premiums are projected to increase significantly. A “hold-harmless” provision in the Medicare … Read more

Medicare Part B covers drugs that are usually not self-administered, such as many intravenous medications and chemotherapy drugs. Medicare Part D, on the other hand, generally covers self-administered outpatient prescription drugs.  On March 11, 2016, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule in the Federal Register aimed at reforming how Medicare … Read more

Since its implementation in 1965, Medicare has excluded coverage for hearing aids and related audiology services despite the large numbers of older Americans that have hearing loss. It is increasingly well-documented, however, that untreated hearing loss often leads to a variety of serious health problems and injuries. This means the cost of not treating audiology … Read more

Today, the U.S. House of Representatives passed the Bipartisan Budget Act of 2015.  Broadly speaking, this agreement avoids a pending government default by raising the nation’s debt ceiling, and prevents relief from budgetary “sequester” spending limits that have constrained social service programs.  The bill also provides temporary stability to the Social Security Disability Insurance fund. … Read more

If Congress and the Administration truly seek ways to limit Medicare premiums and deductibles, they ought to look at CMS's hospital Observation Status policy. A major cause of the Part B increase is likely the parallel increase in so-called "outpatient" Observation Status, the use of which has more than doubled since 1999. The result of this … Read more

Today the Social Security Administration announced that, based on Bureau of Labor Statistics inflation numbers released today, there will be no Cost of Living Adjustment (COLA) for 2016. The announcement makes official the assumption underlying the 2015 Medicare Trustees Report premium and deductible projections for 2016. According to the 2015 Medicare Trustees Report, Part B … Read more

The Chair of the Leadership Council of Aging Organizations (LCAO), Max Richtman, sent a letter to Senators today urging support of the “Protecting Medicare Beneficiaries Act of 2015” S. 2148. This legislation would keep the 2016 premiums and deductible stable for all Medicare beneficiaries, by protecting the premiums of the 30% of beneficiaries who will … Read more

According to the 2015 Medicare Trustees Report, Part B premiums are expected to increase for 30% of beneficiaries by 52% – from $104.90 to $159.30 per month. The trustees also predict that this increase will be accompanied by an increase in the Part B deductible—up to $223 from $147. These are projections; the final numbers … Read more

Government contractors administering Medicare benefits are routinely denying coverage to cancer patients for claims involving the surgical removal of decayed and infected teeth caused by an aggressive course of radiation treatment to the head and neck.[1] The decayed and infected teeth, when left untreated, place these cancer patients at increased risk for infection, thereby decreasing … Read more

Beneficiaries who seek Medicare coverage for expanded types and features of Speech Generating Devices (SGDs) have reason to be optimistic.  Electronic devices that meet the definition of a Speech Generating Device will be coverable.  This could include a tablet, computer, or smart phone. On April 29, 2015 the Centers for Medicare and Medicaid Services (CMS) … Read more

CMS Rescinds Restrictive Policy and Will Reconsider Technological Advances CMS announced yesterday that it has begun the process of updating its Medicare coverage policy for Speech Generating Devices (SGDs). A new SGD National Coverage Determination (NCD) is expected to be completed by July 31, 2015.  While CMS considers a new coverage rule for SGDs, it … Read more

Report prepared by Mario Ramsey, Center for Medicare Advocacy Summer Health Policy Fellow I.                   Introduction Since the introduction of the Competitive Bidding Program (CBP), trade organizations––representing the billion dollar Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS) industry––have been opposed to Medicare's congressionally mandated competitive bidding program.  In keeping with this opposition, supplier organizations were … Read more

On July 11, 2014, the Centers for Medicare & Medicaid Services (CMS) released its proposed rules for the 2015 calendar year.  Among these proposed rules, CMS adds four additions to covered telehealth services: psychoanalysis and psychotherapy (including family psychotherapy with and without the patient present), prolonged outpatient services such as evaluation and management, and annual … Read more

June 26, 2014 Medicare's Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program was enacted by Congress as a cost and fraud protection measure.  From its inception, there have been questions about the program's complexity and fairness, and whether it would hinder beneficiary access to necessary DMEPOS items and services.  Background information about … Read more

Technology can help the most vulnerable among us live with more capabilities than we would have considered possible, even a few short years ago.  Rather than encourage technological advances that promote independence and safety, however, the Centers for Medicare & Medicaid Services (CMS) is reducing access to technology in an ill-conceived effort to control short-term … Read more

On Tuesday, April 1st, President Obama signed into law the "Protecting Access to Medicare Act of 2014" (H.R. 4302).[1] This bill is a one year short-term "fix" or "patch" to pending Medicare physician payment cuts under the current physician payment formula called the "sustainable growth rate" or "SGR".  Passed by voice vote in the House … Read more

Introduction Checklist for Outpatient Therapy Discharges Checklist for Outpatient Therapy Appeals Quick Screen: Medicare Coverage for Outpatient Therapy Outpatient Therapy Appeal Details   Additional Information 1. Introduction Dear Medicare Patient: The Center for Medicare Advocacy has produced this packet to help you understand Medicare coverage and how to file an appeal if appropriate. Medicare is the … Read more

