Center for Medicare Advocacy

Advancing Access to Medicare and Healthcare

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Acute Hospital Care Articles

It’s Time: Repeal the 3-Day Inpatient Hospital Requirement for Medicare Skilled Nursing Facility Coverage February 10, 2022

The outdated requirement of a 3 Day stay hasn't changed since 1965, when average stays were 13 days.

CMS Issues Instructions Regarding the Medicare Outpatient Observation Notice (MOON) February 15, 2017

Beginning no later than March 8, 2017, and as required by the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act),  Hospitals must use the written notice ...

Hospitals Must Give Patients Notice of Their Observation Status, Beginning March 8, 2017 December 14, 2016

Effective August 6, 2016, the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) requires acute care hospitals to provide oral and written notification to patients who are classified as outpatients or observation status patients for more than 24 hours.  Notice of non-inpatient status must be provided within 36 hours.  On August ...

Medicare’s Value-Based Purchasing Program for Hospitals: Paying More to Low-Cost Hospitals That Provide Low Quality Care July 6, 2016

In 2012, the Centers for Medicare & Medicaid Services (CMS) announced expansion of Medicare’s Value-Based Purchasing (VBP) Program for acute care hospitals.  Beginning in Fiscal Year 2015, and as mandated by Congress in the Affordable Care Act, CMS would incorporate a new measure for “Medicare Spending Per Beneficiary.”  CMS suggested this efficiency measure would reward ...

Observation Status and the NOTICE Act: Advocates Not Over the MOON April 27, 2016

In proposed rules updating Medicare reimbursement to acute care hospitals,  Effective August 6, 2016, the NOTICE Act requires that hospitals provide written and oral notice, within 36 hours, ...

Reducing Hospital Readmissions by Addressing the Causes April 18, 2016

Reports that 20% or more of unplanned hospital readmissions are avoidable has led to considerable interest in policymakers in reducing readmissions.  Actively reducing hospital readmissions is seen as a route to lower Medicare spending and improved patient care. The Affordable Care Act (ACA) established a penalty program for preventable readmissions.  Under the Hospital Readmissions Reduction Program, ...

Office of Inspector General Authorizes Hospitals to Discount or Waive Certain Drug Charges for Patients Classified as “Outpatients” December 10, 2015

The Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS) released a statement on October 30, 2015 that advises hospitals that it will not administratively sanction them if they discount or waive charges for an outpatient’s self-administered drugs. Thus, hospitals now have the option, and a greater incentive, not ...

Revisions to “Two-Midnight Rule” Do Not Help Hospitalized Medicare Patients in Observation Status December 2, 2015

In 2013, the Centers for Medicare & Medicaid Services (CMS) promulgated the Two-Midnight Rule, which, for the first time in the Medicare program’s 50-year history, determined patient status in a hospital by reference to time.  Specifically, CMS’s new rule provided that a patient would be considered an inpatient, and the hospital stay would be covered ...

Proposed Revisions to “Two-Midnight” Rule Provide Little, If Any, Relief for Medicare Beneficiaries Stuck in the Hospital in Observation Status July 9, 2015

In the annual update to Medicare reimbursement of acute care hospitals for outpatient care (July 8, 2015) the Centers for Medicare & Medicaid Services (CMS) includes proposed revisions to the “Two-Midnight Rule” and its enforcement. If the proposed changes lead to an increased number of patients being formally admitted as inpatients (rather than, as now, placed ...

Bundling Payments for Post-Acute Care May 14, 2015

The traditional Medicare program pays individual health care providers for the specific services and care they provide to beneficiaries and guarantees that patients have “freedom of choice” to select their Medicare providers.  A current focus of Congress and policymakers is changing Medicare payment policy to pay, instead, for episodes of care for beneficiaries.  One issue ...

Observation Status: Hospitals May Begin Rebilling Medicare Patients Who Were Hospitalized After October 1, 2013 September 4, 2014

Medicare patients need to be aware that if they were hospitalized after October 1, 2013, hospitals may be contacting them about their bills. Final rules that were published in August 2013 and became effective October 1, 2013 created a new regulatory provision, 42 C.F.R. 414.5, "Hospital services paid under Medicare Part B when a Part A ...

Inpatient Rehabilitation Facilities and Skilled Nursing facilities: Vive La Difference! July 31, 2014

A study assessing the outcomes of patients who were treated in inpatient rehabilitation facilities (IRFs) with clinically and demographically similar patients who received their post-acute rehabilitation in skilled nursing facilities (SNFs) finds that IRFs provide better care to their patients over a number of outcome measures – IRF patients live longer, spend more days at ...

Harm from Medicare’s Hospital Observation Status Debated In Congressional Hearing – Center for Medicare Advocacy Presents Beneficiary Perspective May 21, 2014

May 21, 2014 The May 20, 2014 hearing on "Current Hospital Issues in the Medicare Program," held by the Health Subcommittee of the House Committee on Ways and Means, was the first Congressional hearing to consider the impact of observation status on hospitalized Medicare patients.  At the hearing, the Center for Medicare Advocacy's Senior Policy Attorney, ...

New CMS Rules Do NOT Change Requirement for 3-Day Qualifying Inpatient Hospital Stay October 31, 2013

The Center for Medicare Advocacy has heard that some Medicare beneficiaries believe that new federal rules authorize Medicare to pay for their nursing home care if they are inpatients in a hospital for two midnights.  This belief is NOT CORRECT.  New rules published by the Centers for Medicare & Medicaid Services (CMS) in August 2013, ...

Observation Status: New Final Rules from CMS Do Not Help Medicare Beneficiaries August 29, 2013

Effective October 1, 2013, new rules for inpatient hospital reimbursement under the Medicare program  Neither set resolves the ...

CMS Updates Guidance for Hospital Discharge Planning May 30, 2013

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-participating hospitals must make their discharge planning process available to ...

CMS Addresses Observation Status Again… And Again, No Help for Beneficiaries May 16, 2013

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 ...

Déjà Vu All Over Again: CMS Decides (Again) Not to Decide About Observation Status November 20, 2012

On July 30, 2012, as part of proposed rulemaking on the outpatient prospective payment system, the Centers for Medicare & Medicaid Services (CMS) asked for public comment on potential policy options related to "observation status." What is Observation Status? Observation status refers to the classification of a patient in an acute care hospital as an outpatient, even ...

CMS Invites Public Comment on Observation Status August 9, 2012

August 9, 2012 Note to Alert readers: This Posted version contains additional information beyond that in the emailed version.As part of a notice of proposed rulemaking published in the Federal Register on July 30, 2012, the Centers for Medicare & Medicaid Services (CMS) is asking for public comments on potential policy changes related to observation status.  ...

Compare Hospitals or Nursing Homes Using Medicare’s Online Tools July 20, 2012

Two websites that help Americans make informed choices about hospitals and nursing homes have been redesigned and will make more information available to the public, CMS announced on July 19, 2012.The two sites – Hospital Compare and Nursing Home Compare – have been enhanced to make navigation easier by users, and have added important new ...

More Concerns About Observation Status: Hospitals Join the Chorus July 12, 2012

Hospital case managers and the hospital industry have joined the chorus of those opposed to observation status – a designation that renders a beneficiary ineligible for Medicare-covered skilled nursing facility (SNF) care.  This Alert discusses a recent survey by the American Case Management Association and an amicus brief filed by the American Hospital Association in ...

Brown University Confirms Observation Continues to Replace Hospital Admission Status June 7, 2012

Since 2008, the Center for Medicare Advocacy (the Center) has been reporting that an increasing number of Medicare beneficiaries are being placed in acute care hospital beds for multiple days – receiving medical and nursing care, diagnostic tests, treatments, medications, and food – but are being called “outpatients” in observation status, rather than admitted “inpatients.”  ...

Medicare Hospital Readmissions May 2, 2012

Reducing hospital readmissions is generating lots of confusion.  The rules are complicated.  In addition, some hospitals, facilities, and health care networks have adopted protocols, and have in place some level of procedures for reduction in hospital readmissions in advance of the requirements set forth in the Affordable Care Act (ACA). In general, the Centers for Medicare & ...

Reducing Rehospitalizations… The Right Way March 1, 2012

For several years, reducing rehospitalizations of Medicare beneficiaries has been a key public policy goal, the intent of which is to improve quality of care for beneficiaries and reduce costs for the Medicare program.  Studies have shown that rehospitalizations are common and expensive.  In 2006, for example, nearly one-quarter of nursing home residents (23.5%) were ...

Preserving Access to Necessary Care: Ending Hospital “Observation Status” November 3, 2011

The Center for Medicare Advocacy has heard increasingly about beneficiaries throughout the country whose entire stays in a hospital, including stays as long as 14 days, are classified by the hospital as outpatient observation.  In some instances, the beneficiaries' physicians order their admission, but the hospital retroactively reverses the decision.  As a consequence of the classification of ...

Congressman Joe Courtney and Center for Medicare Advocacy Hold Congressional Briefing on Observation Status October 24, 2011

Coalition Urges Congress to Pass Legislation Safeguarding Medicare Beneficiaries' Skilled Nursing CareFor Immediate Release October 21, 2012 Terry Berthelot 860-456-7790 Toby Edelman 202-293-5760Washington, DC. – A Congressional briefing on "observation status," sponsored by Congressman Joe Courtney (D. CT), was held yesterday afternoon to examine Medicare beneficiaries' being denied Medicare coverage for care in a skilled nursing facility (SNF) when their ...

Study Finds that Use of Hospitalists Shifts Costs from Inpatient Care to Post-Discharge Setting September 8, 2011

Hospitalists are defined as physicians who are based full-time in acute care hospitals and who provide care to hospitalized patients.  The past decade has witnessed a rapid growth in hospitals' use of hospitalists, who have been shown to lead to reduced lengths of inpatient hospital stays.  A new study, however, finds that decreased inpatient costs ...

CMA And Others Support Legislation to End “Observation Status” June 21, 2011

Max Richtman, Chair May 20, 2011 The Honorable John Kerry The Honorable Olympia Snowe United States Senate Washington, DC 20510 The Honorable Joe Courtney The Honorable Tom Latham United States House of Representatives Washington, DC 20515 Dear Senators Kerry and Snowe and Representatives Courtney and Latham: The Leadership Council of Aging Organizations (LCAO) – a coalition of national not-for-profit organizations representing 60 million older Americans – ...

Extended Observation Stays in Acute Care Hospitals: Criticism, Legislation and Discussion August 26, 2010

“Observation” is the term used to describe the outpatient status of a patient who is in a hospital, but not as an inpatient. Although the Medicare Manuals limit observation to 24-48 hours, many beneficiaries nationwide are experiencing extended stays in acute care hospitals under observation. A major consequence for beneficiaries of not being classified as ...

The Right to Visit Partners and Others In Medicare Participating Hospitals June 22, 2010

The Centers for Medicare & Medicaid Services (CMS) has recently issued new rules for Medicare and Medicaid participating hospitals that require written policies protecting patients’ rights to choose their visitors during a stay in the hospital. The landmark rules ensure same-sex partners will have visitation rights, along with friends and other ...

Observation Services: What Can Beneficiaries and Advocates Do? February 18, 2010

What are Observation Services? CMS Brochure Favorable DecisionsWhat Should Beneficiaries and their Advocates Do? Continuing WorkBeing in a hospital bed in a Medicare-participating hospital is no guarantee that a Medicare beneficiary is an inpatient.  In our December 11, 2008 Alert, the Center for Medicare Advocacy described the increasingly common practice of placing Medicare beneficiaries in acute care hospital beds ...

Antipsychotic Drugs

HHS Inspector General: Too Many Nursing Home Residents Still Inappropriately Receive Psychotropic Medications December 8, 2022

Bottom line - fewer nurses equals more drugged patients.

HHS Inspector General Finds CMS Data Understates Antipsychotic Drug Use in Nursing Homes May 13, 2021

A serious and longstanding quality of care problem in nursing homes is the inappropriate use of antipsychotic drugs with residents who have dementia.

Drug Company Sued Over Kickbacks for Off-Label Marketing of Psychotropic Drug for Nursing Home Residents to Pay Over $115 Million October 17, 2019

Background When the Centers for Medicare & Medicaid Services (CMS) launched a national campaign to reduce the off-label prescribing of antipsychotic drugs for nursing home residents in 2012, Avanir Pharmaceuticals directed its sales force to talk to nursing facilities about using Nuedexta as a substitute for antipsychotic drugs. The Food and Drug Administration had approved Nuedexta ...

Stop Drugging Nursing Home Residents Without their Written Consent August 29, 2019

Background. Nursing homes administer antipsychotic drugs to approximately 20 percent of residents nationwide. Sadly, and too often, nursing homes use these drugs as a way of chemically restraining residents exhibiting the behavioral symptoms of dementia, despite the Food and Drug Administration’s (FDA) “black box” warning against using antipsychotic drugs on elderly patients with dementia. The ...

Study Finds Link Between Registered Nurse Hours and Antipsychotic Drug Use September 20, 2018

Human Rights Watch (HRW) published a devastating report in February 2018, which found that over 179,000 nursing home residents were being administered off-label antipsychotic drugs every week. Antipsychotic drugs are indicated to treat specific clinical conditions, such as schizophrenia, and not the behavioral symptoms of dementia. Nevertheless, the HRW report noted that most of the ...

Did CMS’s Partnership to Improve Dementia Care Reduce the Inappropriate Prescribing of Antipsychotic Drugs for Nursing Home Residents as Much as CMS Claims? Two Recent Studies Say No June 28, 2018

The Centers for Medicare & Medicaid Services (CMS) has ended its campaign to reduce the inappropriate use of antipsychotic drugs for long-stay residents in nursing facilities (formally called the National Partnership to Improve Dementia Care in Nursing Homes) for facilities that reduced their antipsychotic drug usage by 34% by the end of 2016 (from 23.9% ...

Elder Justice Alert: New York Times Publishes Article on Drug Use Among Older Adults March 29, 2018

Revelations have shed light on an opioid crises in the United States that remained largely hidden until recently. These drugs have affected the lives of children and adults nationwide. Unfortunately, the inappropriate use of medication – legally or illegally – is not limited to opioids in its multigenerational reach. As the New York Times reports ...

Elder Justice Alert: Human Rights Watch Publishes In-Depth Report on Antipsychotic Drug Use in U.S. Nursing Homes February 7, 2018

On February 5, 2018, Human Rights Watch published an in-depth report on antipsychotic drug use in U.S. nursing homes. The Report, entitled “‘They Want Docile’: How Nursing Homes in the United States Overmedicate People with Dementia,” finds that over 179,000 nursing home residents are given off-label antipsychotic drugs every week. The Report notes that most ...

CMA Alert, October 18, 2017 – Nursing Home Rights Roundup; ACA Stabilization; More October 18, 2017

This Week in ACA Sabotage Bipartisan Agreement on ACA Stabilization Package Nursing Home Rights RoundupCMS Signals End of Campaign to Reduce Unnecessary Use of Antipsychotic Drugs In Nursing Homes; Claim of Success is Grossly Overstated OIG Report about Nursing Home Complaints Leaves Questions Unanswered Congressional Letter Asks for Revision and Delay of Nursing Home Requirements of ParticipationThis Week In ...

Elder Abuse in Nursing Facilities: The Over-Administration of Antipsychotic Drugs to Nursing Home Residents June 15, 2016

The Administration on Aging defines a subcategory of elder abuse – “physical abuse” – as “inflicting physical pain or injury on a senior, e.g. slapping, bruising, or restraining by physical or chemical means.” Administering antipsychotic drugs to more than a quarter of a million nursing home residents meets the definition of elder abuse and, left unanswered, ...

Antipsychotic Drugs and Nursing Home Residents: What Do the Different Numbers Mean? March 12, 2015

Last week’s Alert discussed the Centers for Medicare & Medicaid Services’ (CMS’s) National Partnership to Improve Dementia Care and the Government Accountability Office’s (GAO) recent report on antipsychotic drugs.  The CMS Partnership and the GAO reported different numbers of nursing home residents receiving antipsychotic drugs.  Some of the differences appear to reflect the different databases ...

Has CMS’s Partnership with the Nursing Home Industry Really Reduced the Inappropriate Use of Antipsychotic Drugs by Nursing Home Residents as Much as CMS Claims? No. March 5, 2015

In September 2014, the Centers for Medicare & Medicaid Services (CMS) reported that the National Partnership to Improve Dementia Care had reduced the use of antipsychotic drugs with nursing home residents by 15.1%, “exceeding” the Partnership’s 15% drug reduction goal for long-stay residents.  That claim of success was overstated.  When CMS originally announced the initial ...

CMA Report: Inappropriate Use of Antipsychotic Drugs in Nursing Homes, Part Three – Recommendations to Improve the Citing of Deficiencies January 23, 2014

As required by the 1987 federal Nursing Home Reform Law, CMS has developed, tested, and periodically revised a survey protocol that state surveyors, who are generally employed by the state health departments, must use to determine nursing facilities' compliance with federal standards of care.  The survey protocol, which is composed of two Appendices to the ...

CMA Report on Inappropriate Use of Antipsychotic Drugs in Nursing Homes – Part Two: What the Surveyors Say January 2, 2014

The Center for Medicare Advocacy (the Center) has reported on the misuse of antipsychotic drugs by nursing homes for many years, discussing Congressional hearings and federal reports and the high personal and financial cost of the misuse of the drugs.  In December 2013, we reported on a study that the Center undertook with Dean Lerner ...

CMA Report: Examining Inappropriate Use of Antipsychotic Drugs in Nursing Facilities December 12, 2013

The misuse of antipsychotic drugs by nursing homes has been the subject of Congressional hearings and Government reports for many decades.  With funding from the Commonwealth Fund of New York and in cooperation ...

Misuse of Antipsychotic Drugs in Nursing Homes: Are We Making Any Progress? November 14, 2013

The recent settlement of criminal and civil charges against Johnson & Johnson for off-label marketing of Risperdal for nursing home residents once again brings the issue of antipsychotic drugs and nursing homes to public attention.  A group of residents' advocates working to reduce the inappropriate use of antipsychotic drugs in nursing facilities recently issued a ...

$2.2 Billion Johnson & Johnson Settlement Sends New Warning: Antipsychotic Drugs Should Not Be Used to Treat Dementia November 14, 2013

November 14, 2013 For Immediate Release Statement of California Advocates for Nursing Home Reform, Center for Medicare Advocacy, Legal Aid Justice Center, Long Term Care Community Coalition, The National Consumer Voice for Quality Long-Term Care Washington, DC – The Department of Justice's $2.2 billion settlement with Johnson & Johnson over allegations that it illegally promoted Risperdal to treat ...

Examining Inappropriate Use of Antipsychotic Drugs, Part Three: Recommendations October 24, 2013

Examining Inappropriate Use of Antipsychotic Drugs, a Report in three Parts, looks at Survey and Certification deficiency citations for antipsychotic drug use in skilled nursing facilities (SNFs) and nursing facilities (NFs) from two perspectives.  First, it analyzes all of the approximately 300 antipsychotic drug deficiencies that were cited by seven states over a two-year period, ...

Examining Inappropriate Use of Antipsychotic Drugs, Part One: How Seven States Cite Antipsychotic Drug Deficiencies October 24, 2013

The misuse of antipsychotic drug is a pervasive problem in American nursing facilities.  Misuse causes physical and psychological harm and death to residents and costs many hundreds of millions of dollars annually, both for the drugs themselves and in efforts to reverse the poor resident outcomes that are the common consequence of their misuse.  Examining ...

Letter to Inspector General Regarding Suspension of Antipsychotics Investigation July 26, 2013

July 26, 2013 Daniel R. Levinson Inspector General Department of Health and Human Services 330 Independence Avenue, SW Washington, DC 20201 Submitted Electronically Dear Mr. Levinson: A report today that your office has canceled plans to investigate antipsychotic drug use in nursing homes is disappointing and alarming. Two years ago we answered your challenge to advocates for nursing home residents to be “outraged” by ...

Fact Sheet – Observation Stays Deny Medicare Beneficiaries Access to Skilled Nursing Facility Care July 15, 2013

Medicare beneficiaries are being denied access to Medicare’s skilled nursing facility (SNF) benefit because acute care hospitals are increasingly classifying their patients as “outpatients” receiving observation services, rather than admitting them as inpatients.  Patients are called outpatients despite the fact that they may stay for many days and nights in hospital beds and receive medical ...

Senate Hearing on Oversight of Recovery Audit Contractors: Center’s Statement Regarding Beneficiary Impact June 25, 2013

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 – costs related to hiring ...

Recognizing Elder Abuse Awareness Day: Working Together to Curb Misuse of Powerful Antipsychotic Drugs in Nursing Homes June 14, 2012

On May 31, 2012, the Centers for Medicare & Medicaid Services (CMS) announced an initiative to reduce the rampant misuse and overuse of antipsychotic drugs in nursing facilities.  The Center for Medicare Advocacy has been working to educate policy makers, advocates, and the public about the misuse of antipsychotic drugs for many years, and is ...

Press Release – Fewer Antipsychotic Drugs, More Nurses Will Improve Care in Nursing Homes and Save Money April 19, 2012

April 18, 2012 Contact: Toby S. Edelman at (202) 293-5760 tedelman@medicareadvocacy.org The Center for Medicare Advocacy knows that huge savings in nursing facility costs, and advances in resident care, could be achieved if facilities eliminated the inappropriate use of antipsychotic drugs and provided sufficient staff to meet resident needs.  The Center commends the Senate Special Committee on Aging for holding ...