Medicare-covered outpatient physical, speech and occupational therapy services are subject to an annual dollar-amount payment cap.  As a result, many Medicare beneficiaries have their therapy terminate prematurely when they reach the cap.  While there is an Exceptions process in place that allows beneficiaries to receive therapy in excess of the caps, it is set to … Read more

As policymakers consider proposals to slash successful community programs including Medicare and Medicaid, older Americans and their families continue to face barriers to necessary health care, including access to dental coverage and services. A new report from Oral Health America highlights this growing dental crisis for older Americans. According to the report, lack of affordable … Read more

On July 1, 2013, Medicare Part B will implement a national mail-order competitive bidding program specifically for diabetic testing supplies. [1],[2]  The program applies to all zip codes in the 50 United States, the District of Columbia, Puerto Rico, U.S. Virgin Islands, Guam and American Samoa.[3] Once implemented, beneficiaries in traditional Medicare[4] will purchase diabetic … Read more

Medicare's Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program is once again under attack.  Many questions have been raised about whether the program is fair to providers and whether beneficiaries will be able to obtain needed DMEPOS items.  Since its inception, the program has been repeatedly started and stopped by Congress.  While … Read more

In the wake of the tragedy in Newtown, Connecticut policymakers, the media, and advocates across the country have turned their attention to the state of mental health care in the United States. In addition to societal stigma, people with mental health needs often face barriers to adequate medical coverage and treatment for their conditions. While … Read more

September 20, 2012 With the Balanced Budget Act of 1997 (BBA1997), Congress began an expansion of preventive benefits and services available through Medicare.[1]   The Medicare Modernization Act of 2003 (MMA) added additional preventive services.[2]  The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) made refinements to Medicare's preventive services.[3]  Finally, the Patient Protection … Read more

On May 9, 2012, the Center for Medicare Advocacy (the Center) testified before the Subcommittee on Health, Committee on Ways and Means, U. S. Congress.  The Subcommittee hearing was called by its Chair, Wally Herger (R-CA), to explore the implementation of the Congressionally-mandated Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS) competitive bidding program. Alfred … Read more

Last week, the Senate Health Education Labor and Pensions Subcommittee on Primary Health and Aging held a hearing to discuss the growing dental crisis in America. As the Center recently wrote, most people who rely on Medicare go without basic dental care due to lack of coverage. The Senate hearing revealed dismaying new facts about … Read more

On November 29, 2011, CMS announced its decision to include coverage for obesity screening and counseling services for Medicare beneficiaries.[1] This new coverage for Medicare beneficiaries is another tool aimed at emphasizing prevention and wellness by CMS, which has already implemented coverage of certain preventive services and screenings as part of the Affordable Care Act.[2] … Read more

Part B Cost-Sharing Lower Than Expected for 2012 Today the Obama Administration announced that, overall, Part B cost-sharing will be less than projected for all beneficiaries in 2012.  The Part B deductible will decrease by $22 in 2012, from $162 per year in 2011 to $140 in 2012.  Further, monthly Part B premiums will increase … Read more

On October 27, 2011 the Centers for Medicare and Medicaid Service (CMS) released notices detailing the Medicare Part A and Part B premiums and Deductibles for calendar year 2012. Hospital Deductible: $1,156 per spell of illness Hospital Coinsurance: Days 0-60: $0 Days 61-90: $289 / day Days 91-150: $578 / day Skilled Nursing Facility Coinsurance … Read more

On August 19, 2011, the Centers for Medicare & Medicaid Services (CMS) announced Round 2 of its DMEPOS competitive bidding program.[1]  Bidding is to begin in January 2012.  Round 2 adds more product categories for competitive bidding and expands the number of competitive bidding areas (CBAs) affected. CMS also announced on August 19ththat it will … Read more

CMS has posted 27 FAQs for Providers/Suppliers of preventive services for traditional Medicare to the Medicare Learning Network® Products Preventive Services webpage; to access the entire list of 27 FAQs, scroll to the “Related Links Inside CMS” section at and select “Preventive Services FAQs.”  Or, find the answer to an individual FAQ below. Annual Wellness … Read more

This article, a 38 page .pdf file from the William Mitchell Law Review (37 William Mitchell Law Review 132-169 (2010)) discusses the general process for obtaining Medicare coverage for durable medical equipment (DME) and the specific requirements for Medicare coverage of power operated vehicles (POVs) and scooters used as wheelchairs, including the Advance Determination of … Read more

When it comes to obtaining Medicare coverage for Mobility Assistive Equipment (MAE),[1] coverage criteria, particularly patient assessment standards, continue to be misunderstood by providers and beneficiaries.  The spectrum of fraud and abuse complicates matters.  In addition, over the last several years, the Centers for Medicare & Medicaid Services (CMS) has modified its rules for covering … Read more

Older Americans are not getting six key preventive services or appropriate treatment for hypertension that clinical practice guidelines indicate they generally should receive, according to two studies recently published in the Journal of the American Medical Association.  The preventive services study raises questions about disparities in health care based on economic status, and about the … Read more