Toby Edelman Statement to Senate Committee Regarding Antipsychotic Drugs in Nursing Facilities April 19, 2012

The Future of Long-Term Care: Saving Money by Serving Seniors Senate Special Committee on Aging April 18, 2012 2:00 p.m. Statement for the Record Toby S. Edelman Senior Policy Attorney Center for Medicare Advocacy 1025 Connecticut Avenue, NW, Suite 709 Washington, DC  20036 The Center for Medicare Advocacy suggests that huge savings in the cost of care in nursing facilities could be achieved if facilities ...

Chronic Conditions Articles

NIH Establishes New Research Program to Address Health Disparities of Chronic Diseases August 29, 2016

The National Institute on Minority Health and Health Disparities (NIMHD), part of the National Institutes of Health, is launching the Transdisciplinary Collaborative Centers (TCC) for Health Disparities Research on Chronic Disease Prevention program. This program responds to the need for more robust, ecological approaches to address chronic diseases among racial and ethnic minority groups, under-served ...

Center Submits Comments to Senate Finance Committee’s Bipartisan Chronic Care Working Group (CCWG) February 3, 2016

In December 2015, the Senate Finance Committee’s Bipartisan Chronic Care Working Group released a Policy Options Document.  The Policy Options Document was issued as part of a process begun in May 2015 to develop legislation to address challenges facing Medicare beneficiaries with chronic conditions.   According to a press release issued by the Committee, the Options ...

Center for Medicare Advocacy Submits Comments to Senate Finance Committee and CMS Regarding Important Health Care Proposals June 25, 2015

1. Comments to Senate Finance Committee Chronic Care Workgroup On June 22, 2015, the Center for Medicare Advocacy submitted comments to the Senate Finance Committee Chronic Care Workgroup in response to the Committee’s May 22, 2015 request for comments on reforming care for individuals with chronic conditions. The Committee identified three overarching goals to guide the development ...

New IRS guidance will impact people eligible for Medicare based on End Stage Renal Disease (ESRD) and those who must pay a premium for Part A January 8, 2014

Introduction In general, people who are eligible for Medicare may not purchase Marketplace plans (also called Qualified Health Plans or QHPs). However, IRS guidance released in June, 2013 clarifies that two sub-populations of Medicare eligible individuals may be able to forego Medicare coverage to buy Marketplace plans: people who must pay Part A premiums (also ...

Warning: Medicare Payment Limits Are Bad for Health! December 13, 2012

One of the deficit reduction proposals being discussed to achieve savings from Medicare is to introduce new cost-sharing for home health care. As a means to ward off such potential home health co-payments, some instead suggest capping Medicare payment for episodes of care, effectively limiting the duration of time individuals could access home health services. ...

Settlement Reached to End Medicare’s “Improvement Standard” October 25, 2012

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. was filed in federal District Court on October 16, 2012.  When the judge approves the proposed agreement, a process that may ...

Many Uninsured Individuals with Pre-Existing Conditions Will Find It Easier to Obtain Coverage June 2, 2011

Individuals with pre-existing conditions who have been uninsured for six months may now find it easier to obtain coverage through the Pre-Existing Condition Insurance Plan (PCIP).  PCIP was created by the Affordable Care Act to provide interim coverage until the Health Insurance Exchanges are up and running in 2014. Twenty-seven states administer their own PCIP. ...

Medicare for People with Alzheimer's Disease and other Chronic Conditions December 14, 2010

As the New York Times reported on March 31, 2002 (p.1), Medicare advocates have been successful in convincing the Centers for Medicare and Medicaid Services (CMS) to loosen Medicare’s denial practices for people with Alzheimer’s disease and other cognitive impairments. Unfortunately, Medicare has a decades-long policy of denying coverage to people who need services which are ...

How the 'Improvement Standard' Improperly Denies Coverage to Medicare Patients with Chronic Conditions – text of article printed in Clearinghouse Review, Vol. 43, No. 9-10, Jan-Feb. 2010 February 22, 2010

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. Ms. Prendergast, who needed an electric wheelchair, ...

Medicare for People with Chronic Conditions December 17, 2009

People with chronic conditions and long-term illnesses are too often denied Medicare coverage on the grounds that they will not improve, need “maintenance services only,” have “plateaued” or are “chronic and stable”. Taken together, these reasons are referred to here as the Medicare “Improvement Standard.” Because Medicare is often the sole ...

The "Improvement Standard" is a Barrier to Necessary Care March 26, 2009

Mrs. P, 68 years old, was diagnosed with Amyotrophic Lateral Sclerosis (ALS, also known as Lou Gehrig’s Disease) five years ago.  She now needs a wheelchair, cannot stand on her own, needs assistance to move from bed to wheelchair, and is losing the use of her arms and hands. Mrs. P has ...

Connecticut Consumers Articles

Connecticut Coalition of Resident Council Presidents Urge Lawmakers to Prioritize Nursing Home Staffing Challenges February 2, 2023

Letter to state lawmakers details harm from inadequate staffing.

CT Long-Term Care Ombudsman Program and CMA Launch Innovative Partnership with First Virtual Educational Session February 24, 2022

Educational series to benefit the state’s long-term care residents and families.

Eileen Ossen: In Memory, With Gratitude November 4, 2021

The Center for Medicare Advocacy joins in sorrow with the family, friends, and CT community upon the death of Eileen Ossen.

Connecticut Enacts Legislation with Wide-Ranging Impact for Long-Term Care July 1, 2021

CT lawmakers considered several bills to address significant issues in long-term care post-COVID.

Connecticut Expands Medigap Options for Medicare Beneficiaries Under Age 65 July 1, 2021

Connecticut has one of the country's most robust Medigap programs.

Medigap Rates December 1, 2011

 Connecticut as of 11/15/2011: http://www.ct.gov/cid/lib/cid/Medicare_Supplement_Insurance_Rates.pdf   Find policies in your area at: http://www.medicare.gov/find-a-plan/questions/medigap-home.aspx

Coverage for People with Disabilities

National Assistive Technology Awareness Day – Shining a Light on the Value of Technology and Advocacy April 7, 2022

Assistive Technology is both a critical necessity for those living with disabilities and a pathway to building inclusive communities for everyone.

Center Submits Comments Opposing Social Security Administration Proposal to Increase Frequency of Disability Benefit Reviews February 6, 2020

The Center for Medicare Advocacy (“Center”) and California Health Advocates (“CHA”) submitted joint comments in opposition to a proposed Social Security Administration (SSA) rule to increase the frequency of continuing disability reviews (CDRs) (see Notice of Proposed Rulemaking on Rules Regarding the Frequency and Notice of Continuing Disability Reviews, 84 Fed. Reg. 36588 (November 18, ...

Outpatient Therapy Caps: What Now? January 31, 2018

Since the Balanced Budget Act of 1997, outpatient therapy under Medicare Part B has been subject to dollar limits, or caps.  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 ...

What Would Work Better for You? Deciding Between Traditional Medicare and a Medicare Advantage Plan November 9, 2016

In last week’s Alert, we posed 10 questions to ask before deciding between traditional Medicare and a Medicare Advantage Plan. This week we discuss what your answers may mean.Do you qualify for payment assistance or have access to other coverage through any of the following…Medicare Savings Program? Part D Low Income Subsidy? Employer/Military/Other Insurance? Medigap Plan?Response: Contact the ...

Barriers to Medigap Coverage for Beneficiaries Under Age 65 October 26, 2016

Medicare is commonly known for providing health insurance for older people; however, a significant portion of the program’s beneficiaries are under age 65. Individuals with permanent disabilities and End Stage Renal Disease (ESRD) qualify for Medicare before turning 65. This subset of Medicare beneficiaries, who often deal with multiple chronic conditions and serious health complications, ...

Medicare Annual Enrollment Period Has Begun – Ends December 7 October 19, 2016

Fall is the time for Medicare beneficiaries to explore their options regarding traditional Medicare, Part D prescription drug plans and Part C Medicare Advantage plans.  The Annual Coordinated Election Period (ACEP) starts on October 15th and ends on December 7th. This means that Medicare beneficiaries have to analyze their options and make choices by December ...

Transition of Coverage: The Affordable Care Act and Medicare September 21, 2016

The Affordable Care Act (ACA), signed into law in 2010, was enacted to increase the quality and affordability of health care and lower the rate of uninsured by expanding private and public health insurance.  One mechanism the ACA established to achieve this goal was the creation of health insurance “Exchanges” – regulated online marketplaces where ...

Center for Medicare Advocacy Presents at National SHIP and SMP Conference about Medicare for Beneficiaries Under 65 August 10, 2016

The Center for Medicare Advocacy was pleased to attend, exhibit and present at this year's national SHIP and SMP conference. Pursuant to a Target Population Grant from the Administration for Community Living (ACL), the Center is working to enhance outreach and education for younger Medicare beneficiaries.  At the conference, we discussed progress and next-steps in ...

CMA Survey on Access for SHIPs and SMPs April 29, 2016

1. Are you with (Pick one):Created with Highcharts 4.1.1SHIP: 27.88%SHIP: 27.88%SHIP: 27.88%SMP: 43.27%SMP: 43.27%SMP: 43.27%Both SHIP and SMP: 28.85%Both SHIP and SMP: 28.85%Both SHIP and SMP: 28.85%SHIPPercent: 27.88%Count: 29       SHIP 27.88% 29SMP 43.27% 45Both SHIP and SMP 28.85% 30  Total Responses 104  Skipped 02. I work with the State of:Created with Highcharts 4.1.1Alabama: 3.85%Alabama: 3.85%Alabama: 3.85%Alaska: 0.96%Alaska: 0.96%Alaska: 0.96%Arizona: 4.81%Arizona: 4.81%Arizona: 4.81%Arkansas: 1.92%Arkansas: 1.92%Arkansas: 1.92%California: 2.88%California: ...

New IRS guidance will impact people eligible for Medicare based on End Stage Renal Disease (ESRD) and those who must pay a premium for Part A January 8, 2014

Introduction In general, people who are eligible for Medicare may not purchase Marketplace plans (also called Qualified Health Plans or QHPs). However, IRS guidance released in June, 2013 clarifies that two sub-populations of Medicare eligible individuals may be able to forego Medicare coverage to buy Marketplace plans: people who must pay Part A premiums (also ...

Dental/Oral Health

Medicare & Oral Health Care – Webinar Recording March 14, 2024

A discussion of Medicare oral health coverage, payment, access, and partnerships working on those issues.

Proposal Could Expand Adult Dental Benefits in ACA plans December 14, 2023

States would be free to include routine adult dental coverage in benchmark plans.

CMS Final Rule Includes Important Oral Health Clarification November 9, 2023

Clarifies reimbursement for dental services necessary to the clinical success of certain cancer treatments.

Oral Health & Possible Dementia Risk October 12, 2023

It is clear that oral health impacts overall health, well-being and quality of life. The Center will continue to advocate for a comprehensive oral health benefit in Medicare Part B.

Center Comments on Proposed Clarification of Dental Services September 7, 2023

We urge groups and individuals to also submit supportive comments. Comments are due to the CMS by Sept. 11, 2023.

Proposed Medicare Rule Clarifies Specific Dental Service Coverage July 20, 2023

Proposal would permit Medicare payment for certain dental services required prior to or along with some Medicare-covered cancer treatments.

CMS Publishes Guidance on Medicare Dental Coverage July 13, 2023

Information directed towards health care providers discusses the care coordination and documentation that are necessary.

In Major Milestone, Medicare to Cover Additional Dental Treatments November 3, 2022

CMS to expand certain medically necessary oral health coverage.

Center Comments on Medically Necessary Oral Health Coverage September 8, 2022

This opportunity to broaden medically necessary oral health coverage must be taken.

Medicare Proposal to Cover Dental Treatments that are Clinically Integral to Covered Medical Services  August 19, 2022

Medicare Oral health Comments due 9/6/22 - here are samples to use!

Medically Necessary Oral Health Coverage Included in Medicare Proposed Rule July 14, 2022

Proposed rule includes plan to broaden reimbursement for medically necessary dental services and seeks comments.

Oral Health Advocacy Update July 7, 2022

Continuing our years-long efforts for medically necessary oral health care to be covered by Medicare, as authorized under current law.

New Fact Sheet Addresses Dental/Oral Health in Management of Kidney Disease December 23, 2021

Individual prevention and management of oral and dental disease are important in the context of certain underlying health problems, access to affordable dental coverage and care can be absolutely vital as well.

Analysis Provides Options for Containing the Cost of a New Medicare Dental, Hearing, and Vision Benefit October 7, 2021

Policymakers must address wasteful MA overpayments, particularly if not doing so squanders this opportunity to improve Medicare.

Lack of Oral Health Coverage in Medicare Has Catastrophic Effects June 17, 2021

Center client illustrates need for oral health coverage.

Fact Sheets | Medicare and the Impact of Oral Health on Major Health Conditions May 6, 2021

Series of brochures explains the interrelationship between oral health and major medical conditions.

New Oral Health Resources April 22, 2021

New Infographics on oral health available from the ADA Health Policy Institute.

Work For Oral Health Continues March 31, 2021

Partnership works to to advance goal of adding a comprehensive oral health benefit to Medicare.

Advocates Call for Comprehensive Oral Health Coverage February 25, 2021

A call for comprehensive oral health coverage on Health Affairs Blog.

Report Calls for Congress to Add Oral Health and Other Key Coverage to Medicare and Medicaid December 31, 2020

Serious health consequences can arise from untreated dental, vision and hearing needs.

Confirmed: Without Good Oral Health, Complete Health Is Simply Not Possible December 17, 2020

Journal of the American Medical Association calls attention to the need to strengthen Medicare coverage for medically necessary oral health services.

Please Join this Important Oral health Letter to the Incoming Biden Administration December 11, 2020

Add your organization to this sign-on letter to share oral health policy recommendations with the incoming Biden-Harris Administration.

COVID-19 and Teeth December 3, 2020

Additional research on COVID-19 and oral health is necessary. Current concerns underscore what advocates for expanded oral health coverage have long stated: oral health is part of overall health.

Toolkit to Educate Candidates about Medicare Oral Health August 20, 2020

The Oral Health Progress and Equity Network (OPEN) has developed a new Medicare Dental Toolkit to help educate candidates about the importance of oral health for Medicare beneficiaries. Access the full toolkit here. Please also join us on September 2nd for OPEN’s Virtual Day of Action with a Twitter Chat at 2pm ET – @OPENoralhealth.More information on OPEN: https://medicareadvocacy.org/new-oral-health-advocacy-collaborative-begins/

Center Attorneys Participate in Oral Health Gathering August 13, 2020

We continue to advocate for a comprehensive oral health benefit in Part B of Medicare, and expanded coverage of oral health services that are integral to medical treatments.

Medicare Oral Health Care Update February 6, 2020

Addressing the problem of Medicare’s lack of meaningful oral health coverage has long been a focus of the Center for Medicare Advocacy.  Over the decades, the Center has assisted beneficiaries who require access to medically necessary oral health care, challenged Medicare’s restrictive coverage policy in litigation, and worked with broad coalitions to expand Medicare oral ...

Support Medically Necessary Oral Health Care in Medicare January 30, 2020

For the past few years, a coalition of beneficiary advocates, disease organizations, industry groups,  oral health and medical health professionals has been advocating for medically necessary oral health care to be covered by Medicare, as authorized under current law.  The Coalition recently launched a web-based platform for members of the public to express their support ...

Recent Polling Shows Strong Support Among Voters for Medicare Oral Health Benefit December 24, 2019

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 ...

Caution: Hospital “Outpatient” Rule Negates Statutory Inpatient Coverage for In-Hospital Dental Care December 12, 2019

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 ...

Support for Medicare Oral Health Benefits November 14, 2019

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, ...

Center Attorneys Participate in Oral Health Convening and Advocacy Day October 24, 2019

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 ...

New Oral Health Advocacy Collaborative Begins July 3, 2019

The Center for Medicare Advocacy is pleased to share a new opportunity for advocates working to add a comprehensive oral health benefit to Medicare. The Oral Health Progress Equity Network (OPEN), a national network of individuals and organizations that believe oral health is essential to overall health and wellbeing, is organizing across the country to ensure that ...

Special Update – Issue Brief: Medicare Coverage of Dental Services May 6, 2019

One of the core considerations of the Center for Medicare Advocacy’s Medicare Platform is to expand Medicare coverage to include oral health and dental care for all beneficiaries. We have also long advocated for coverage of medically necessary oral health care, which we think is currently supported by the Medicare statue but is, unfortunately, significantly limited ...

Oral Health in Medicare: Kaiser Family Foundation Releases Issue Brief April 4, 2019

Oral Health in Medicare: Kaiser Family Foundation Releases Issue Brief Kaiser Family Foundation recently released an issue brief, Drilling Down on Dental Coverage and Costs for Medicare Beneficiaries that examines the state of oral health for Medicare beneficiaries, including use of dental services and out-of-pocket spending. Medicare currently does not cover routine dental care, and ...

Oral Health Highlight March 21, 2019

This week Center for Medicare Advocacy Policy Attorney Kata Kertesz presented a webinar together with Justice in Aging regarding Medicare Basics for OPEN, the Oral Health Progress and Equity Network. OPEN is a national network of individuals and organizations that believe oral health is essential to overall health and wellbeing.  OPEN is organizing across the country ...

Improve and Expand Medicare: Oral Health January 17, 2019

Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations for Medicare, now and in the future, is the need to expand and Improve Medicare for all current and future beneficiaries, not just those in private Medicare plans. One of the key issues faced by beneficiaries ...

Senator Cardin Introduces Bill to Add Oral Health Coverage to Medicare January 10, 2019

One of the Center for Medicare Advocacy’s top priorities is to expand Medicare coverage to include oral and dental care for all beneficiaries. We have also long advocated for coverage of medically necessary oral health care, which is currently supported by the Medicare statue but is significantly limited in practice due to Medicare policy. In the opening ...

Legal Memorandum: Statutory Authority Exists for Medicare to Cover Medically Necessary Oral Health Care January 3, 2019

The following is the Center for Medicare Advocacy’s legal analysis and does not represent the federal Medicare agency’s (CMS') position or interpretation of its dental coverage policy. Medicare coverage for medically necessary oral health care is supported by the Medicare statute, its legislative history, Centers for Medicare and Medicaid Services (CMS) policy, and precedent established by ...

State of Decay: Report Examines Oral Health for Older Americans April 26, 2018

Oral Health America (OHA) recently published the fourth volume in a series of reports titled A State of Decay, surveying the state of oral health for older Americans.  The first volume in the series focused on the cost of services and financial reimbursement rates as the primary barrier to accessing oral healthcare.  Since then, the ...

Oral Health Update – “The Painful Truth About Teeth” (Washington Post) May 17, 2017

A recent Washington Post article, “The Painful Truth About Teeth: You Can Work Full Time But not have the Money to Fix Your Teeth – Visible Reminders of the Divide Between Rich and Poor” outlines the devastating impacts of the lack of adequate oral health care in the country. As Congress considers drastic cuts to Medicaid ...

Medicare Oral Health News: District Court in Lodge Cautions Against Strict Application of Same Time/Same Dentist Rule May 10, 2017

Henry Lodge was diagnosed with life-threatening head and neck squamous cell cancer in 1996.  His treatment involved radical dissection of his neck, implantation of radioactive seeds in the base of his tongue, and 30 days of direct beam radiation.  The surgery and the scarring from radiation permanently impaired his ability to speak and swallow, and ...

Issue Brief Examines Oral Health for Older Adults in California August 10, 2016

Justice in Aging, one of the Center's longtime partners, recently released an issue brief, Oral Health in California: What About Older Adults? The Issue Brief includes a summary of the state of oral health for older adults in California. It cites disparities in oral health based on income level, education and race. The Brief also outlines the unique ...

New York Times Article on Noninvasive Alternative to Dental Fillings July 13, 2016

The New York Times reported on July 11, 2016 that a noninvasive alternative to dental fillings that could save money, while preventing future decay, has gained increased traction among dentists. The liquid – Silver Diamine Fluoride, or S.D.F. – can be brushed on certain types of cavities, removing the need for a drill or injection.  The ...

Organizing for Comprehensive Oral Health Care June 29, 2016

As part of the Center for Medicare Advocacy’s commitment to improving oral health for older people and people with disabilities, Center attorneys recently attended a DentaQuest convening in Cambridge, Massachusetts aimed at unifying partners in this common mission. The convening focused on leadership strategies, shared network goals and collaborative work in social justice.  The Center’s ...

Selected Beneficiary Comments from Center for Medicare Advocacy Petition Regarding Oral Health Care June 29, 2016

“Dental care has been the most frustrating part of being a senior, and has the most to do with maintaining health in general.” – Michael Allen, California “This is a very important issue, the ability to eat is vital to a person health, at age 71 I needed new dentures and I had no coverage, they ...

Former CMS Administrator Says Expand Medicare Access to Dental Care June 8, 2016

In a recent Boston Globe piece, former CMS Administrator Donald M. Berwick, MD called for expanded access to dental care, which he characterized as a critical aspect of health care that is out of reach for many. People with low incomes, people with disabilities, and older Americans all have difficulty accessing routine, preventive, and medically essential ...

Report Studies Oral Health in Older Adults May 25, 2016

Oral Health America recently released a report, A State of Decay, a state-by-state ranking of healthcare delivery and public health factors that affect the oral health of older adults. Some of the Report’s Findings76% or 38 states earned a Composite Score of Fair (22%) or Poor (54%); Ten states received a Composite Score of Good; Only ...

Center for Medicare Advocacy and Partners Meet with CMS to Discuss Medicare Coverage of Oral Health Care May 11, 2016

On May 5, 2016 Center for Medicare Advocacy executive director Judith Stein and Senior Attorney Wey-Wey Kwok, the Dental Lifeline Network, the Medicare Rights Center, and former CMS (then HCFA) administrator Bruce Vladeck, met with CMS officials to discuss coverage of medically necessary oral health care. The group’s primary goal was to advance Medicare coverage for ...

The Medicare Dental Exclusion: Is it Being Used to Deny Vulnerable Beneficiaries Needed Care? May 28, 2015

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. The decayed and infected teeth, when left untreated, place these cancer patients at increased risk for infection, thereby decreasing ...

New Report: Expanded Dental Coverage Needed to Confront Health Crisis October 24, 2013

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 ...

Congressional Subcommittee Examines Issues of Dental Health March 8, 2012

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 ...

Discharge Planning Articles

Medicare Coverage for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) When a Beneficiary is Discharged from a Facility December 2, 2021

Going from facility to home is challenging - proper planning can help.

Medicare Skilled Nursing Facility Coverage, Discharges, and Transfers During the COVID Crisis April 9, 2020

Skilled nursing facilities (SNFs/nursing homes) often tell residents and families that they are discharging the resident because Medicare will no longer pay for the resident’s stay.  In a previous Alert (Jan. 2016), the Center for Medicare Advocacy explained that Medicare coverage for care and discharge from SNFs are two distinct issues, each with its own ...

Nursing Home Study Finds Discharges Linked to Medicare Copayments June 6, 2019

   Background. Medicare beneficiaries are entitled to a maximum of 100 days of skilled nursing facility (SNF) care in a benefit period when they meet specific coverage criteria. However, Medicare Part A only covers the full cost of a beneficiary’s skilled care during the first 20 days of a nursing home stay. Starting on day ...

Reducing Hospital Readmissions by Addressing the Causes April 18, 2016

Reports that 20% or more of unplanned hospital readmissions are avoidable has led to considerable interest in policymakers in reducing readmissions.  Actively reducing hospital readmissions is seen as a route to lower Medicare spending and improved patient care. The Affordable Care Act (ACA) established a penalty program for preventable readmissions.  Under the Hospital Readmissions Reduction Program, ...

“Discharge” from a Skilled Nursing Facility: What Does it Mean and What Rights Does a Resident Have? January 13, 2016

Skilled nursing facilities (SNFs) often tell Medicare beneficiaries and their families that they intend to “discharge” a Medicare beneficiary because Medicare will not pay for the beneficiary’s stay under either Part A (traditional Medicare) or Part C (Medicare Advantage).  Such a statement unfortunately misleads many beneficiaries into incorrectly believing, not only that Medicare has decided ...

Discharge Planning: Tips for Evaluating a Hospital’s Skilled Nursing Facility Placement Choices November 17, 2015

Medicare beneficiaries often need care in a Medicare- participating skilled nursing facility (SNF) after an inpatient hospitalization.  For these patients, hospitals are responsible for identifying skilled nursing facilities within the geographic region that can meet the patient’s medical needs.  Until such a placement is found, the beneficiary will not be responsible for her hospital stay.  ...

Proposed Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals (CAHs), and Home Health Agencies (HHAs) November 12, 2015

On November 3, 2015, the Centers for Medicare & Medicaid Services (CMS), published in the Federal Register (80 Fed. Reg. 68126), proposed revisions to requirements for discharge planning for hospitals, CAHs, and HHAs. The proposed rule is also available at http://www.gpo.gov/fdsys/pkg/FR-2015-11-03/pdf/2015-27840.pdf.  Comments on the proposed rule must be submitted to CMS by 5 p.m. on ...

CMS Updates Guidance for Hospital Discharge Planning May 30, 2013

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-participating hospitals must make their discharge planning process available to ...

Medicare Discharge Planning: Think Through Your Needs December 21, 2009

Introduction Discharge planning is an important tool for reviewing and making arrangements for on-going healthcare needs across healthcare settings, including hospitals, skilled nursing facilities, home health, or hospice.  When focusing on discharge planning, beneficiaries and their advocates should carefully read all documents that purport to explain rights to services, including discharge evaluations and discharge planning documents.  ...

Medicare and Discharge Planning: Thinking Through Your Needs December 3, 2009

Discharge planning is an important tool for reviewing and making arrangements for on-going healthcare needs across healthcare settings, including hospitals, skilled nursing facilities, home health, or hospice. When focusing on discharge planning, beneficiaries and their advocates should carefully read all documents that purport to explain rights to services, including discharge evaluations and discharge planning documents. ...

Health Care Reform – the Affordable Care Act (ACA) Articles

Proposal Could Expand Adult Dental Benefits in ACA plans December 14, 2023

States would be free to include routine adult dental coverage in benchmark plans.

ACA No-Cost Preventive Services Will Continue Pending Appeal June 15, 2023

An agreement was reached this week in a lawsuit regarding preventive benefits, allowing cost-free coverage of services such as annual wellness visits and many cancer screenings to continue essentially unchanged for the time being.

CMS Reports Record Enrollment in 2022 Affordable Care Act Health Plans January 6, 2022

With a month left, enrollment for health coverage through Healthcare.gov and state-based marketplaces had already reached a record high.

The ACA is Here to Stay, Improving Medicare and Health Security for Millions June 17, 2021

Case should never have been brought and certainly should never have reached the Supreme Court.

ACA Celebrates 11th Anniversary with Expansions in Enrollment and Coverage March 25, 2021

The 11th anniversary of the ACA was greeted with support for, and expansions of, the law.

U.S. Government Changes Position in Supreme Court Affordable Care Act Case February 11, 2021

Striking down the ACA would have devastating effects on Medicare beneficiaries and the Medicare program itself.

Center for Medicare Advocacy and Medicare Rights Center Urge Biden Administration to Take Immediate Action on Key Issues Facing Medicare Beneficiaries February 11, 2021

Center and allies urge Biden Administration to take swift action to strengthen Medicare, Medicaid, and the ACA.

Supreme Court Hears Case Challenging Affordable Care Act November 12, 2020

The Center for Medicare Advocacy strongly opposes the meritless lawsuit, and was encouraged by the skepticism shown by several Justices.

Center for Medicare Advocacy’s Statement on Supreme Court ACA Oral Argument November 10, 2020

Striking down the ACA would be devastating for Medicare and the older adults and people with disabilities who rely on it.

Five Days until the Affordable Care Act is in Front of the Supreme Court November 5, 2020

Striking down the ACA would have disastrous ramifications for Medicare beneficiaries and the U.S. health care system as a whole.

Dismantling the Affordable Care Act Would Harm Medicare and Medicare Beneficiaries October 29, 2020

The ACA strengthened the long-term financial stability of the Medicare program. Dismantling the ACA would eliminate those savings.

Dismantling the Affordable Care Act Would Harm Medicare and Medicare Beneficiaries October 22, 2020

Undoing the ACA would jeopardize drug coverage for millions of Medicare beneficiaries.

Dismantling the ACA Would Harm Medicare and Medicare Beneficiaries | Highlight on Preventive Services October 15, 2020

The ACA has affected every part of the health care system, including Medicare. Dismantling it would be a disaster for millions.

Administration Asks Supreme Court to Strike Down Entire Affordable Care Act June 25, 2020

Several states and the Trump Administration are asking the Supreme Court to strike down the entire Affordable Care Act.

Center for Medicare Advocacy and Colleagues File Supreme Court Amicus Brief in Support of the Affordable Care Act May 13, 2020

May 13, 2020 Today the Center for Medicare Advocacy, along with AARP and Justice in Aging, filed an amicus brief urging the Supreme Court to uphold the Affordable Care Act (ACA). In their brief, the three organizations highlight the ACA’s critical protections for older adults and the disastrous ramifications that will ensue if the law is ...

Decisive Win for Affordable Care Act: Supreme Court Rules Sabotage Attempt Illegal April 30, 2020

The Supreme Court has ruled that an attempt to sabotage the Affordable Care Act (ACA) by reneging on payments to insurers was illegal. The “risk corridors” program guaranteed payments to insurance companies that had unexpected losses during the first three years of the operation of the ACA’s online insurance exchanges. The program aimed to stabilize ...

Supreme Court to Hear Affordable Care Act Repeal Case March 5, 2020

On March 2, 2020, the U.S. Supreme Court agreed to hear the case that seeks to strike down the entire Affordable Care Act as unconstitutional. The case (California v. Texas) was brought by Texas and several other states and is supported by the Trump administration. The Center is pleased that the Court granted review of ...

Report: Affordable Care Act Narrowed Disparities in Health Care Access February 27, 2020

The Commonwealth Fund recently released a report, How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care. The Report found significant coverage gains nationwide as a result of the Affordable Care Act (ACA), with historic reductions in racial disparities in coverage and access. Some key findings from the report:Coverage expansions ...

Update on ACA-Repeal Lawsuit January 23, 2020

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 ...

Center for Medicare Advocacy Supports Supreme Court Review of ACA-Repeal Lawsuit January 16, 2020

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 ...

The Affordable Care Act Strengthens Medicare & Health Care January 10, 2020

Since the landmark Affordable Care Act (ACA) was signed into law on March 23, 2010, it has increased access to needed health services, reduced costs and improved care for millions. Yet, as this progress continues and the law’s most impactful provisions near implementation, threats to the law continue, through repeal efforts, budget cuts and legal ...

Court Decision Could Lead to the Demise of the Entire Affordable Care Act December 19, 2019

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 ...

CMS Administrator Seema Verma Testifies on Health Care Sabotage Before House Subcommittee October 24, 2019

Over the last several years, the Center for Medicare Advocacy (the Center) has written at length about the Trump Administration’s detrimental changes to the Affordable Care Act (ACA), Medicare, Medicaid, and other vital health care programs. On October 23, 2019, the House Committee on Energy & Commerce, Subcommittee on Oversight and Investigations, held a hearing ...

More People Went Without Health Insurance in United States in 2018 September 12, 2019

On September 10, 2019 the Census Bureau released the annual national-level income, poverty and health insurance statistics for 2018 in two reports, Income and Poverty in the United States: 2018 and Health Insurance Coverage in the United States: 2018. According to the reports, “the rate and number of people without health insurance increased from 7.9%, ...

Court Hearing Next Week in Case that Threatens the Affordable Care Act – Act Now July 3, 2019

Oral argument in Texas v United States, the lawsuit seeking to dismantle the Affordable Care Act, will be held Tuesday July 9, 2019. At stake in this case is the health care of millions of Americans. The case will affect the entire health care system and every aspect of the Affordable Care Act, not just the much-discussed ...

Health Care Sabotage News: Court Strikes Blow for Health Care; Advocates File Amicus Brief in Texas ACA Case April 4, 2019

Court Strikes Blow For Health Care Last week, a federal district court judge put a stop to another effort by the Administration to sabotage the Affordable Care Act (ACA). The judge’s ruling halts an attempt by the Department of Labor to expand Association Health Plans and weaken the ACA. In past Alerts, we have highlighted the ...

Trump Administration Works to Undermine the Affordable Care Act – Yet Again March 28, 2019

— Statement from the Medicare Rights Center and Center for Medicare Advocacy — Washington, DC – This week, the Department of Justice took a new, more extreme position in a federal case challenging the constitutionality of the Affordable Care Act (ACA), agreeing with a federal district court in Texas that the entire law should be invalidated. Now ...

Texas Lawsuit Sabotage of the Affordable Health Care Act December 20, 2018

The Center for Medicare Advocacy and the Medicare Rights Center recently issued a joint statement on the misguided decision of a federal court in Texas against the Affordable Care Act (ACA). If this decision stands, all of the ACA’s coverage and consumer protections will be null and void. People with pre-existing conditions and those who ...

Health Care Sabotage Continues as ACA Open Enrollment Comes to an End December 13, 2018

There are only two days left to get covered! Consumers have until December 15th to obtain health insurance through the Affordable Care Act (ACA) Marketplace. Those who need coverage should visit www.healthcare.gov to shop, compare and find a plan that meets their needs. It is important to keep in mind that ACA plans prohibit annual or ...

Health Care Sabotage: Administration Doubles Down on States’ Ability to Undermine ACA December 6, 2018

We have previously written about new guidance from the Administration that will make it easier for states to both ignore Affordable Care Act (ACA) coverage and consumer protection rules, and weaken the ACA Marketplace. Last week, the Centers for Medicare & Medicaid Services (CMS) issued waiver concepts about how states can implement the new guidance. As ...

ACA Open Enrollment Ends December 15th November 29, 2018

There is not much time left to obtain health insurance from the Affordable Care Act (ACA) Marketplace during this year's Open Enrollment period. Consumers who need coverage should visit www.healthcare.gov to shop, compare and find a plan that meets their needs. Consumers should act quickly.  Not only has this year’s Open Enrollment period been shortened ...

ACA Open Enrollment Begins November 1, 2018

Today is the first day of Open Enrollment for the Affordable Care Act (ACA) Marketplace. Consumers who need coverage should visit www.healthcare.gov to shop around and find an ACA plan that meets their needs. Unfortunately, due to actions taken by the Administration to undermine the Marketplace, there is not as much assistance available to help ...

Health Care Sabotage: Administration Issues New Guidance Making it Easier to Ignore ACA Rules October 25, 2018

This week the Administration issued new guidance that will make it easier for states to ignore Affordable Care Act (ACA) rules and weaken the ACA Marketplace. The new guidance concerns state innovation waivers which would allow states to expand inadequate coverage such as short-term plans and Association Health Plans. As Politico reports, “Many health insurance ...

Health Care Sabotage Continues: New Pre-Existing Conditions Legislation Not What It Seems; GAO Critical of HHS ACA Enrollment Actions August 30, 2018

New Legislation Dealing with Pre-existing Conditions is Not What it Seems Last week Sen. Thom Tillis (R-NC) and others introduced the Ensuring Coverage for Patients with Pre-Existing Conditions Act. This bill would amend the Health Insurance Portability and Accountability Act to supposedly guarantee the availability of health coverage. The sponsors of the legislation claim that the ...

Major Health Care Sabotage: HHS Issues Final Rule on Short-Term Limited-Duration Insurance August 9, 2018

Last week, the U.S. Department of Health and Human Services (HHS) released the final rule expanding the use of Short-Term Limited-Duration Insurance. For months, we have been highlighting how these “Junk Plans” would adversely impact both the Affordable Care Act (ACA) Marketplace and consumers with complex care needs. Short-term insurance is meant to be a ...

Health Care Sabotage: Poll Shows Voters are Watching July 26, 2018

This week, the Kaiser Family Foundation released a poll showing that 56% of Americans believe that the Administration is “trying to make the ACA fail.” The polling also shows that by nearly seven to one, people think this is a negative thing. Over the last few months, we’ve highlighted negative actions taken by the Administration ...

Health Care Sabotage – Navigators Face another Round of Cuts July 12, 2018

Last year, we highlighted how the Administration cut funding for Affordable Care Act (ACA) outreach and enrollment assistance. They are at it again. This week it was reported that the Administration is slashing even more funding for organizations called “navigators” that assist people who need health insurance. The Washington Post reports that for the upcoming ...

Health Care Sabotage: Impact of Sabotage on the Exchanges July 5, 2018

This week, the Centers for Medicare and Medicaid Services (CMS) released their reports on the performance of the exchanges and individual health insurance market. These reports include the Early 2018 Effectuated Enrollment Snapshot, Exchange Trends Report and the Trends in Subsidized and Unsubsidized Enrollment. In the press release for these reports, CMS makes a few ...

Eighth Anniversary of the Affordable Care Act March 23, 2018

Today marks the eighth anniversary of the Affordable Care Act (ACA), the most significant piece of healthcare legislation since Medicare was enacted in 1965. Like Medicare, the ACA provides security, peace of mind and comprehensive coverage for millions of Americans every day. The ACA has moved us closer to realizing that fair access to quality ...

Health Care Sabotage Continues January 17, 2018

Throughout 2017 we called on the Administration to stop undermining the Affordable Care Act (ACA) and protect the care of millions of consumers in need of quality coverage. We highlighted the Administration’s actions cutting the ACA enrollment period in half; slashing funding for enrollment assistance, refusing to participate in enrollment events; shutting down www.healthcare.gov during ...

CMA Alert – Tax Cuts will Hurt, Not Help; Sherman Fairness Hearing Set; “Homebound” Settlement Objections Due; More December 20, 2017

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, 2018Words Matter. Tax Cuts Will ...

Alert – Tax Cut Harm Just Got Worse; This Week in Sabotage; CMS Pushing MA Plans; SNF Deregulation November 15, 2017

Tax Cut Bill Just Got Worse. Health Care at Risk. This Week in Sabotage CMS Steering to Medicare Advantage Administration And Nursing Home Industry: Lockstep in Deregulating Nursing Facilities & Reducing Resident ProtectionsTax Cut Bill Just Got Worse.  Health Care at Risk.Free Webinar Series Next Webinar: Hospital Observation Status Update January 24, 2018 3:00 p.m. ET  Presenters: Center for Medicare Advocacy Litigation Director, attorney ...

CMA Alert, October 18, 2017 – Nursing Home Rights Roundup; ACA Stabilization; More October 18, 2017

This Week in ACA Sabotage Bipartisan Agreement on ACA Stabilization Package Nursing Home Rights RoundupCMS Signals End of Campaign to Reduce Unnecessary Use of Antipsychotic Drugs In Nursing Homes; Claim of Success is Grossly Overstated OIG Report about Nursing Home Complaints Leaves Questions Unanswered Congressional Letter Asks for Revision and Delay of Nursing Home Requirements of ParticipationThis Week In ...

CMA Alert – Joint Replacement Model Undermines Care; OTC Hearing Aids Legislation Passed; More August 23, 2017

Care is Compromised Under CMS’s Comprehensive Care for Joint Replacement (CJR) Model: A Case In Point Over-the-Counter (OTC) Hearing Aid Act Signed into Law Severe Harm if ACA Cost-Sharing Payments EndCare is Compromised Under CMS’s Comprehensive Care for Joint Replacement (CJR) Model: A Case In Point On a Friday this past March, “Ms. T”, a 70-year old Medicare ...

CMA Alert – Critical Issue Roundup: MA Overpayment; HH Payment; Observation; More August 16, 2017

Former CMS Administrator Comments on Medicare Advantage Overpayments Proposed Home Health Rules – Payments Drive Delivery of Care, Harming Beneficiaries Observation Status Harms Low-Income Medicare Beneficiaries Poll: Americans Favor Making the ACA WorkFormer CMS Administrator Comments on Medicare Advantage Overpayments In Austin Frakt’s August 7, 2017 The Upshot blog in the New York Times (“Medicare Advantage Spends Less on ...

Health Repeal Myths & Facts: The Fight Continues July 5, 2017

Congress is on recess, but we can’t be – the health care repeal debate continues!  In their home states and through tough, ongoing negotiations, Senators are making up their minds about the future of the ACA, Medicaid, and Medicare.  This CMA Alert provides updated “Myths & Facts” about the most recent potential changes to the ...

The Affordable Care Act in 2017: Myths and Facts March 15, 2017

Facts should be key to participating in the debate about the Affordable Care Act (ACA) and its future. To help separate what is true from what is often stated, we offer the following Myths and Facts.ACA MythsACA FactsAffordabilityThe ACA makes it too hard for middle-income Americans to purchase insurance in the individual Marketplace.The ACA has ...

CBO Report Confirms ACA Repeal Legislation Will Reduce Health Coverage, Care and Undermine Medicare March 15, 2017

The proposed Affordable Care Act (ACA) repeal legislation, the American Health Care Act, would cause 24 million people to lose coverage by 2026 and cut Medicaid by $880 billion over the next ten years, according to the Congressional Budget Office (CBO), a non-partisan, independent group of budget economists and analysts used to score the financial ...

American Health Care Act (AHCA): A Repeal and Regress Plan March 7, 2017

March 7, 2017, Washington, DC – Last night House Republicans presented a bill to repeal the Affordable Care Act (ACA) and cut Medicaid payments to states.  While the new bill, “America Health Care Act” (AHCA) lacks either an estimate of how many people will lose their health insurance coverage as a result of the bill ...

President Trump’s Address to Congress Brings No New News on Health March 1, 2017

Last night, President Trump, in a speech to Congress, discussed health care but offered no new insight into his Administration’s plans concerning the Affordable Care Act, Medicaid and Medicare.  A day after noting that “nobody knew health care could be so complicated”, the President stated "onight, I am also calling on this Congress to repeal ...

Back to the Future: High Risk Pools Annotated Bibliography February 22, 2017

Many Americans are greatly concerned that repeal of the Affordable Care Act (ACA) will once again leave people with pre-existing conditions without health insurance. The ACA replacement proposal released by Speaker Ryan on February 16 would move coverage from the general ACA marketplace to specific High Risk Insurance Pools. These High Risk Pools would separate ...

Repealing Medicaid Expansion Could Lead to Thousands of Deaths in the U.S. Annually February 22, 2017

According to a recent report from Vox, Congressional plans to repeal key provisions of the Affordable Care Act (ACA) will have devastating consequences for thousands of Americans each year. Vox’s Julia Belluz cites evidence to estimate that 24,000 Americans would die annually if Congress repeals vital provisions of the ACA without simultaneously enacting an appropriate ...

Affordable Care Act Replacement Proposals – Concerns and Resources February 15, 2017

The Administration and the Republican Congress threaten to repeal the Affordable Care Act (ACA), and have suggested various ideas about what a replacement to ACA would include. To better understand these proposals we’ve compiled a list of ACA replacement materials available from colleagues and partnering organizations. Though there is no consensus about what an ACA replacement ...

Reports Highlight Devastating Effects of Repealing the Affordable Care Act and Turning Medicaid into Block Grants December 14, 2016

As we approach a new year, a new Administration and a new session of Congress, the catastrophic risks to health care coverage include threats to repeal the Affordable Care Act – without an agreed-upon replacement, turning Medicaid into a block grant or per capita cap program, and further privatizing Medicare. Several recently-issued/updated reports underscore some ...

Transition of Coverage: The Affordable Care Act and Medicare September 21, 2016

The Affordable Care Act (ACA), signed into law in 2010, was enacted to increase the quality and affordability of health care and lower the rate of uninsured by expanding private and public health insurance.  One mechanism the ACA established to achieve this goal was the creation of health insurance “Exchanges” – regulated online marketplaces where ...

Medicaid Expansion Update February 12, 2015

As originally enacted, the Affordable Care Act (ACA) required each state to expand Medicaid eligibility to 138 % of the Federal Poverty Level.  However, the 2012 U.S. Supreme Court’s decision National Federation of Independent Business v. Sebelius, changed that.  The National Federation decision gives states the option to accept federal funds, reject the funds altogether and ...

Affordable Care Act Enrollment Season Begins Saturday for 2015 Coverage November 13, 2014

The open enrollment period for health insurance coverage for 2015 under the Affordable Care Act (ACA) begins November 15, 2014, and ends on February 15, 2015.More information on the ACA health insurance Marketplace is available at: https://www.healthcare.gov/Plans With Automatic Enrollment Some individuals who are currently enrolled in a health plan through the Marketplace will have their ...

ACA Health Insurance Exchanges October 30, 2014

Signed into law by President Obama in 2010, a primary goal of the Affordable Care Act (ACA) is to provide health insurance for citizens who lack such coverage. This alert is designed to guide new and returning consumers on accessing the ACA’s exchanges and purchasing an appropriate policy through them. One way the ACA provides health ...

Impact of ACA on Mid-term Elections; Beneficiary and Family-Centered QIOs; and More September 11, 2014

Kaiser Family Foundation Poll: Potential Impact of Affordable Care Act (ACA) on the Mid-term Elections On September 9, 2014, the Kaiser Family Foundation issued its August – September 2014 Health Tracking Poll analyzing the potential impact of voter opinion of the Affordable Care Act on the November mid-term elections. The results found that health care broadly was ...

Corporations Don’t Bleed: The Disturbing Hobby Lobby Decision July 3, 2014

The Supreme Court decision in Burwell, Secretary of Health and Human Services, et al. v. Hobby Lobby Stores, Inc., et al. (5-4 decision), 573 U.S. ___ (2014) is ominous. Not only is the decision, and its interpretation of the Religious Freedom Restoration Act (RFFA) a blow to a woman's access to preventive and contraceptive care, its ...

Medicare Advantage Payment Reductions Are Good News for Medicare February 27, 2014

On February 21, 2014, the Centers for Medicare & Medicaid Services (CMS) issued its draft 2015 Call Letter to Medicare Advantage (MA) and Part D plan sponsors, which includes a proposed rate for MA payment for 2015.  Much anticipated, the draft Call Letter, which will be finalized in April, was preceded by an aggressive advertising ...

The Health Care Reform Marketplace is NOT for People with Medicare! October 17, 2013

Beware of Scammers Trying to Sell Marketplace Plans to People with Medicare The Health Insurance Marketplace, created by the Affordable Care Act (ACA), opened for business on October 1, 2013.  Uninsured people can shop for and purchase health insurance on the Marketplace. They can also apply for public programs on the Marketplace like Medicaid and tax ...

Health Insurance Marketplaces Open – What Does it Mean for You? October 3, 2013

On October 1, 2013, online health insurance Marketplaces opened in every state. These Marketplaces, which are a central feature of the Affordable Care Act (ACA), allow uninsured Americans to shop for and purchase health insurance. The Marketplaces also allow individuals to apply for Medicaid and subsides to help pay for insurance. Open enrollment will continue ...

Good News: Trustees Project Longer Medicare Solvency May 31, 2013

Today, the Medicare Trustees issued their annual report on Medicare's financial status.   According to this year's report, the Part A (Hospital Insurance) Trust Fund has sufficient reserves to fully pay Medicare benefits until 2026 – two more years than projected in last year's report.  Since 1970, the Trustees have projected the Medicare Trust Fund would be ...

Medicare’s Future: Letting the Affordable Care Act Work, While Learning From the Past May 7, 2013

This article is part of a NAELA Journal symposium edition that focuses on "The Future of Elder Law and Special Needs Planning." This article will provide an overview of the policy debate that led to the creation of the Medicare program.  It will identify key cost and quality problems facing the program and review solutions included ...

Happy Anniversary, Affordable Care Act March 21, 2013

Since the landmark Affordable Care Act (ACA) was signed into law on March 23, 2010, it has increased access to needed health services, reduced costs and improved care for millions.  Yet, as this progress continues and the law’s most impactful provisions near implementation, threats to the law continue, through repeal efforts, budget cuts and legal ...

Medicare Facts and Fiction: Costs and Spending Edition January 10, 2013

In the past few weeks, the media spotlight on the country's fiscal issues has led to a flurry of attacks on Medicare. Pundits and some policymakers decry Medicare spending as "the largest driver of the federal debt" and argue that the program on which millions of American families rely is unsustainable and must be radically ...

States Can’t Get Full Federal Funding for Partial Medicaid Expansion December 27, 2012

Under the Affordable Care Act, states will be eligible for greatly increased federal-match payments beginning in 2014 if they expand their Medicaid programs to cover adults with incomes up to 133% of the Federal Poverty Level (FPL).  In a letter dated December 10, 2012, Secretary of Health and Human Services (HHS) Kathleen Sebelius said that ...

The Affordable Care Act Moves Forward: What’s Up for 2013 November 8, 2012

Over two years after becoming law, the Affordable Care Act (ACA) continues to improve health care and lower costs for millions of Americans, including those who rely on Medicare. The recent election was key to the future of the landmark legislation, which will expand access to health care coverage and work to improve quality of ...

Medicare and ACA Facts and Updates; Jimmo Update November 1, 2012

Medicare: Just the Facts! Misinformation about Medicare and the Affordable Care Act is widespread and increasing as the election nears.  Below, we try to dispel misinformation and base discussions on a factual foundation.  Spread the word. Help set the record straight!The FactHere's WhyThe Affordable Care Act does NOT cut Medicare for beneficiaries.The Affordable Care Act achieves ...

House Votes for 33rd Time to Repeal Health Reform July 12, 2012

Yesterday, the House of Representatives voted once again to repeal the Affordable Care Act with a 244-185 vote. Despite the Supreme Court affirming the law, House leaders proceeded in scheduling yet another vote to end it – the 33rd such attempt. Meanwhile, more data has been released showing the Affordable Care Act continues to help millions ...

Cut Through the Rhetoric: Questions to Ask After the Supreme Court ACA Decision June 22, 2012

Originally Published at Nieman Watchdog, in ASK THIS, June 14, 2012 (available at http://niemanwatchdog.org/index.cfm?fuseaction=ask_this.view&askthisid=00569), we offer reporters and editors a checklist for stories when the Supreme Court rules on the Affordable Care Act (ACA): 1. Did the Court strike down (or uphold) the entire law?   2. If the entire law is struck down:What will happen to the Medicare Part D Donut ...

A Reporter’s Checklist for the Impending Obamacare Ruling June 15, 2012

Originally Published at Nieman Watchdog, in ASK THIS, June 14, 2012 Health care expert Judith Stein, director of the Center for Medicare Advocacy, offers reporters and editors a checklist for stories when the Roberts Court's ruling on the Affordable Care Act is released. The Center for Medicare Advocacy suggests reporters and editors consider the following when they review ...

Affordable Care Act in Action: People with Medicare Continue to See Savings May 3, 2012

New data released this week shows that families and individuals who rely on Medicare continue to see direct benefits from the Affordable Care Act by saving billions of dollars on prescription drug costs. So far in 2012, older and disabled Americans have saved an average of $837 on their drug purchases after reaching the donut-hole ...

Medicare Under Threat: Health Reform Versus the Ryan Budget April 5, 2012

Last week, two separate, but related, events in Washington added to the threats facing the Medicare program.  First, the Supreme Court heard oral arguments in a case challenging the constitutionality of the Affordable Care Act (ACA), otherwise known as Health Care Reform.  An adverse decision would potentially roll back Medicare improvements that have already begun. ...

Health Care Reform On Trial March 29, 2012

This week, the Supreme Court heard arguments over the constitutionality of the Affordable Care Act (ACA, or health care reform).  As we wrote last week, ACA helps millions of American families by extending health care to those who are either uninsured or underinsured. As the arguments before the Court have revealed, the path to health ...

The Second Anniversary of Health Care Reform is Good News Will There be a Third? March 21, 2012

It's been two years since President Obama signed the landmark Affordable Care Act (ACA) into law on March 23, 2010.  When fully implemented, ACA will provide access to health insurance for virtually all Americans.  Along the way to full implementation, ACA has already helped American families gain access to needed care, while reducing costs and ...

Investing in Our Future: Strengthening Medicare for 2012 and Beyond February 9, 2012

This year brings another election season, another Congressional session, and another opportunity to fortify Medicare, both for those who rely on it now and for future generations. Medicare has been strengthened during the past few years.  However, dangerous rhetoric and schemes to weaken and dismantle the program threaten the health and economic security of millions ...

Health Care Reform Update: Where Are We, and What’s Up for 2012? November 10, 2011

The Affordable Care Act (ACA), passed in March 2010, has been implemented steadily over the past two years. ThisAlert will review some of the important ...

First Appellate Court Rules on Health Reform Law, Holds it Constitutional June 29, 2011

In a decision issued earlier today, the United States Court of Appeals for the Sixth Circuit issued the first appellate decision on the Patient Protection and Affordable Care Act (ACA, often referred to as Healh Care Reform) and held that it was constitutional.  Thomas More Law Center v. Obama, No. 10-2388 (6th Cir., June 29, ...

New Rules for Medicare Advantage and Part D Plans June 2, 2011

On April 15, 2011, the Centers for Medicare & Medicaid Services (CMS) issued final regulations to provide policy and technical changes to the Medicare Parts C (Medicare Advantage) and D programs.  The regulations address concerns raised by Medicare beneficiary advocates, and implement provisions of the Affordable Care Act.  They also codify into regulation some existing ...

Many Uninsured Individuals with Pre-Existing Conditions Will Find It Easier to Obtain Coverage June 2, 2011

Individuals with pre-existing conditions who have been uninsured for six months may now find it easier to obtain coverage through the Pre-Existing Condition Insurance Plan (PCIP).  PCIP was created by the Affordable Care Act to provide interim coverage until the Health Insurance Exchanges are up and running in 2014. Twenty-seven states administer their own PCIP. ...

Combating Fraud, Waste and Abuse in Health Care May 26, 2011

Combating fraud, waste and abuse in health care and in other federal programs remains a popular refrain for reducing federal expenditures. In a survey conducted by AARP in September 2009, 80% of Medicare beneficiaries age 65 and older agreed that eliminating waste, fraud, and abuse in Medicare "should be at least one of the top ...

Happy Anniversary, Health Care Reform March 23, 2011

One year ago, on March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act, the Health Care Reform law that will provide access to health insurance for virtually all Americans. As the Center for Medicare Advocacy has reported over the past year, Health Care Reform is good for Medicare, good for ...

Medicare Changes Effective January 1, 2011 December 30, 2010

This Alert serves as a reminder about changes to Medicare that go into effect on January 1, 2011. 1.      The Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) competitive bidding program Beginning January 1, 2011, beneficiaries in nine areas around the country will have to get medical equipment and supplies through suppliers that have a contract with ...

Health Care Reform Does Not Cut Medicare Benefits October 28, 2010

Health care reform does not cut Medicare benefits. In fact, health care reform expands Medicare coverage, by eliminating cost-sharing for preventive services, adding a yearly wellness visit, limiting some cost-sharing in private Medicare plans, and closing the Part D "Donut Hole." It also improves the solvency of the Medicare program itself. Reform does, however, change ...

Affordable Care Act Expands Medicare Coverage for Prevention and Wellness September 9, 2010

The Affordable Care Act (ACA) adds coverage for a new "Wellness Visit" and eliminates cost-sharing for almost all of the preventive services covered by Medicare, effective January 1, 2011. This Alert discusses both provisions. Wellness Visit Starting next year, Medicare will cover a new annual wellness visit and will provide payment for the creation of a personalized ...

Health Reform in Action: Donut Hole Rebate Checks Start Arriving June 10, 2010 June 10, 2010

Medicare beneficiaries who enter the prescription drug coverage gap (known as the "Donut Hole") anytime before the end 2010 should receive a one time $250 rebate check from Medicare.  The first checks, for people who hit the Donut Hole by March 31, 2010, should arrive around June 10, according to Secretary of the Department of ...

Home Health Care Articles

Medicare-Covered Home Health Care Declining April 25, 2024

2024 Medicare Payment Advisory Commission Report to CongressHome health agencies provided services to 15% fewer traditional Medicare beneficiaries from 2019 to 2022. Home health agencies reported a 23% marginal profit from traditional Medicare beneficiaries ...

Medicare Program Cannot Afford Medicare Advantage “Stability” – Especially as New Study Shows Inferior Home Health Care Provided by MA Plans March 7, 2024

Industry's idea of MA "stability" is continued wasteful overpayments, despite documented poor coverage and outcomes.

When Should Medicare Coverage be Available for Home Health Care? February 8, 2024

A quick guide to home health coverage

Senate Finance Committee Confirms Medicare Home Health Coverage Can Be Long-Term September 21, 2023

Center Director Judith Stein says if we really want to fix Medicare home health care we need to enforce the law that already exists.

Make Your Voices Heard! August 24, 2023

Make sure your voices are heard so that beneficiaries can access the aide services they need to keep them safe at home.

Make Your Voices Heard! Please Respond to CMS Request for Information About the Importance of Home Health Aides August 10, 2023

Beneficiaries and advocates must discuss the critical need for availability of aide services and the consequences when qualifying coverage is not available.

Newly Revised CMS Home Health Benefit Brochure July 6, 2023

CMS Updates home health info to reflect Jimmo case and more.

Center Appeals Dismissal of Home Health Aide Lawsuit June 8, 2023

Medicare’s home health benefit can cover up to 28-35 hours per week of aides, but Medicare's policies and practices restrict the availability and coverage of such services.

Study: People with Dementia Receive Less Home Health and Hospice Care in Their Final Months February 23, 2023

Study: "current health models are not always equipped for the sustained burdens of dementia, resulting in inadequate end-of-life care, or even none at all."

Meet One of the Named Plaintiffs in the Center’s Home Health Aide Lawsuit November 3, 2022

Article explains her challenges in accessing the Medicare-covered home health aide services she qualifies for.

CMS’s Home Health Care Proposed Rule Would Allow Medicare-Covered Services to Become Less Accessible for More Patients August 11, 2022

Submit comments about the proposed home health care rule to CMS at Regulations.gov.

Home Health Comments 2023 August 11, 2022

2023 Comments on Home Health Prospective Payment System Rate Update; Home Health Quality Reporting Program Requirements; Home Health Value Based Purchasing Expanded Model Requirements; and Home Infusion Therapy Service Requirements.

Center for Medicare Advocacy Contributes to Report on the Medicare Home Health Benefit April 28, 2022

Report raises valid issues, but completely mis-defines the home health benefit.

New Resource | Home Health FAQs February 3, 2022

Answers to frequently asked questions about Medicare coverage of home health services.

Home Health Webinar Q & A January 21, 2022

Information based on questions that were received from the January 12, 2022 webinar on Medicare coverage of home health services

CMA Home Health Survey | Medicare Beneficiaries Likely Misinformed and Underserved December 15, 2021

the Center conducted a survey of 217 Medicare-certified home health agencies (HHA) in 20 states to learn more about what beneficiaries experience. The results were not encouraging.

Center Responds to CMS Proposed Rules That Would Diminish Access to Medicare Home Health Care August 5, 2021

The proposed rules and policies, if finalized, will significantly diminish the ability of many beneficiaries to access home health care.

New Medicare Home Health Fact Sheet – Focus on Home Health Aides July 29, 2021

Our new Fact Sheet explains who qualifies for Medicare-covered home care, and what Medicare should cover, with a handy infographic.

79 Organizations Call on CMS and ACL to Ensure Access to Medicare-Covered Home Health Care June 3, 2021

Ensure current law is followed for those who qualify, and take advantage of a historic opportunity to expand home care coverage.

New Factsheet | Medicare Home Health Coverage and Jimmo v. Sebelius May 27, 2021

Medicare home health coverage is not just a short-term, acute care benefit. Unfortunately, unfair coverage denials still occur on the basis that the individual was not "improving."

Shrinking Medicare Home Health Coverage: It’s Time to Act April 22, 2021

It’s time to make sure people who rely on Medicare to access care can obtain the home and community-based services they need.

Issue Brief | Medicare Home Health Coverage: Reality Conflicts with the Law April 7, 2021

People who legally qualify for Medicare coverage frequently have great difficulty obtaining and affording necessary home care.

CMS Plans to Expand Program that Interferes with Patient Access to Medicare Covered Home Health Care January 14, 2021

The HHVBP model should not continue, let alone expand, until quality care for all patients is included in the measurements.

Comments Submitted Regarding Medicare Home Health Proposed Rule for 2021 August 27, 2020

The Center for Medicare Advocacy (Center) submitted comments to the Centers for Medicare and Medicaid Services (CMS) about the Calendar Year 2021 Home Health Prospective Payment System Rate Update; Home Health Quality Reporting Requirements; and Home Infusion Therapy Service Requirements.

Center Comments on Proposed Home Health Rules August 27, 2020

New rules should be proposed that encourage agencies to provide care for all people who qualify under the law, for all services covered under the law.

Medicare Home Health Case Settled with Full Coverage for Beneficiary with Chronic Conditions July 23, 2020

Advocates should continue to be alert for inappropriate denials of coverage based on lack of improvement or on “stability” – particularly for individuals with chronic conditions.

Issue Brief: Medicare Payment vs. Coverage for Home Health & Skilled Nursing Facility Care March 3, 2020

New Issue Brief: Medicare Payment vs. Coverage for Home Health & Skilled Nursing Facility Care The Centers for Medicare & Medicaid Services (CMS) — the federal agency responsible for administering the Medicare program — has begun implementing new Medicare payment models for both home health and skilled nursing facility care. These payment models create a different ...

Medicare Coverage of Home Health Care Has Not Changed Under the New Payment System (PDGM) February 20, 2020

Background.  On January 1, 2020, the Centers for Medicare & Medicaid Services (CMS) began implementing a new Medicare payment system—“Patient Driven Groupings Model” (PDGM)—for home health services. Under PDGM, home health agencies have a new set of financial incentives to consider when admitting and continuing care for Medicare beneficiaries. Unfortunately, those financial incentives are harmful ...

Home Health Practice Guide with Case Study (January 2020) January 7, 2020

Medicare Home Health Coverage and CareIs Jeopardized By the New Payment Model –The Center for Medicare Advocacy May Be Able to HelpActual Recent Case StudyMrs. 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, for skilled nursing and ...

Potential Impacts of New Medicare Payment Models On Skilled Nursing Facility and Home Health Care October 31, 2019

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 ...

Proposed Home Health Rules – Payment Shouldn’t Impede Access September 12, 2019

The Center for Medicare Advocacy (the Center), submitted comments this week regarding the 2020 proposed rules for Medicare home health care. The Center is pleased CMS plans to allow therapist assistants to perform maintenance therapy (therapist assistants are currently allowed to perform improvement therapy), recognizing equal coverage for beneficiaries who need safe and effective therapy ...

As Home Care Needs Increase, Access Issues Must Be Addressed September 5, 2019

According to a recent New York Times Article, “Home health care is the fastest growing major job category in the country, one of the most emotionally and personally demanding, and one of the worst paid.” Families – and state governments – are struggling with a growing demand for long-term services and supports (LTSS) such as ongoing ...

CMS Proposed Medicare Home Health Rules Raise Concerns for Access to Care – Comments due September 9, 2019 August 29, 2019

The Center for Medicare Advocacy is concerned that proposed home health rules will further steer home health agencies away from providing care for beneficiaries who need it the most and toward beneficiaries with short-term post-acute care needs.Beginning in 2020, payments to home health agencies under the new model will provide higher payments for individuals who ...

More Doors to Medicare Home Health Closing, More Harm for Observation Status Patients July 18, 2019

Many Medicare hospital patients classified as observation status “outpatients” currently forego necessary skilled nursing facility (SNF) care and head home to continue care through Medicare’s home health care benefit. This is because they lack a 3-day inpatient hospital stay, which is required for Medicare coverage of most beneficiaries’ post-acute care in a SNF. Beginning January ...

New Medicare Home Health Fact Sheet June 20, 2019

One of the core considerations of the Center for Medicare Advocacy’s Medicare Platform is to reduce ongoing barriers to care. Home health is one area in particular where the Center has seen a disturbing increase in access issues. Advocates, policy-makers and CMS must all work to ensure access to home health coverage and care is ...

Inadequate Personal Care at Home Increases Overall Medicare Costs June 13, 2019

Medicare home health coverage plays a vital role in supporting the health, safety, and well-being of adults in need of community-based care. Unfortunately, the Center for Medicare Advocacy (the Center) regularly hears from Medicare beneficiaries and their families about their inability to access care, or the appropriate amount of care, despite meeting the necessary coverage ...

Study Finds Home Health Lowers Costs and Readmission Rates Compared to Hospital Care March 28, 2019

A recently published study in The American Journal of Accountable Care finds that home health care may result in lower costs and a lower hospital readmission rate for Medicare beneficiaries after emergency room visits. The study, “Improved Cost and Utilization Among Medicare Beneficiaries Dispositioned From the ED to Receive Home Health Care Compared With Inpatient ...

Home Infusion Therapy Services March 13, 2019

(The Content below is taken from the Centers for Medicare & medicaid Services: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Home-Infusion-Therapy/Overview.html) 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 . The components needed ...

Home Health Aide Coverage Continues to Shrink: Attention Must Be Paid February 21, 2019

As we have reported in the past, the ability to get Medicare-covered home health aide care has greatly declined in recent years. This is true even when individuals meet the law’s homebound and skilled care requirements – and thus qualify for coverage. Sadly, and incorrectly, Medicare beneficiaries are often told the only aide care they ...

Case Spotlight: A Medicare Beneficiary in Need of Home Health Aides February 21, 2019

The Problem Mrs. B contacted the Center for Medicare Advocacy seeking assistance with Medicare home health coverage. She lives with her husband who has advanced Parkinson’s disease. He receives physical therapy and speech language pathology through a Medicare-certified home health agency, but the agency told Mr. and Mrs. B they are “over Medicare’s income limit for ...

Keep Medicare Home Health Care an Age-Friendly Benefit December 27, 2018

– Join us for Our Medicare Home Health Webinar · January 23 at 3pm EST– Guest Speaker: Physical Therapist Cindy Krafft, PT, MS Last week, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress.  One of the core considerations to improve Medicare for all beneficiaries, now and in the future, is the ...

Home Health Telephone Survey November 15, 2018

As part of a project supported by the Ossen Family Foundation, Center for Medicare Advocacy staff recently called the 16 home health agencies that, according to Medicare’s Home Health Compare tool, serve the two counties near our CT office. Home health agencies were asked about their ability to provide care to a beneficiary with a chronic ...

Successful Advocacy for Home Health Beneficiary in Need of Maintenance Physical Therapy November 15, 2018

Mrs. R contacted the Center for Medicare Advocacy about her husband, who has ALS, and was told his home health physical therapy was about to be terminated. While receiving physical therapy, Mr. R had reduced pain, allowing him to decrease pain medications, improved bowel function, and increased ability to clear airway secretions. Nonetheless, home health agency ...

Home Health Aide Coverage Continues to Shrink in Traditional Medicare While CMS Enhances it in Medicare Advantage November 15, 2018

For years the Center for Medicare Advocacy and other stakeholders have advocated for Medicare coverage for home health aides without the current prerequisites that the individual be homebound and require skilled nursing or therapy. Unfortunately, the ability to get Medicare-covered home health aide care has greatly declined in recent years, even when individuals meet the ...

Home Health Issue Brief November 15, 2018

Since 2017 the Center for Medicare Advocacy has been writing and disseminating a ten-part Home Health Issue Brief Series examining the growing crisis in access to Medicare-covered home health care, and outlining the Center’s work to address the issue. This Home Health Issue Brief includes all ten prior Briefs in one document. We hope this ...

Plans to Address and Resolve the Medicare Home Care Crisis October 18, 2018

This is Part Ten of a ten-part CMA Issue Brief Series examining the growing crisis in access to Medicare home health coverage and necessary care – and outlining the Center for Medicare Advocacy’s work to address these issues. We invite you to follow this Issue Brief Series and submit Medicare home health stories to the ...

Checklist for Medicare Home Health Care “Improvement Standard” Denials October 18, 2018

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy has produced a new Checklist to help Medicare beneficiaries and their families respond to unfair Medicare denials for home health care based on an erroneous “Improvement Standard.” The Checklist outlines the coverage criteria for home health care and emphasizes language from the ...

Center Comments on Harmful Proposed Home Health Rule August 30, 2018

The Center for Medicare Advocacy (the Center) submitted comments to the Centers for Medicare and Medicaid Services (CMS) about the devastating impact a proposed rule will have on access to Medicare home health care for vulnerable older and disabled people. The proposed rule purports “to better align payment with patient care needs and better ensure that ...

Re-Review of Some Home Health Denials Now Available August 30, 2018

In January, Vermont Legal Aid and the Center for Medicare Advocacy settled a case on behalf of Medicare beneficiaries in the six New England states and New York who had had been denied coverage of home health services for not being “homebound.” The settlement in Ryan v. Price, 5:14-cv-269 (D. Vt.), calls for re-review of ...

Statistical Trends and Published Articles with Studies and Research from 2002-2017 August 23, 2018

This is part nine of a ten-part CMA Issue Brief Series examining the growing crisis in access to Medicare home health coverage and necessary care – and outlining the Center for Medicare Advocacy’s work to address these issues. We invite you to follow this Issue Brief Series and submit Medicare home health stories to the ...

Proposed Home Health Rule Affirms Medicare Coverage and Payment for Patients Who Will Not Improve and May Need More Care than the Norm July 12, 2018

In the proposed rule, published in the Federal Register on July 12, 2018, CMS confirms that a patient’s condition does not need to improve for home health care to be covered by Medicare. CMS also acknowledges the following:There have been reports of difficulty accessing coverable home health care, especially when the patient’s condition is not ...

Medicare Home Health Rules Proposed by CMS to “Improve Access to Solutions” Will Further Reduce Patient Access to Care July 5, 2018

The announcement on July 2, 2018, that CMS seeks to “modernize” Medicare home health care is filled with patient-oriented rhetoric, but will actually further gut the Medicare home health benefit – which is already being implemented in a way that doesn't work for many patients who are most in need. New payment policies, such as those ...

Home Health Pre-Claim Review Demonstration Model, Take Two June 14, 2018

In April 2017, the Centers for Medicare and Medicaid Services (CMS) abandoned a multi-state Medicare Pre-Claim Review Demonstration Model that had so many flaws it never made it out of the initial implementation state, Illinois. The latest proposed model promises to improve on the past model and boasts of greater flexibility and choice for providers ...

Home Health Highlight: People Can Leave Home and Still Receive Medicare-Covered Home Care May 17, 2018

The Center for Medicare Advocacy hears from Medicare beneficiaries throughout the country who are living with serious illnesses and injuries without the home care they need – and that should be covered by Medicare. There are many reasons for these access problems. Patients are told they don’t meet the qualifying criteria because they aren’t “homebound,” ...

Medicare Home Health Coverage is Not a Short Term Benefit ‒ Congress Reiterated This in the Balanced Budget Act of 1997 (BBA ’97) May 3, 2018

In 1997 Congress specifically recognized that Medicare home care was not a short term, acute care benefit and addressed payment methodologies under Parts A and B to meet the costs of longer-term home care. The Balanced Budget Act of 1997, signed into law on August 5, 1997, made some major changes to the Medicare Act.One of ...

Fact Sheet – Medicare Home Health Coverage In Light of Jimmo v. Sebelius April 12, 2018

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy provides the following Fact Sheet to help Medicare home health beneficiaries and their families respond to unfair Medicare denials based on an erroneous “Improvement Standard.” The Fact Sheet emphasizes language from the Jimmo Settlement Agreement, wherein the Centers for Medicare & Medicaid ...

Proposed CMS Payment Rules Will Worsen the Home Care Crisis March 15, 2018

This is the eighth of a ten-part CMA Issue Brief Series examining the growing crisis in access to Medicare home health coverage and necessary care – and outlining the Center for Medicare Advocacy’s work to address these issues. We invite you to follow this Issue Brief Series and submit Medicare home health stories to the ...

Medicare Home Health Highlight March 1, 2018

Home health access problems have ebbed and flowed over the years, depending on the reigning payment mechanisms, systemic pressures, and misinformation about Medicare home health coverage.  Regrettably, as we’ve been reporting, access issues are on the upswing.  This is the second of several Practice Tips to help maximize Medicare-covered home care under the law. Family Members ...

Medicare Home Health Highlight February 22, 2018

Home health access problems have ebbed and flowed over the years, depending on the reigning payment mechanisms, systemic pressures, and misinformation about Medicare home health coverage.  Regrettably, as we’ve been reporting, it seems access issue are on the upswing.  Here is the first of several Practice Tips to help maximize Medicare-covered home care under the ...

Toolkit: Medicare Home Health Coverage & Jimmo v. Sebelius February 15, 2018

Jimmo v. Sebelius, No. 11-cv-17 (D. VT), is a nationwide class-action lawsuit brought on behalf of Medicare beneficiaries who received care in skilled nursing facilities, home health care, and outpatient therapy and who were denied Medicare coverage on the basis that they were not improving or did not demonstrate a potential for improvement (known as ...

Barriers to Home Care Created by CMS Payment, Quality Measurement, and Fraud Investigation Systems February 7, 2018

This is Part Seven of a ten-part CMA Issue Brief Series examining the growing crisis in access to Medicare home health coverage and necessary care – and outlining the Center for Medicare Advocacy’s work to address these issues. We invite you to follow this Issue Brief Series and submit Medicare home health stories to the ...

Medicare Home Health Access Problems Continue January 17, 2018

As we have reported, the Center for Medicare Advocacy has been hearing from people unable to access Medicare-covered home health care, or the appropriate amount of care, despite meeting Medicare coverage criteria.  In particular, people living with long-term and debilitating conditions find themselves facing significant access problems. In a January 17 NPR article, Susan Jaffe of ...

Beneficiary Protections Expanded in Revised Home Health Conditions of Participation January 3, 2018

This is Part Six of a ten-part CMA Issue Brief Series examining the growing crisis in access to Medicare home health coverage and necessary care – and outlining the Center for Medicare Advocacy’s work to address these issues. We invite you to follow this Issue Brief Series and submit Medicare home health stories to the ...

Alert – Spotlight on Medicare Home Health Care; Tax Cuts Set Stage for Medicare/Medicaid Cuts; ACA News November 8, 2017

Medicare Home Health Coverage is Not a Short-Term, Acute Care Benefit ─ Congress Acted in 1980 to Provide for Longer-Term Coverage Final Home Health Rules and Interpretive Guidance: Proposed Payment Model Rescinded Advocates Oppose House Tax Cuts Bill that Would Set the Stage for Deep Cuts to Medicare & Other Programs This Week in Sabotage – and Some ...

CMA Alert – It’s Enrollment Season; CMS Reissues HH Booklet; “Homebound” Case Settlement; More November 1, 2017

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, 2018It's Health Care Enrollment SeasonFree Webinar Series Next Webinar: Social Security Disability Insurance (SSDI) Part 2 – Overview of Benefits for Those Who Qualify, and Best Practices for Applications November ...

CMA Alert – Changes to Help QMBs; Home Health Updates; ACA Sabotage October 4, 2017

CMS Changes Will Help Ensure Low Income Beneficiaries Are Not Illegally Billed CMS Reissues Improved Medicare Home Health Booklet Dispelling a Myth: Medicare Home Health Coverage is NOT a Short Term, Post-Acute Care Benefit The ACA Sabotage ContinuesCMS Changes Will Help Ensure Low Income Beneficiaries Are Not Illegally Billed The Centers for Medicare and Medicaid Services (CMS) is changing ...

CMA Alert – Harmful Proposed Home Health Rules; Equitable Relief Ending Soon; ACA Sabotage September 27, 2017

Proposed Home Health Rules Harm the Most Vulnerable Beneficiaries We Called It: Continued Sabotage of the ACA “Equitable Relief” Ends this Week – Sign Up for Medicare Part BProposed Home Health Rules Harm the Most Vulnerable Beneficiaries In July, CMS proposed new payment, case-mix adjustment and quality reporting rules that will make it harder for individuals to access ...

CMA Alert – Critical Issue Roundup: MA Overpayment; HH Payment; Observation; More August 16, 2017

Former CMS Administrator Comments on Medicare Advantage Overpayments Proposed Home Health Rules – Payments Drive Delivery of Care, Harming Beneficiaries Observation Status Harms Low-Income Medicare Beneficiaries Poll: Americans Favor Making the ACA WorkFormer CMS Administrator Comments on Medicare Advantage Overpayments In Austin Frakt’s August 7, 2017 The Upshot blog in the New York Times (“Medicare Advantage Spends Less on ...

The Home Care Crisis: An Elder Justice Issue August 2, 2017

This is Part Five of a ten-part CMA Issue Brief Series examining the growing crisis in access to Medicare home health coverage and necessary care – and outlining the Center for Medicare Advocacy’s work to address these issues. We invite you to follow this Issue Brief Series and submit Medicare home health stories to the ...

CMA Alert – Senate Health Bill, Again; Medicare Trustees Report; HH CoPs; More July 13, 2017

Here We Go Again: Senate Health Repeal Bill Released Today, Vote Planned for Next Week Medicare Trustees Project Increase in Solvency Delay of New Medicare Home Health Conditions of Participation Advocacy News from the CapitolHere We Go Again: Senate Health Repeal Bill Released Today, Vote Planned for Next Week After backing off of plans to vote on its Better ...

Misleading and Inaccurate CMS Medicare Home Health Publications June 21, 2017

This is Part Four of a ten-part CMA Issue Brief Series examining the growing crisis in access to Medicare home health coverage and necessary care – and outlining the Center for Medicare Advocacy’s work to address these issues. We invite you to follow this Issue Brief Series and submit Medicare home health stories to the ...

Medicare Coverage for Home Care Is Based On a Need For Skilled Care – Improvement Is Not Required May 31, 2017

This is Part Three of a ten-part CMA Issue Brief Series examining the growing crisis in access to Medicare home health coverage and necessary care, and outlining the Center for Medicare Advocacy’s work to address these issues. We invite you to follow this Issue Brief Series and submit Medicare home health stories to the Center ...

CMA Issue Brief Series: Medicare Home Health Care Crisis May 31, 2017

A ten-part CMA Issue Brief Series examining the growing crisis in access to Medicare home health coverage and necessary care, and outlining the Center for Medicare Advocacy’s work to address these issues. We invite you to follow this Issue Brief Series, and submit Medicare home health stories to the Center at https://www.medicareadvocacy.org/submit-your-home-health-access-story/.Download the complete Brief (.pdf) ...

Brief Description of Medicare Home Health Coverage Under the Medicare Act May 3, 2017

This is Part Two of a Ten-Part CMA Issue Brief Series to examine, and inform work to resolve, the growing crisis in access to Medicare home health coverage and necessary care.  We invite you to follow this Series and provide Medicare home health stories at https://www.medicareadvocacy.org/submit-your-home-health-access-story/. CMA Issue Brief Series: Medicare Home Health Care CrisisOverview – ...

April is National Minority Health Month April 26, 2017

From the Centers for Medicare & Medicaid Services (CMS): Many minorities experience a disproportionate burden of preventable disease, including diabetes, heart disease, kidney failure, and obesity. Providers should talk to patients about the importance of preventive care and recommend appropriate Medicare-covered preventive services. For More Information:Medicare Preventive Services Educational Tool Mapping Medicare Disparities Tool CMS Office of Minority Health ...

Overview: The Crisis in Medicare Home Health Coverage and Access to Care April 19, 2017

Today the Center for Medicare Advocacy launches a Ten-Part Series to examine and continue work to resolve the growing crisis in access to Medicare home health coverage and necessary care. We invite you to follow this Series and provide Medicare home health stories at https://www.medicareadvocacy.org/submit-your-home-health-access-story/ Medicare Home Health Crisis SeriesOverview – The Crisis in Medicare Home ...

The Promise and Failure of Medicare Home Health Coverage December 15, 2016

1.The Problem The Center for Medicare Advocacy has been hearing from people who meet Medicare coverage criteria but are unable to access Medicare-covered home health care, or the appropriate amount of care. These problems have been escalating in 2016. Care provided often falls short of care that is covered under the law and ordered by the ...

Medicare Home Health Benefit’s Face-to-Face Encounter Requirement November 8, 2016

As a condition of payment for Medicare home health benefits, a physician must certify that a patient is confined to the home, needs skilled services, receiving the services under a plan of care established and periodically reviewed by a physician, and under the care of the physician.  The Affordable Care Act (ACA) added a requirement ...

An Open Letter to CMS About Fraud September 28, 2016

Can we talk about fraud? It exists. It’s not good for Medicare. Efforts to eliminate its damage to the program are necessary.  But CMS’ war on fraud seems to be indiscriminate, full of tactical errors and collateral damage. Rather than carefully targeting the perpetrators of fraud, a wide net is cast, resulting in legitimate claims ...

Center for Medicare Advocacy Launches Home Health Access Initiative ​To Open Doors to Home Health Care September 15, 2016

As we have reported, the Center has been hearing more and more about people who meet Medicare criteria but cannot obtain, or retain, necessary home health care ordered by their physicians. In particular, people living with long-term and debilitating conditions such as ALS, MS, paralysis and Parkinson’s disease find themselves without necessary home care. For ...

The Promise of Medicare Home Health Coverage September 13, 2016

The Center for Medicare Advocacy has been hearing from people who meet Medicare coverage criteria but are unable to access Medicare-covered home health care, or the appropriate amount of care.   In particular, people living with long-term and debilitating conditions find themselves facing significant access problems. For example, patients have been told Medicare will only cover ...

Proposed Rules Will Add to Problems Accessing Necessary Home Health Care August 24, 2016

The Center for Medicare Advocacy has been hearing about people who clearly meet Medicare criteria but are unable to access home health care ordered by their physicians. In particular, people living with long-term and debilitating conditions find themselves without necessary home care. For example, they have been told Medicare will only cover 1 to 5 ...

Medicare’s Home Health Benefit Under Threat March 2, 2016

1. CMS Proposes Medicare Home Health Prior Authorization Demonstration On February 5, 2016, the Centers for Medicare & Medicaid Services (CMS) published a two-page Paperwork Reduction Act notice in the Federal Register announcing their effort to seek approval from the Office of Management and Budget (OMB) to “collect information” relating to a demonstration project.  Pursuant to ...

Case Study: Home Health Coverage and Medicare Advantage Plan Responsibilities August 13, 2015

The Center for Medicare Advocacy received an e-mail inquiry from an individual requesting assistance advocating for her sister, Mrs. B.  Mrs. B is a Medicare beneficiary enrolled in a Medicare Advantage plan and in need of home health services.  The questions raised demonstrate several important issues that often arise with both the home health benefit ...

New CMS Proposed Homebound Policy Would Leave Medicare Beneficiaries Without Coverage November 7, 2013

Medicare only covers home health care if, among other requirements, the beneficiary is homebound. As of November 19, 2013, the Centers for Medicare & Medicaid Services (CMS) will require new criteria for purposes of meeting the homebound requirement.  These new requirements will leave many Medicare beneficiaries without access to the medically reasonable and necessary home ...

Caution: Home Health Episode Payment Caps October 10, 2013

Legislation was introduced on October 4th that could lead to a cap on the home health services available to a Medicare beneficiary.  In the midst of a government shutdown, Representatives Matheson (D-Utah) and Guthrie (R-Kentucky) introduced the "Medicare Home Health Fraud Reduction Act" (H.R. 3245).  This bill would establish maximum annual reimbursements to Medicare home ...

Warning: Medicare Payment Limits Are Bad for Health! December 13, 2012

One of the deficit reduction proposals being discussed to achieve savings from Medicare is to introduce new cost-sharing for home health care. As a means to ward off such potential home health co-payments, some instead suggest capping Medicare payment for episodes of care, effectively limiting the duration of time individuals could access home health services. ...

Annual Medicare Payment Limits for Home Health – Even Worse Than Co-Pays for Beneficiaries December 5, 2012

The Center for Medicare Advocacy has represented Medicare beneficiaries since 1986. As one of the few advocacy organizations in the nation solely serving Medicare beneficiaries, we strongly oppose home health episodic payment caps or any other such defined payment limits. The counterpart to this notion, caps on outpatient therapy, has created significant barriers to necessary ...

A Client Profile January 1, 2010

One of our clients, Mrs. Brown, who has been living alone with Multiple Sclerosis and various related health problems since 1986. She is declining. Currently, she is essentially bed bound and has to rely on assistance from at least one other person in order to transfer out of bed. She has little use of her ...

The Improvement Standard Articles

Know Jimmo | Watch our Symposium to hear from Jimmo Pros April 11, 2024

Watch and learn.

Know Jimmo | Use the CMS Information April 4, 2024

Use the information from CMS

Know Jimmo | You Do Not Have to Decline March 28, 2024

You do not have to decline in order to receive Medicare coverage for care to maintain or slow decline.

Know Jimmo | CMS Reiterates that Medicare Coverage is Available to Maintain Function or Slow Decline March 14, 2024

Coverage can't be denied for lack of improvement, progress or anything similar. Use CMS' own words.

Know Jimmo | It’s Not About Care Setting March 7, 2024

Repeat after us - Improvement isn't required for Medicare to cover skilled care.

Know Jimmo | CMS Reminder to MA Plans February 29, 2024

CMS outreach continues - providers and plans should listen.

Know Jimmo | Skilled Nursing Facility Policy February 22, 2024

Skilled maintenance services are covered in a nursing home.

Know Jimmo | New CMS Implementation Activity! February 15, 2024

CMS Joins CMA to Advance Access to Medicare-Covered Skilled Care to Maintain One’s Condition or Slow Decline.

Know Jimmo | Home Health Policy February 8, 2024

Home health service coverage right from the Medicare manual.

When Should Medicare Coverage be Available for Outpatient Therapy? February 1, 2024

A quick list of the criteria for coverage of physical, speech-language pathology, and occupational therapies.

Know Jimmo | The Medicare Policy Manual February 1, 2024

From the Medicare Policy Manual to you - Maintenance is covered.

Know Jimmo | Right from the Medicare Agency January 24, 2024

CMS acknowledges Jimmo - providers and intermediaries should too.

Know Jimmo | Share a Success Story January 18, 2024

Have you or someone you know successfully argued for coverage of skilled care to maintain a condition, or slow decline, rather than being told there’s a need to “improve?”Let us know! Share your story with us at https://medicareadvocacy.org/medicare-info/improvement-standard/.Learn MoreTo learn more about the historic Jimmo Settlement, including watching a recording of CMA’s recent Jimmo Symposium – Jimmo v. Sebelius at ...

Know Jimmo | It’s about the Care January 11, 2024

Medicare coverage is about skilled care, not about improvement.

Know Jimmo | No Improvement Needed January 4, 2024

Get the facts right from CMS

Know Jimmo | Jimmo Was a Historic Moment December 27, 2023

It was momentous. It was hopeful. It was justice.

Know Jimmo | Priscilla’s Sister December 21, 2023

The CMS.gov web page includes a variety of documents related to the Jimmo Settlement to clarify that improvement is not required in order to qualify for Medicare.

Know Jimmo | When It’s Known, It Works December 7, 2023

The webinars and written materials from CMA were the difference makers.

Know Jimmo – CMS Reminded Providers & Contractors in 2021 November 30, 2023

Skilled Nursing Care & Skilled Therapy Services to  Maintain Function Or Prevent or Slow Decline.

Know Jimmo | Medicare Law and CMS Policy Spell It Out November 16, 2023

Know Jimmo - It's law AND policy!

Know Jimmo – Jimmo Can Open Doors to Necessary Care November 9, 2023

Settlement confirmed that skilled care in all these settings is coverable to maintain an individual’s condition or slow decline.

Know Jimmo | Underscoring the Value of Physical Therapy: A New American Physical Therapy Association Report October 26, 2023

New report provides evidence therapy has an economic benefit to the health system.

Center Symposium on the Jimmo Settlement Calls for Sustainable Implementation September 28, 2023

A discussion of medically necessary skilled maintenance care, as well as ongoing challenges to getting and providing such care.

Senate Finance Committee Confirms Medicare Home Health Coverage Can Be Long-Term September 21, 2023

Center Director Judith Stein says if we really want to fix Medicare home health care we need to enforce the law that already exists.

Join Your CMA Community For A Jimmo Symposium August 31, 2023

Join this virtual meeting to hear from advocates, providers, beneficiaries, and others who will discuss practical tips and strategies for obtaining medically necessary services pursuant to the Jimmo settlement.

Guest Post: Jimmo Enforced, Preventive & Maintenance Therapy Affirmed December 9, 2021

Two major audits overturned as Jimmo is recognized after 5 years of fighting.

Jimmo Implementation Council Meeting | June 16, 2021 June 23, 2021

while progress has been made in educating providers and patients about rights under the Jimmo Settlement, there is more work to be done.

Guest Author – The Myth of the Medicare Improvement Standard December 31, 2020

Medicare rules have never prevented Medicare recipients from receiving coverage for necessary nursing or therapy services when they ceased to improve.

Medicare Home Health Case Settled with Full Coverage for Beneficiary with Chronic Conditions July 23, 2020

Advocates should continue to be alert for inappropriate denials of coverage based on lack of improvement or on “stability” – particularly for individuals with chronic conditions.

Issue Brief: Medicare Payment vs. Coverage for Home Health & Skilled Nursing Facility Care March 3, 2020

New Issue Brief: Medicare Payment vs. Coverage for Home Health & Skilled Nursing Facility Care The Centers for Medicare & Medicaid Services (CMS) — the federal agency responsible for administering the Medicare program — has begun implementing new Medicare payment models for both home health and skilled nursing facility care. These payment models create a different ...

You Do Not Have to Improve! New Jimmo Resources for Appealing Medicare Denials in Nursing Homes October 28, 2019

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 ...

Expedited/Fast-Track Medicare Appeals in Skilled Nursing Facilities in Light of the Jimmo v. Sebelius Settlement Agreement * October 24, 2019

Background The United States District Court for the District of Vermont approved a settlement agreement in Jimmo v. Sebelius on January 23, 2013. The Jimmo Settlement required the Centers for Medicare & Medicaid Services (CMS) to confirm that Medicare coverage of skilled nursing facility, home health, and outpatient therapy services must be determined on the basis ...

CMS Could Truly Put “Patients over Paperwork” By Fully Implementing the Jimmo Settlement August 22, 2019

The Centers for Medicare & Medicaid Services (CMS) launched a “Patients over Paperwork” initiative in 2017 “to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience.” Unfortunately, most of CMS’s efforts under this initiative focus on reducing so-called provider “burden” instead of improving beneficiary ...

Self-Help Resources for Improvement Standard Denials – August, 2019 August 1, 2019

Medicare coverage of skilled nursing and/or therapy services depends on a beneficiary’s need for the skilled care, not on the individual’s potential for improvement. The Settlement Agreement in Jimmo v. Sebelius, approved by a federal district court in 2013, required the Centers for Medicare & Medicaid Services (CMS) to confirm that coverage of skilled nursing ...

New Issue Brief: Implementing Jimmo v. Sebelius: An Overview June 27, 2019

In 2013, a federal district court approved a settlement agreement in Jimmo v. Sebelius, No. 5:11-CV-17 (D. VT). The Jimmo Settlement confirmed that Medicare coverage should be determined based on a beneficiary’s need for skilled care (nursing or therapy), not on the individual’s potential for improvement. The Jimmo Settlement and court decisions pertain to all ...

The National Association of Insurance Commissioners Recognizes Maintenance Therapy, Bolstering the Jimmo Settlement Agreement June 13, 2019

The National Association of Insurance Commissioners (NAIC) is a standard-setting and regulatory support organization governed by chief insurance regulators from across the country. NAIC’s website indicates that organizational members and its resources, “form the national system of state-based insurance regulation in the U.S.” One such resource is NAIC’s Glossary of Health Insurance and Medical Terms, ...

New Fact Sheet Available – Medicare Inpatient Rehabilitation Hospital/Facility Coverage In Light of Jimmo v. Sebelius April 11, 2019

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy has produced a new Fact Sheet to help Medicare beneficiaries and their families respond to unfair Medicare denials for care at inpatient rehabilitation hospitals/facilities (IRH/F). The Fact Sheet outlines the coverage criteria for IRH/Fs and emphasizes language from the Jimmo Settlement Agreement. ...

Jimmo Implementation Update: Where is CMS? February 28, 2019

The Settlement Agreement in Jimmo v. Sebelius, No. 5:11-CV-17 (D. VT), was approved by a federal district court in January 2013. The Centers for Medicare & Medicaid Services (CMS) was required to confirm that Medicare coverage is determined by a beneficiary’s need for skilled care and is not based on a beneficiary’s potential for improvement. ...

Medicare Coverage In Light of Jimmo v. Sebelius For Providers, Contractors, and Adjudicators December 10, 2018

With support from The John A. Hartford Foundation, the Center for Medicare Advocacy has produced a new Fact Sheet to help Medicare providers, contractors, and adjudicators apply the correct legal standard to Medicare coverage and payment determinations – as required by the Jimmo v. Sebelius Settlement Agreement. The Jimmo Settlement means that Medicare coverage and payment ...

Jimmo Implementation: Beneficiary Successfully Appeals Denial of Maintenance Therapy November 8, 2018

Despite the Jimmo case’s confirmation that Medicare coverage of a stay in a skilled nursing facility (SNF) is appropriate to maintain a resident’s functional status, when the nursing or therapy services must be provided by a professional nurse or therapist, SNFs and managed care plans frequently continue to deny medically necessary coverage.  Expedited appeals to ...

Checklist for Medicare Nursing Home “Improvement Standard” Denials October 25, 2018

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy has produced a new Checklist to help Medicare beneficiaries and their families respond to unfair Medicare denials for skilled nursing facility care based on an erroneous “Improvement Standard.” The Checklist outlines the coverage criteria for SNF care and emphasizes language from the Jimmo Settlement ...

Checklist for Medicare Home Health Care “Improvement Standard” Denials October 18, 2018

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy has produced a new Checklist to help Medicare beneficiaries and their families respond to unfair Medicare denials for home health care based on an erroneous “Improvement Standard.” The Checklist outlines the coverage criteria for home health care and emphasizes language from the ...

Center for Medicare Advocacy Survey: CMS’ Jimmo v. Sebelius “Improvement Standard” Education Still Not Working October 4, 2018

The Center for Medicare Advocacy recently completed a survey of Jimmo v. Sebelius stakeholders to analyze the effectiveness of the Centers for Medicare & Medicaid Services’ education efforts regarding the Jimmo Settlement, which clarified that Medicare must cover skilled maintenance care in the home health, skilled nursing facility and outpatient therapy settings. Unfortunately, the results ...

New Jimmo Resources from the Center for Medicare Advocacy and The John A. Hartford Foundation September 6, 2018

With support from The John A. Hartford Foundation, the Center for Medicare Advocacy has produced two new Checklists to help Medicare beneficiaries and their families respond to unfair Medicare denials based on an erroneous “Improvement Standard.” Per the Jimmo Settlement, CMS revised the Medicare Benefit Policy Manual to clearly disavow any notion that residents of ...

Fact Sheet – Medicare Home Health Coverage In Light of Jimmo v. Sebelius April 12, 2018

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy provides the following Fact Sheet to help Medicare home health beneficiaries and their families respond to unfair Medicare denials based on an erroneous “Improvement Standard.” The Fact Sheet emphasizes language from the Jimmo Settlement Agreement, wherein the Centers for Medicare & Medicaid ...

Fact Sheet – Skilled Nursing Facility Coverage and Jimmo v. Sebelius April 5, 2018

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy provides the following Fact Sheet to help Medicare nursing home beneficiaries and their families respond to unfair Medicare denials based on an erroneous “Improvement Standard.” The Fact Sheet emphasizes language from the Jimmo Settlement Agreement, wherein the Centers for Medicare & Medicaid ...

Administrative Law Judge Rules Medicare Covers Outpatient Therapy to Maintain Function, Indefinitely if Needed April 5, 2018

A young man who suffered a traumatic brain injury (TBI) following a fall in 2008 was receiving outpatient physical therapy three times a week.  While his therapy was originally covered by his Medicare Advantage (MA) plan, the plan denied further coverage of his therapy, contending that the recovery period for TBI had passed and that ...

Toolkit: Medicare Outpatient Therapy and Jimmo v. Sebelius April 2, 2018

Jimmo v. Sebelius, No. 11-cv-17 (D. VT), is a nationwide class-action lawsuit brought on behalf of Medicare beneficiaries who received care in skilled nursing facilities, home health care, and outpatient therapy and who were denied Medicare coverage on the basis that they were not improving or did not demonstrate a potential for improvement (known as ...

Toolkit: Medicare Home Health Coverage & Jimmo v. Sebelius February 15, 2018

Jimmo v. Sebelius, No. 11-cv-17 (D. VT), is a nationwide class-action lawsuit brought on behalf of Medicare beneficiaries who received care in skilled nursing facilities, home health care, and outpatient therapy and who were denied Medicare coverage on the basis that they were not improving or did not demonstrate a potential for improvement (known as ...

Congress Repeals Medicare Outpatient Therapy Caps, Strengthening the Jimmo Settlement Agreement February 14, 2018

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. Pursuant to the Balanced Budget Act of 1997, Medicare Part ...

CMA Alert – The REST of the Tax Cut Plan; “Jimmo” Improvement Standard Update; QMB News; Enrollment Periods End Soon November 30, 2017

The Plan: Pass a Devastating Tax Bill, Balloon the Deficit, then Gut the Social Programs We Rely On Jimmo Update: Court Orders CMS to Modify Special Jimmo Webpage ACA and Medicare Enrollment Periods End Soon Changes to Notice of Qualified Medicare Beneficiary (QMB) StatusThe Plan: Pass a Devastating Tax Bill, Balloon the Deficit, then Gut the Social Programs ...

CMA Alert – OIG Warns of Abuse in SNFs; Ted Kennedy, Jr. Joins CMA Advisory Board; “Jimmo” Corrective Action Plan August 30, 2017

HHS OIG Warns of Potential Elder Abuse in Skilled Nursing Facilities Connecticut State Senator Ted Kennedy, Jr. Joins Center for Medicare Advocacy Advisory Board Jimmo Corrective Action Plan CompletedHHS OIG Warns of Potential Elder Abuse in Skilled Nursing Facilities Last week, the HHS Office of Inspector General (OIG) issued an Early Alert, warning of the Centers for Medicare ...

Jimmo v. Sebelius Plaintiffs Return to Court to Urge Enforcement March 2, 2016

Beneficiaries Across the Country Still Denied Needed Coverage Due to Illegal Use of Improvement Standard March 1, 2016 – Today, Plaintiffs’ counsel, the Center for Medicare Advocacy and Vermont Legal Aid, filed a Motion for Resolution of Non-Compliance with the Settlement Agreement in the landmark case, Jimmo v. Sebelius. The filing comes after three years of ...

Practice Tip: Orders Needed for Maintenance Skilled Care October 7, 2015

Based on recent experience, the Center for Medicare Advocacy provides this Practice Tip for providers and advocates for patients who need to change from an improvement mode to maintenance mode for nursing or therapy.The Center is seeing decisions from Medicare Contractors requiring that providers obtain new orders when a patient’s goals change to maintenance skilled ...

The Jimmo Implementation Council June 25, 2015

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy has created a council of beneficiary advocates, providers, policy-makers and other partners to discuss, analyze and advance the implementation of the Jimmo v. Sebelius "Improvement Standard" Settlement. The Center convened the first meeting of the multi-disciplinary Council on June 23, 2015 at the ...

Jimmo Class Members Can Now Have Their Coverage Denials Re-Reviewed January 30, 2014

If you are covered by Medicare and you have a long-term or chronic condition, you may be eligible to have Medicare re-review your claims that were denied in prior years.  Please read carefully. In addition to revising Medicare manual provisions to now allow Medicare coverage for skilled maintenance care, the Settlement Agreement in Jimmo v. Sebelius ...

Medicare Policy Manuals Revised as Required by Jimmo Settlement January 9, 2014

As of December 6, 2013, Centers for Medicare & Medicaid Services (CMS) Policy manuals have been updated to reflect the settlement in Jimmo vs. Sebelius, No.11-cv-17 (D.VT, January 24, 2013).  The manuals now make it clear that improvement is not necessary for coverage of skilled nursing and therapy services. For example, the home health section of ...

Improvement Standard Update: CMS Revises Medicare Policy to Ensure Coverage for Skilled Maintenance Care December 9, 2013

December 9, 2013 – 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 Manual revisions, which clarify that improvement is not required to obtain Medicare coverage, were published by the Centers for Medicare & Medicaid Services (CMS) on Friday ...

Jimmo v. Sebelius Improvement Standard Case Summary May 30, 2013

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 the ...

Why the Jimmo v. Sebelius Case Matters: Improvement Standard Stories May 30, 2013

(print stories only)Mrs. JimmoLead plaintiff in the Improvement Standard case, Glenda Jimmo of Bristol, Vermont is blind and has had her right leg amputated due to complications from diabetes. She requires a wheelchair, and receives multiple home health care visits per week for various treatments for her complex condition. However, Medicare denied coverage for these ...

Frequently Asked Questions (FAQs) Regarding the Jimmo v. Sebelius “Improvement Standard” Settlement May 30, 2013

GeneralQuestion: Are professional therapy services available under Medicare only for patients who are improving or who are expected to improve?Answer: No. The Jimmo Settlement confirms that services by a physical therapist, occupational therapist, and speech and language pathologist are covered by Medicare, Parts A and B, and by Medicare Advantage Plans in skilled nursing ...

Jimmo v. Sebelius: Federal Settlement Invalidated Medicare Improvement Requirement February 11, 2013

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 on ...

Warning: Medicare Payment Limits Are Bad for Health! December 13, 2012

One of the deficit reduction proposals being discussed to achieve savings from Medicare is to introduce new cost-sharing for home health care. As a means to ward off such potential home health co-payments, some instead suggest capping Medicare payment for episodes of care, effectively limiting the duration of time individuals could access home health services. ...

The Improvement Standard: Real Stories November 26, 2012

In October 2012, the Center for Medicare Advocacy announced the settlement of the “Improvement Standard” class action lawsuit, Jimmo vs. Sebelius. For more than thirty years, the wrongful interpretation of the Medicare statue led to the illegal denial of Medicare coverage and health care for tens of thousands of Medicare beneficiaries on the grounds that ...

Medicare and ACA Facts and Updates; Jimmo Update November 1, 2012

Medicare: Just the Facts! Misinformation about Medicare and the Affordable Care Act is widespread and increasing as the election nears.  Below, we try to dispel misinformation and base discussions on a factual foundation.  Spread the word. Help set the record straight!The FactHere's WhyThe Affordable Care Act does NOT cut Medicare for beneficiaries.The Affordable Care Act achieves ...

Settlement Reached to End Medicare’s “Improvement Standard” October 25, 2012

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. was filed in federal District Court on October 16, 2012.  When the judge approves the proposed agreement, a process that may ...

Federal Judge Refuses to Dismiss Medicare Beneficiaries’ Challenge to the Medicare “Improvement Standard” October 27, 2011

Plaintiffs in a lawsuit filed by the Center for Medicare Advocacy and Vermont Legal Aid on behalf of Medicare beneficiaries with long-term and chronic conditions have overcome a major hurdle.  In a comprehensive 35-page decision, a federal judge in Vermont refused the federal government's request to throw out a lawsuit that seeks to end use ...

Recent Coverage: Improvement Standard Lawsuit February 22, 2011

Recent Coverage:Gram, Dave. 2011. Patients, groups sue Medicare over service cuts, Associated Press, January 18. As a syndicated service, the Associated Press article was picked up by many others: Bloomberg, Huffington Post, MSNBC, LA Times, ABC News, Yahoo News, Forbes.com, Boston Globe, CBS News, Philadelphia Inquirer, Newsday, Seattle Times, Miami Herald, Vermont Public Radio, Washington Examiner, ...

New Medicare Home Health Regulations: Improvement is Not Required to Obtain Coverage December 30, 2010

The Centers for Medicare & Medicaid Services (CMS) issued new regulations on November 17th regarding coverage for home health services. The new regulations clarify Medicare coverage for home health services, including physical therapy, occupational therapy and speech-language pathology services. The regulations are effective January 1, 2011; however, since they clarify rather than change coverage rules, ...

Medicare for People with Alzheimer's Disease and other Chronic Conditions December 14, 2010

As the New York Times reported on March 31, 2002 (p.1), Medicare advocates have been successful in convincing the Centers for Medicare and Medicaid Services (CMS) to loosen Medicare’s denial practices for people with Alzheimer’s disease and other cognitive impairments. Unfortunately, Medicare has a decades-long policy of denying coverage to people who need services which are ...

Two Federal Courts Reject "Improvement Standard" for Denying Medicare Coverage November 1, 2010

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. Although CMS continues to claim formally that there exists no such ...

The Medicare Improvement Standard: A Barrier to Necessary Care August 10, 2010

Mrs. P, 68 years old, was diagnosed with Amyotrophic Lateral Sclerosis (ALS, also known as Lou Gehrig's Disease) five years ago.  She now needs a wheelchair, cannot stand on her own, needs assistance to move from bed to wheelchair, and is losing the use of her arms and hands. Mrs. P has been receiving home ...

How the 'Improvement Standard' Improperly Denies Coverage to Medicare Patients with Chronic Conditions – text of article printed in Clearinghouse Review, Vol. 43, No. 9-10, Jan-Feb. 2010 February 22, 2010

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. Ms. Prendergast, who needed an electric wheelchair, ...

Medicare for People with Chronic Conditions December 17, 2009

People with chronic conditions and long-term illnesses are too often denied Medicare coverage on the grounds that they will not improve, need “maintenance services only,” have “plateaued” or are “chronic and stable”. Taken together, these reasons are referred to here as the Medicare “Improvement Standard.” Because Medicare is often the sole ...

The "Improvement Standard" is a Barrier to Necessary Care March 26, 2009

Mrs. P, 68 years old, was diagnosed with Amyotrophic Lateral Sclerosis (ALS, also known as Lou Gehrig’s Disease) five years ago.  She now needs a wheelchair, cannot stand on her own, needs assistance to move from bed to wheelchair, and is losing the use of her arms and hands. Mrs. P has ...

Medicare Advantage Articles

Medicare Advantage Payment Rates for 2025 Released April 4, 2024

MA plans will still be significantly overpaid, even after these adjustments take effect.

Study Examines Health Equity Differences between Medicare and Medicare Advantage April 4, 2024

"MA plans’ care management strategies do not provide appropriate care to all patients"

Report on Improper Payments Shows Billions Wasted on Private Medicare Plans March 28, 2024

Both amounts are increases from 2022. And they only keep going up.

Medicare Program Cannot Afford Medicare Advantage “Stability” – Especially as New Study Shows Inferior Home Health Care Provided by MA Plans March 7, 2024

Industry's idea of MA "stability" is continued wasteful overpayments, despite documented poor coverage and outcomes.

Medicare Advantage Plans Under Scrutiny by Department of Justice and Office of Inspector General February 29, 2024

Medicare Advantage isn’t working for any group: the government, patients, taxpayers, and now even investors.

Medicare Advantage Proposed Payment for 2025 and Other Updates February 22, 2024

The Centers for Medicare & Medicaid Services (CMS) has issued proposed Medicare Advantage (MA) and Part D payment rates for 2025.  As discussed below, the insurance industry is already trying to pressure the agency to increase their payment in the final announcement.  In addition, there have been other recent MA policy developments, including a request ...

Medicare Program Proposes to Increase Medicare Advantage Payment for 2025 February 1, 2024

MA overpayments go up again, wasting billions.

As Medicare Advantage Enrollment Grows, So Does Awareness of Problems January 24, 2024

Much more action is required by both CMS and Congress to rein in out of control MA plans.

Medicare Advantage Industry Support Letter Circulating in Senate – Center for Medicare Advocacy Urges Senators Not to Sign On January 18, 2024

Instead of promoting “payment and policy stability” for insurance companies, ensure that all Medicare beneficiaries have access to the care they need.

Advocacy Tip for Medicare Advantage Enrollees Facing Difficulty Obtaining In-Network Care January 18, 2024

The Center regularly hears from MA enrollees and those who assist them that they are unable to obtain medically necessary care from an in-network provider.

Center for Medicare Advocacy Submits Comment on Proposed 2025 Medicare Advantage and Part D Rule January 11, 2024

While positive, there is room for more MA oversight .

Improving Medicare by Reining in Medicare Advantage Overpayments: Policy Options January 11, 2024

Legislative and academic proposals that could use recouped MA overpayments to expand Medicare.

Insurance Industry Group Issues Misleading Medicare Advantage Report December 7, 2023

Industry seems to think providing less care is a good thing.

Advocates Send Letter Regarding Misleading MA Advertising December 7, 2023

Advertising misleads those eligible for both Medicare & Medicaid

STAT News Report Further Exposes Medicare Advantage Misconduct Concerning Prior Authorization Using Restrictive Algorithmic Tools November 16, 2023

CMA has been trying to raise awareness of the inappropriate use of restrictive algorithmic software for years.

Medicare Advantage Focus: Drawbacks During Annual Enrollment Period November 2, 2023

Finally, an increase in news coverage about Medicare, Medicare Advantage, and needed improvements that is more objective, and neutral.

Center Testimony for Senate Hearing on MA Marketing November 1, 2023

There are many things that Congress and the Centers for Medicare & Medicaid Services (CMS) can and should do to address Medicare Advantage problems.

Senate Finance Committee Holds Hearing on Medicare Advantage Marketing Misconduct October 19, 2023

Addressing the many issues brought up at the hearing is a start, but more is needed. We hope this is the first in many oversight hearings leading to meaningful change in Medicare Advantage rules and financing.

Connecticut Medicare Advantage Plans Announce Changes for 2024 October 12, 2023

Insurers offering MA plans focus on easy-to-provide “additional” benefits. We encourage beneficiaries to look carefully at all their coverage options.

Counterweight to Medicare Advantage Marketing Still Needed October 5, 2023

Materials from the Medicare program itself should be straightforward and unbiased in their presentation of Medicare coverage options.

New Study – Medicare Advantage Overpayments as High as $140 Billion a Year October 5, 2023

The amount of overpayments, if not wasted on private MA plans, could eliminate Medicare Part B premiums or fully fund Part D, and more.

Look Before You Leap: Medicare Annual Enrollment Period Approaches September 28, 2023

Many challenges are faced by Medicare beneficiaries who are trying to navigate the Medicare coverage landscape. Look before you leap.

Medicare Advantage Plans Receive Bloated Bonus Payments with Little to Show for It August 24, 2023

Bonus payments don't mean better care, and ratings systems are flawed and inaccurate.

Growing Chorus to Protect and Expand Traditional Medicare August 24, 2023

25 sitting members of Congress advocating for traditional Medicare.

Policymakers Must Address Medicare Advantage Abuses August 3, 2023

Medicare Advantage plans are overpaid and abuse the prior authorization and coverage determination process. It is getting harder for policymakers to ignore these issues. 

Highlighting the Harms of Medicare Advantage: Advocates and Members of Congress Rally to Support Real Medicare July 27, 2023

The Center has long called for reforms to Medicare Advantage and is proud to partner with organizations like Be A Hero to help raise awareness of the problems with private Medicare Advantage.

Media Advisory: Medicare Advantage Patients and Families Join Members of Congress to Call for an End to Wrongful Delays and Denials July 20, 2023

The Call for an End to Wrongful Medicare Advantage Delays and Denials takes place in Washington, D.C.. on Tuesday July 25th, 4:30 pm Eastern at the House Triangle,

Ongoing Scrutiny of Medicare Advantage Plans July 13, 2023

Overpayments to MA plans now exceed $75 billion annually, and access to care problems, including inappropriate use of prior authorization, are widespread.

New Research Outlines Extent of Medicare Advantage Overpayments: It’s Much Worse Than We Thought June 22, 2023

"Overpayments to Medicare Advantage plans now exceed 20% or $75 billion annually, underscoring the urgent need for reform.”

CMS Report Highlights Quality of Care Concerns in MA June 22, 2023

Dually eligible beneficiaries with disabilities fare worse on several quality measures, and inequities exist among all duals compared to non-duals.

Senate Committee Holds Hearing re: Medicare Advantage Denials and Delays in Care May 18, 2023

Senate hearing, House Committee presses major insurer, Ady Barkan on the harms of privatized Medicare, and more.

Medicare Advantage Enrollment Passes 50%: Much More Oversight and Accountability Is Needed May 11, 2023

Recent measures fall far short of stemming the flow of billions of dollars in annual wasted payments.

Special Report | Recent Medicare Advantage (MA) and Part D Rule – Important Consumer Protections re: MA Prior Authorization and Marketing May 4, 2023

Rule includes improvements to prior authorization process and consumer protections re: marketing.

Be A Hero Joins the Fight for a Strong Traditional Medicare Program April 27, 2023

Be a Hero is concerned about the various problems with, and costs of, private Medicare Advantage (MA) plans.

CMS Issues Final Medicare Advantage Payment Rates for 2024 and Final Rule Addressing Prior Authorization, Marketing, and Other Issues April 6, 2023

Delayed and limited efforts to rein in MA overpayments aren't enough.

Medicare Advantage: It’s Not “Over-reach” – It’s Fraud March 30, 2023

It’s high time that this over-reach of private Medicare Advantage plans is called what it is: Fraud. 

Medicare Advantage Under Increased Scrutiny Pending Final Payment and Oversight Rules March 23, 2023

Insurance industry continues to fight against efforts to increase oversight and rein in their overpayments.

Barriers to Care for Medicare Advantage Enrollees Highlighted even as Insurance Industry Continues Effort to Retain Their Overpayments March 16, 2023

What have Medicare Advantage enrollees – and the public – gotten in return for wasteful overpayments to MA plans? More restrictive coverage and care.

New Campaign: Finalize Proposed MA Payment Changes & Crack Down on Waste and Abuse March 16, 2023

Remind Members of Congress and the Administration that insurance companies are abusing Medicare Advantage by overcharging seniors and taxpayers by billions of dollars each year.

Medicare Advantage Industry Continues to Fight Minor, Overdue Course Corrections March 9, 2023

Minor MA changes are long-overdue and good for Medicare and those who need it, but the industry continues to lie about them and fight them.

Medicare Advantage Industry Continues to Mislead Public to Protect Their Overpayments March 2, 2023

MA industry calls 1.03% pay raise a “cut” and threatens enrollees in scare tactics to get more.

70 Members of Congress Call for Medicare Advantage Reforms, Including Reining in Overpayments February 16, 2023

We applaud these members of Congress for standing up for all Medicare beneficiaries who would helped by these reforms.

Center for Medicare Advocacy Comments on Proposed Part C & D Rule February 16, 2023

After years of administrations letting the MA program do as it will, we applaud the proposals in this rule,

Insurance Industry Response to Proposed Medicare Advantage Payment for 2024 February 16, 2023

Proposed Medicare Advantage Payment Rates for 2024 are actually a smaller RAISE, not even close to a cut.

Traditional Medicare or Medicare Advantage? February 9, 2023

Don't just be tempted by minor extras - think about overall needs - and remember what "Insurance" means.

Medicare Advantage Updates – Audits, Payment, and Prior Authorization February 9, 2023

CMS is finally addressing overpayments to private plans, denials by prior authorization, and more.

Center for Medicare Advocacy Statement on Recent Medicare Advantage Payment Policies and Proposals February 3, 2023

While steps taken to increase MA oversight are encouraging, the Administration must hold fast, and Congress should act to stop wasteful overspending.

Medicare Advantage Round-Up December 15, 2022

MA Issues finally seem to be getting more attention in the media and independent reports. We urge policymakers to respond.

CMS Issues Proposed Rules Impacting Medicare Advantage – Part C & D Rule for 2024, and Separate Prior Authorization Rule December 15, 2022

Rules address several advocate concerns, but there is more work to do.

Medicare Annual Enrollment Period Ends December 7th December 1, 2022

Medicare Annual Enrollment ends soon, but there are still chances to get out of an MA plan.

Disputes with Medicare Advantage Plans: Know the Difference Between Appeals and Grievances November 17, 2022

Knowing the difference between these two ways of raising issues with your plan is key to safeguarding your Medicare rights.

Sale of “Ancillary Products” to Fill Gaps in Medicare Advantage Highlight Both Coverage Shortfalls and Need for Stronger Regulation of the MA Marketplace November 17, 2022

An overhaul of Medicare Advantage marketing rules, among other things, is urgently needed.

Senate Report Highlights Widespread Medicare Advantage Marketing Misconduct – But the Driving Forces of Misconduct Are Broader November 10, 2022

The onslaught of Medicare Advantage marketing, and the legions of agents and brokers incentivized by commissions, bonuses and other rewards, must be addressed.

Special Report | Recent Articles and Reports Shed Light on Medicare Advantage Issues October 31, 2022

Fraud and overpayments to Medicare Advantage clearly drain public funds, but is there political will to address the problem?

Recent Articles Address Medicare Advantage Overpayments and Inappropriate Denials October 13, 2022

"Medicare Advantage" wastes Medicare money and limits care through repeated, harassing denials. It's not an advantage.

“Medicare & You” Continues to Reverse Bias Towards, and More Accurately Describe, Medicare Advantage September 28, 2022

Medicare & You handbook continues to improve, but there's room for more.

Kaiser Family Foundation Releases Report Regarding Differences Between Traditional Medicare and Medicare Advantage September 21, 2022

MA is touted as "better" than Medicare, but it costs us all more, and offers no true "Advantage."

Center for Medicare Advocacy Submits Comments re: Medicare Advantage September 1, 2022

Barriers to care are even worse for those in MA. CMS must increase oversight and enforcement.

New from the Center: Form to Contest Multiple Medicare Denials Issued by Medicare Advantage Plans August 25, 2022

MA plan issuing repeated, frequent non-coverage notices despite the need for care? File a Grievance with this new form.

Medicare Agency is Seeking Comments on Medicare Advantage August 22, 2022

On August 1, 2022, the Centers for Medicare & Medicaid Services (CMS) published a Request for Information (RFI) that “seeks input from the public regarding various aspects of the Medicare Advantage program. Responses to this request for information may be used to inform potential future rulemaking or other policy development.” The RFI can be accessed ...

Report: Nursing Home MA Issues Survey August 18, 2022

CT Nursing homes report having consistent issues with Medicare Advantage plan denials and delays.

NEJM Perspective: ACO REACH – A Progressive Value-Based Payment Model, Promoting Equity July 21, 2022

While the effectiveness of ACO REACH remains to be seen, maintaining equity should be a central policy goal.

Voices of Medicare | Medicare Advantage Network Inadequacy July 7, 2022

Enrollees should be assured that all MA plans have adequate provider networks, as is the case with traditional Medicare.

Call to Action – Policy Makers Must Increase Medicare Advantage Oversight and Rein in Overpayments May 5, 2022

Five related articles focusing on MA inequities, denials, oversight, waste and more.

Medicare Advantage is Not the Solution to Medicare Equity or Solvency Problems May 5, 2022

Medicare Advantage is essentially good for Medicare Advantage plans but too often not for beneficiaries.

Office of Inspector General (OIG) Issues Another Report Highlighting Inappropriate Medicare Advantage Denials May 5, 2022

Prior authorization and other utilization management tools are barriers to care that MA enrollees are often unaware of until they need to access services.

Insurance Industry v. Provider Response to OIG Report re: MA Denials May 5, 2022

Industry tries to downplay, discredit, and otherwise deflect from damning OIG report, but providers and provider groups concur with findings.

OIG Report Estimates of Inappropriate MA Plan Denials May be Understated May 5, 2022

MA plans routinely deny care that should be covered under Medicare law.

(Most) Policymakers Fail to Act on Medicare Advantage Oversight and Overpayment May 5, 2022

Address the growing inequities between Medicare Advantage (MA) and traditional Medicare that favor MA, and encourage the growing privatization of the Medicare program, to the detriment of those who rely on it.

Government Watchdog Issues Another Report Highlighting Inappropriate Medicare Advantage Denials April 28, 2022

Evidence of ‘widespread and persistent problems related to inappropriate denials of services and payment."

When Artificial Intelligence in Medicare Advantage Impedes Access to Care: A Case Study April 21, 2022

MA plans are using proprietary, algorithm-driven systems to make decisions about approving coverage for services, causing mass denials.

Members of Congress Send Letter to CMS Urging Agency to Address Medicare Advantage Overpayments April 21, 2022

“Medicare Advantage has failed to achieve savings in any year since its inception”... “axpayers and Traditional Medicare beneficiaries are subsidizing the surplus profits of Medicare Advantage plans,” says congressional letter.

Commonwealth Fund Blog Series About Medicare Advantage April 7, 2022

Posts touch on many issues that the Center for Medicare Advocacy has been highlighting,

A Special Alert about Medicare’s Future | Don’t Let Traditional Medicare “Wither on the Vine*” March 31, 2022

Address the growing imbalance between Medicare Advantage and traditional Medicare before the wasteful, private Medicare plans devour the bedrock Traditional Medicare program.

Medicare Advantage Plans Pitch to People Turning 65 March 17, 2022

Insurance companies, brokers, eager to sell MA policies because MA is so profitable for them.

Recent Solicitation Scams Target Medicare-Eligible Adults March 17, 2022

Heads up - Increase in phone and email solicitations targeting Medicare-eligible adults.

CMS Needs to Rein in Medicare Advantage Overpayments and Heighten Oversight of Insurance Industry March 10, 2022

CMS fails to use their discretion to address wasteful Medicare Advantage (MA) overpayments, or increase oversight of MA plans.

House GOP Accuses Dems of Trying to Rein in Medicare Advantage Overpayments in Order to Expand Benefits to All Medicare Beneficiaries: If Only This Were True… March 3, 2022

Despite the potential insolvency of the Part A Trust Fund, both parties continue to ignore their obligation to address Medicare Advantage overpayment.

CMS Releases Proposed 2023 Rule for Medicare Advantage and Part D Plans January 13, 2022

A number of provisions will considerably help consumers, but, in other ways, the proposed rule falls short of providing needed protections.

Reminder: Limited Opportunity to Make Certain Medicare Plan Changes Through the End of March January 6, 2022

Medicare Advantage Open Enrollment Period runs through March 31st.

Study Published in Health Affairs Finds that Medicare Advantage Quality Bonus Program Has Not Improved Quality January 6, 2022

Higher star ratings correlate with increased beneficiary enrollment, but they did not improve quality of care.

New Analysis Provides More Evidence of Wasteful Medicare Advantage Overpayments November 18, 2021

Medicare overpaid the private health plans by more than $106 billion from 2010 through 2019.

Landscape of Medicare Advantage (MA) and Part D Plans in 2022 November 11, 2021

Millions face cost increases if they stay in current plans.

As the Medicare Annual Enrollment Period Progresses, Beware of Marketing Misconduct November 11, 2021

Warnings about general agent and broker conduct, misleading TV advertisements, educational vs. marketing events , and potential recourse.

New Issue Brief | Retiree Auto Enrollment in Medicare Advantage Plans – Choice is Under Threat October 14, 2021

The Center for Medicare Advocacy has heard from numerous dissatisfied beneficiaries faced with automatic enrollment by former employers in private MA plans that done meet their needs.

Special Report | Medicare Annual Enrollment Period Starts Tomorrow – Look Before You Leap October 14, 2021

Most people on Medicare don't bother checking plans each year, and for those who do, the means of comparison are often flawed.

Health Affairs Blog Highlight How the Medicare “Money Machine” Draws Medicare Advantage Plans and Investors into Direct Contracting Demonstrations October 7, 2021

The MA program is “fundamentally flawed,” including risk-adjustment scoring and structural overpayments.

CMS Releases Private Medicare Rates – Choose Your Coverage Wisely September 30, 2021

People with Medicare should carefully examine their coverage choices each year to decide on the options that best meet their health needs.

New Research Raises Questions About Medicare Advantage Payments September 23, 2021

Private Medicare Advantage plan sponsors game the system at the cost of taxpayer money.

MEDICARE & YOU 2022 – An Important First Step Towards Reversing Bias in Favor of Medicare Advantage September 20, 2021

While there is still work to do, the new Handbook makes important strides towards reversing the bias in favor of MA that was prevalent in recent editions.

Medicare is at a Crossroads – Time to Dispel Myths Hindering an Historic Expansion of Benefits September 2, 2021

We clear up the myths and falsehoods being circulated by opponents of historic Medicare improvements.

Report Examines High Spending on Medicare Advantage Plans August 19, 2021

The privatized Medicare Advantage program has never generated savings relative to traditional Medicare. In fact, the opposite is true.

Medicare Advantage Costs and Coverage Concerns August 12, 2021

MA promises of saving taxpayer money have utterly failed, and often with worse coverage and care.

Kaiser Family Foundation Issues Report Comparing Cost-Related Problems for Medicare Advantage Enrollees and Beneficiaries in Traditional Medicare July 8, 2021

CMS must exert greater oversight of the Medicare Advantage program.

Reminder: Medicare Advantage Open Enrollment Period Ends March 31st March 25, 2021

MA enrollees can still switch MA plans or go from an MA plan to traditional Medicare with a Part D plan until next next week.

Policy-Makers Should Review Overpayments to Medicare Advantage when Considering Medicare Fiscal Solvency March 18, 2021

Medicare payments are higher for MA enrollees than the program would spend for similar beneficiaries in traditional Medicare.

Medicare and the Dilemma of “Choice” March 11, 2021

Choice in Medicare can be both burdensome and unequal.

Final 2022 Rule for Medicare Parts C and D Released By Trump Administration February 4, 2021

Rather than focus on plan sponsor “burden,” CMS should focus on consumer education and access to care.

Medicare’s Annual Enrollment Season Enters Final Weeks: Few People Compare Options, and the Means of Comparison are Often Flawed November 19, 2020

Most Medicare beneficiaries do not use the market-based system of Medicare Advantage and Part D plan selection as intended.

MA Plans Allowed to Report Less Data about Appeals Outcomes October 1, 2020

CMS rolls back beneficiary protection in the name of reducing “MA plan burden."

Final Rule for Medicare Parts C and D Includes Weakened Standards for Medicare Advantage Networks May 28, 2020

On May 22, 2020, the Centers for Medicare & Medicaid Services (CMS) published a final rule regarding Medicare Advantage (Medicare Part C) and Part D prescription drug plans (“C & D Rule”). The rule is entitled “Medicare Program; Contract Year 2021 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, ...

Case Study: Medicare Advantage and Repeated Coverage Denials Amid the COVID Crisis May 14, 2020

  Mr. A, is a retired professor from a state university. He was auto-enrolled in his state’s retiree Medicare Advantage (MA) plan. The plan prospectus states that it covers an unlimited number of days in a skilled nursing facility (SNF). An active 73-year old, Mr. A went to his primary care doctor because he was experiencing some ...

Medicare Trustees Report: Projections Similar to Last Year, and Savings Are Available April 30, 2020

On April 22, 2020, the Medicare and Social Security Trustees released their 2020 annual report, which offers projections concerning the fiscal health of the Medicare and Social Security programs.  The Medicare Trustees estimate that the Part A Trust Fund will be depleted by 2026, unchanged from last year’s projection. As noted in a summary issued by ...

Center for Medicare Advocacy Submits Comments on Proposed Medicare Parts C and D Rule April 9, 2020

On February 18, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule entitled Medicare and Medicaid Programs; Contract Year 2021 and 2022 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicaid Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (CMS-4190-P). The ...

Reminder: Medicare Advantage Enrollment Period Ends this Month; Ongoing Opportunity for Special Enrollment Period March 12, 2020

Medicare Advantage Open Enrollment Period (MA-OEP) Effective 2019, for the first 3 months of the calendar year there is a continuous open enrollment and disenrollment period relating to Medicare Advantage (MA) plans called the Medicare Advantage Open Enrollment Period, or MA-OEP. This opportunity is only available to individuals who are enrolled in an MA plan as ...

The Myth of “Choice” in Private Insurance, Including Medicare Advantage March 5, 2020

Policy makers often promote the concept of “choice” as a key pillar of health care and insurance, including within the Medicare program. The importance and availability of “choice” becomes less clear, however, the closer one examines what choice actually means with respect to health insurance coverage – including in the Medicare program. Wendell Potter’s New York ...

Articles Highlight Medicare Advantage Concerns February 27, 2020

MA Limitations, Favoritism, and Quality & Access Issues – New York Times A recent article in the New York Times highlights a number of concerns about the Medicare Advantage (MA) program, many of which have been raised by the Center for Medicare Advocacy.  The concerns include the growing imbalance between MA and traditional Medicare, the limitations ...

Medicare Advantage Continues to Drive Up Medicare Costs – Congress Must Act to Level the Playing Field with Traditional Medicare February 4, 2020

The Center for Medicare Advocacy has long advocated for leveling the playing field between Medicare Advantage (MA) and traditional Medicare. Over the last several years, however, legislative and regulatory policy changes have continued to tip the scales in favor of MA over traditional Medicare. Such efforts include the as-yet-unimplemented Executive Order issued by President Trump ...

Medicare Advantage Marketing Matters: Case Study January 16, 2020

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”) ...

Government Watchdog Agency Once Again Finds Wasteful Medicare Advantage Overpayment December 20, 2019

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 sicker ...

Wasting Time Waiting for Prior Authorization – At What Physical and Emotional Cost? December 5, 2019

Mr. Sullivan had been experiencing involuntary hand tremors, muscle weakness and cramping, tripping and balance problems, and occasional slurring of his speech. He thought these symptoms were the result of overwork and fatigue. But rather than improving over time, his symptoms worsened in intensity and became more frequent. He and his wife were increasingly alarmed ...

Family History of Colon Cancer Should Increase the Frequency of Colonoscopies, but Ultimately the MA Plan, Not the Treating Doctor, May Determine When Procedures Will Occur November 21, 2019

Ms. McNeil has a family history of colon cancer that is well known to her doctors. Her mother’s father died of colon cancer at age 52, her father died of colon cancer at 76. Ms. McNeil and all of her siblings have had pre-cancerous polyps removed during each of multiple colonoscopies over the years. Because ...

MA Plan Prior Authorization Requirements Cause Problems in a Skilled Nursing Facility (SNF) Leading to Patient Re-Hospitalizations November 14, 2019

The SNF referenced here is a highly rated, privately owned, non-profit facility with almost 100 beds. The SNF serves traditional Medicare patients for an average of 14 to 21 days per admission. Typically, as long as the SNF documents that a patient has received necessary daily skilled care in the SNF after at least a ...

Medicare is Being Privatized. Where is the Outcry? November 14, 2019

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 Advantage ...

Medicare Enrollment Problems Persist November 7, 2019

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, copays ...

Medicare Enrollment and Medicare Advantage Updates October 24, 2019

On October 22, the Center for Medicare Advocacy and the National Committee to Preserve Social Security and Medicare launched the second annual Medicare Fully Informed Project, with a variety of unbiased, accurate, up-to-date, and comprehensive information about the full range of Medicare coverage options. The Medicare Fully Informed Project includes an array of tools to ...

Medicare Fully Informed Project October 21, 2019

Providing Medicare Beneficiaries with Complete, Objective Information to Help Them Make the Best Enrollment DecisionThe Center for Medicare Advocacy and the National Committee to Preserve Social Security and Medicare partnered on an education and outreach project to support Medicare beneficiaries and those who assist them enroll and re-enroll in Medicare. The Medicare Fully Informed Project ...

Center for Medicare Advocacy Analysis of President’s Medicare Executive Order: October 10, 2019

Among Vague Language and Proposals, Real Harm to Medicare Beneficiaries On October 3, 2019, President Trump issued his “Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors” (EO). Much of the language of the EO is vague, and much is unknown about what polices might emerge from it. Some of the proposals are clear ...

Connecticut Congressional Delegation Concerned about Medicare Advantage Network Provider Terminations in the State October 3, 2019

As noted in a press release issued by Rep. Rosa DeLauro’s office, on September 30, 2019, members of Connecticut’s congressional delegation sent a letter to the President of Anthem Blue Cross Blue Shield to “express our concern regarding the recently announced provider terminations from Anthem Blue Cross and Blue Shield’s (Anthem) Medicare Advantage (MA) network ...

Senator Brown Leads Call for Better Oversight of Medicare Advantage Plans September 19, 2019

Senator Sherrod Brown (D-OH) recently sent a letter to the Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma, urging the Administration “to be better stewards of taxpayer dollars and conduct sufficient oversight of Medicare Advantage plans, to ensure they are appropriately managing the health care needs of older Americans and people with disabilities” ...

Medicare Platform: Objective Information and Consumer Protections Face Challenges September 5, 2019

At the beginning of the current session of Congress, the Center for Medicare Advocacy laid out a Medicare Platform for the New Congress to guide improvements to Medicare and possible expansion of the Medicare-covered population. One of the core considerations to improve Medicare for all beneficiaries, now and in the future, is the need to preserve ...

Advocates Issue Joint Letter Raising Alarms about New Medicare Plan Finder and Revisions to MA and Part D Marketing Guidelines August 29, 2019

On August 27, 2019, the same day that the Centers for Medicare and Medicaid Services (CMS) debuted the updated Medicare Plan Finder (MPF) tool, four beneficiary advocacy organizations – the Center for Medicare Advocacy, Justice in Aging, Medicare Rights Center, and the National Council on Aging – sent a joint letter to CMS raising concerns ...

Support Traditional Medicare by Leveling the Playing Field with Medicare Advantage August 15, 2019

The Center has previously written about how legislative and regulatory policy changes are tipping the scales in favor of Medicare Advantage (MA) over traditional Medicare. For example, coverage expansions such as the ability to provide new supplemental benefits have been advanced in MA but not in traditional Medicare. In recent years, this has been exacerbated ...

Private Medicare Advantage Plans Overbill Medicare July 25, 2019

This week the CT Mirror published a Kaiser Health News article about overpayments to private Medicare plans. The article, originally titled “Insurers Running Medicare Advantage Plans Overbill Taxpayers By Billions As Feds Struggle To Stop It” underscores the need for improved oversight and enforcement of Medicare Advantage plans. According to the Kaiser Health News article, MA ...

Report Highlights Overpayments to Medicare Advantage Plans and Raises Important Policy Considerations May 23, 2019

The Kaiser Family Foundation (KFF) recently released a report entitled “Do People Who Sign Up for Medicare Advantage Plans Have Lower Medicare Spending?” (May 2019). As summarized in the report, “Even after risk adjustment, the results indicate that beneficiaries who choose Medicare Advantage have lower Medicare spending – before they enroll in Medicare Advantage plans – than similar beneficiaries who ...

Article Raises Concerns about Medicare Advantage and Calls Attention to Limited Medigap Access April 25, 2019

A recent Bloomberg News article highlighted an important issue for Medicare beneficiaries: limited access to Medigap plans. The Center for Medicare Advocacy has long advocated for improved access to Medigap plans for all Medicare beneficiaries. Medigap plans are private plans that provide supplemental health insurance for beneficiaries in Traditional Medicare to assist with out-of-pocket medical expenses, ...

The Growing Disparity Between Medicare Advantage and Traditional Medicare: CMS Publishes Final MA Telehealth Benefit Rule April 18, 2019

The Centers for Medicare & Medicaid Services (CMS) published a Final Rule this week implementing provisions of the Bipartisan Budget Act of 2018. As detailed in this Rule, Medicare Advantage (MA) plans will be allowed to offer telehealth services as a basic benefit starting in 2020. The Rule limits this telehealth benefit to services available ...

Medicare Advantage Case Spotlight March 14, 2019

The son of a hospitalized patient recently called the Center for Medicare Advocacy. His father was ready for discharge. Physicians at both the hospital and the inpatient rehabilitation hospital (IRH) agreed that the patient would benefit from IRH services. However, the patient’s Medicare Advantage (MA) plan refused to authorize IRH care.  The plan instead said ...

Center for Medicare Advocacy Submits Comments to CMS’ Draft 2020 Call Letter for Medicare Advantage and Part D March 7, 2019

On January 30, 2019, the Centers for Medicare & Medicaid Services (CMS) issued Part II of its draft 2020 Call Letter, an annual set of proposed rules, guidelines and clarifications for Part C Medicare Advantage (MA) and Part D plans that want to participate in Medicare in the following calendar year. In collaboration with several ...

Improve and Expand Medicare: CMS Should Provide Objective Information About Medicare Options February 14, 2019

Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations to improve Medicare for all beneficiaries, now and in the future, is the need to preserve and expand consumer protections and quality coverage for all Medicare Beneficiaries – including parity between traditional Medicare and private Medicare ...

Improve and Expand Medicare: Create Parity Between Medicare Advantage and Traditional Medicare February 7, 2019

Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations to improve Medicare for all beneficiaries, now and in the future, is the need to preserve and expand consumer protections and quality coverage for all Medicare Beneficiaries – including parity between traditional Medicare and private Medicare ...

Center Submits Comments on Proposed Medicare Prescription Drug Rule January 31, 2019

The Center for Medicare Advocacy recently submitted comments to a Notice of Proposed Rulemaking issued by the Centers for Medicare & Medicaid Services (CMS) entitled “Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses” (CMS-4180-P).  The Center’s comments are available at: https://www.medicareadvocacy.org/center-comments-on-modernizing-part-d-and-medicare-advantage/.   Currently, Part D prescription drug plans (PDPs) and ...

Today Ends the Medicare Annual Enrollment Period; Does it Begin a New Private Era for Medicare? December 7, 2018

As reported widely, including in The New York Times, and HHS Secretary Azar says he sees Medicare Advantage as the future of Medicare: ...

In Her Own Words: A Beneficiary’s Take On Medicare Advantage Steering December 6, 2018

Dear CMA, I am a retiree and my health plan is Medicare. I am retired 13 years and never have had any problem with my Medicare coverage. Most of my doctors accept Medicare and I have been very pleased with their services. I have become increasingly troubled by the targeted ads to seniors on TV telling viewers ...

Amidst Medicare Open Enrollment, CMS Reports High Rates of Inaccuracy in Medicare Advantage Provider Directories December 6, 2018

The Medicare Annual Coordinated Election Period (ACEP) is the most crucial time of year for Medicare beneficiaries to make decisions about how they wish to receive their Medicare coverage.  This year the Administration seems to be actively promoting Medicare Advantage plans. However, at the same time that this steering toward private plans is occurring, the ...

As Medicare Enrollment Period Draws to a Close, MA Steering Continues – Advocates & Members of Congress Write Letters of Concern to CMS November 30, 2018

As we approach the final week of the Medicare Annual Coordinated Election Period (ACEP), individuals continue to make decisions about how they want to access their Medicare benefits in 2019.  Consumer advocates are concerned, however, that the information put out by the Medicare program about coverage options is incomplete and continues to promote one option ...

Important Health Policy Article Published In New England Journal of Medicine: “Medicare Advantage Checkup” November 29, 2018

The November 2018 New England Journal of Medicine features a article by KFF’s Tricia Neuman and Gretchen Jacobson of the Kaiser Family Foundation (KFF) that “examine the extent to which Medicare Advantage plans are achieving goals with respect to benefits, out-of-pocket costs, plan choice, federal spending and quality. They also highlight areas where more evidence ...

Government Watchdog Agency Raises Concerns About Medicare Advantage Denials October 18, 2018

The Department of Health and Human Services (DHHS) Office of Inspector General (OIG) recently issued a report entitled “Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials” (OEI-09-16-00410) (see summary and full report). Among the report’s findings are that when beneficiaries and providers appealed preauthorization and payment denials, MA plans “overturned ...

Court Ruling May Lead to Even More Overpayments to Medicare Advantage September 13, 2018

As reported in FierceHealthcare, “Medicare Advantage insurers scored a significant legal victory” when a U.S. District Court judge recently “struck down a 2014 rule requiring to report and return overpayments.”  Further, according to Modern Healthcare, this ruling “leaves the federal government with fewer tools to combat upcoding practices that cost the taxpayer-funded Medicare program ...

Studies Differ Regarding Traditional Medicare and Medicare Advantage July 12, 2018

Researchers studying patients with hip fractures found that patients with Medicare Advantage (MA) plans have shorter stays in skilled nursing facilities (SNFs) and receive less rehabilitation than patients in traditional Medicare, but are, nevertheless, less likely to be readmitted to an acute care hospital within 30 days or to become long-term care residents.  These findings ...

Tipping the Scales Toward Medicare Advantage (at the Expense of Medicare) June 21, 2018

Ranking Committee Members Echo Advocates’ Complaints to CMS about Draft 2019 Medicare & You As discussed in a previous CMA Alert, the Center for Medicare Advocacy, Justice in Aging and the Medicare Rights Center recently sent a letter to the Centers for Medicare & Medicaid Services (CMS) raising “strong objections to serious inaccuracies” in the draft ...

Advocates Raise Concerns About Inaccuracies and Bias in Draft MEDICARE & YOU Handbook May 31, 2018

The Center for Medicare Advocacy, Justice in Aging and the Medicare Rights Center recently sent a letter to the Centers for Medicare & Medicaid Services (CMS) raising “strong objections to serious inaccuracies” in the draft 2019 Medicare & You Handbook, and urged CMS to rectify the errors prior to dissemination.  As stated in a joint press ...

Center for Medicare Advocacy Submits Comments on New CMS Medicare Marketing May 3, 2018

On April 26, 2018, the Center for Medicare Advocacy provided comments to the Centers for Medicare & Medicaid Services (CMS) in response to an April 12, 2018  Request for Input on the 2019 Medicare Communications and Marketing Guidelines (MMG).  Unlike previous opportunities to provide comment, CMS did not offer draft language for revisions to the ...

Tipping the Scales Toward Medicare Advantage March 21, 2018

Part C of the Medicare program, also known as Medicare Advantage (MA), is an option available to Medicare beneficiaries who wish to receive their benefits through private insurance companies, primarily HMOs.  In 2017, more than 19 million Medicare beneficiaries (33%) were enrolled in MA plans.  MA enrollment is projected to continue to grow, rising to ...

Center for Medicare Advocacy Submits Comments to CMS’ Draft 2019 Call Letter for Medicare Advantage and Part D March 8, 2018

On February 1, 2018, the Centers for Medicare & Medicaid Services (CMS) issued its draft 2019 Call Letter, an annual set of proposed rules, guidelines and clarifications for Part C Medicare Advantage (MA) and Part D plans that wish to participate in Medicare in the following calendar year.  In collaboration with several other advocacy organizations, ...

JAMA Calls for Release of Medicare Advantage Data – A Full Review of MA is Long Overdue March 8, 2018

The Journal of the American Medical Association (JAMA), recently published a Viewpoint article entitled “Time to Release Medicare Advantage Claims Data” by Niall Brennan, Charles Ornstein, and Austin B. Frakt (February 19, 2018).  After pointing out that almost 33% of the Medicare population is enrolled in Medicare Advantage (MA) plans at a cost of over $200 billion a year, ...

Medicare Advantage Enrollees Have Fewer SNF Options than Traditional Medicare Beneficiaries January 24, 2018

“Medicare Advantage Enrollees More Likely to Enter Lower-Quality Nursing Homes Compared to Fee-For-Service Enrollees,” a report recently published by Health Affairs, examines the quality of skilled nursing facilities (SNFs) used by Medicare Advantage (MA) enrollees and traditional Medicare beneficiaries. As the title indicates, the authors of the report found that traditional Medicare beneficiaries “tended to ...

Alert – Tax Cut Harm Just Got Worse; This Week in Sabotage; CMS Pushing MA Plans; SNF Deregulation November 15, 2017

Tax Cut Bill Just Got Worse. Health Care at Risk. This Week in Sabotage CMS Steering to Medicare Advantage Administration And Nursing Home Industry: Lockstep in Deregulating Nursing Facilities & Reducing Resident ProtectionsTax Cut Bill Just Got Worse.  Health Care at Risk.Free Webinar Series Next Webinar: Hospital Observation Status Update January 24, 2018 3:00 p.m. ET  Presenters: Center for Medicare Advocacy Litigation Director, attorney ...

CMA Alert – Remember You CAN Choose Original Medicare; Equitable Relief; This Week’s Sabotage News October 25, 2017

You Can Choose Original Medicare: CMS Over-Emphasizes Private Medicare Advantage Plans in Open Enrollment Roll-Out CMS Extends Equitable Relief  CMA Joins 30 Organizations in Amicus Brief in Support of Court Challenge to Trump ACA Sabotage And THIS Week in ACA Sabotage…Auto-Enrollment… And No Time to Switch More Repeal Disguised as ReformYou Can Choose Original Medicare: CMS Over-Emphasizes Private Medicare Advantage ...

CMA Alert – Critical Issue Roundup: MA Overpayment; HH Payment; Observation; More August 16, 2017

Former CMS Administrator Comments on Medicare Advantage Overpayments Proposed Home Health Rules – Payments Drive Delivery of Care, Harming Beneficiaries Observation Status Harms Low-Income Medicare Beneficiaries Poll: Americans Favor Making the ACA WorkFormer CMS Administrator Comments on Medicare Advantage Overpayments In Austin Frakt’s August 7, 2017 The Upshot blog in the New York Times (“Medicare Advantage Spends Less on ...

Center Urges CMS to Preserve and Strengthen Consumer Protections in Medicare Advantage and Part D April 26, 2017

As noted in a previous Alert, the Center for Medicare & Medicaid Services (CMS) recently finalized their 2018 Call Letter.  In the same document, CMS issued a Request for Information regarding ideas for “regulatory, sub-regulatory, policy, practice and procedural changes to better accomplish” the goals of “using transparency, flexibility, program simplification and innovation to transform ...

Insurer Reaches Agreement with Provider Network – After Frightening Medicare Advantage Enrollees April 19, 2017

Last month in Connecticut, United Healthcare (UHC) set off a panic among its Medicare Advantage (MA) enrollees by sending out letters indicating that they would no longer be affiliated with Hartford HealthCare HHC), one of Connecticut’s largest provider networks. These MA enrollees often received multiple letters – one for each of their HHC providers. One older ...

CMS Releases Final 2018 Call Letter: Too Little for Consumers April 12, 2017

On February 1, 2017, the Centers for Medicare & Medicaid Services (CMS) issued its draft 2018 Call Letter, an annual set of proposed rules, guidelines and clarifications for Part C Medicare Advantage (MA) and Part D plans that wish to participate in Medicare in the following calendar year.  In collaboration with several other advocacy organizations, ...

What Would Work Better for You? Deciding Between Traditional Medicare and a Medicare Advantage Plan November 9, 2016

In last week’s Alert, we posed 10 questions to ask before deciding between traditional Medicare and a Medicare Advantage Plan. This week we discuss what your answers may mean.Do you qualify for payment assistance or have access to other coverage through any of the following…Medicare Savings Program? Part D Low Income Subsidy? Employer/Military/Other Insurance? Medigap Plan?Response: Contact the ...

10 Questions to Ask Before Deciding Between Traditional Medicare and a Medicare Advantage Plan November 3, 2016

Do you qualify for payment assistance or have access to other coverage through any of the following… :Medicare Savings Program? Part D Low Income Subsidy? Employer/Military/Other Insurance? Medigap Plan?Which providers/facilities will you want to use?How important is it to you to continue seeing them? Do they accept Medicare? What Medicare Advantage Plan networks do they participate in?Are you comfortable with ...

CMS Suspends New Applications for MA “Seamless Conversion” Enrollment October 26, 2016

In a June 2016 Weekly Alert the Center wrote about a process called “seamless conversion enrollment” used by some insurance companies that offer Medicare Advantage (MA) plans to capture enrollment among their pre-Medicare plan enrollees.  As we noted, “Medicare rules allow MA plan sponsors to ‘develop processes to provide seamless enrollment in an MA plan ...

The Center’s Long-Time Concerns Gain Attention August 31, 2016

Prescription Drug Pricing An excellent and well-timed (given #Epi-gate) article appeared in this week’s Journal of the American Medical Association discussing the reason drug costs are so high in the U.S. According to the article, the major cause is the “granting of government-protected monopolies to drug manufacturers, combined with restriction of price negotiation at a level ...

Medicare Beneficiaries Still Prefer Traditional Medicare June 8, 2016

A recent post by health economist Uwe Reinhardt in the Journal of the American Medical Association Forum discusses the fact that despite all the support Medicare Advantage (MA) plans have received, the vast majority of Medicare beneficiaries still prefer Traditional Medicare. 30% of Medicare recipients now receive their coverage through MA plans. This is largely because MA ...

Case Study: Enrolled In a Medicare Advantage Plan Without Her Knowledge Through “Seamless Conversion Enrollment” June 1, 2016

October 21, 2016 – Update on Seamless Conversion: CMS is revisiting the seamless conversion enrollment policy and is temporarily suspending its acceptance of any new seamless enrollment proposals. Read more…Ms. M., a Medicare beneficiary living in the Southwest, turned 65 in October 2015 and became eligible for Medicare on October 1st. On September 30th she signed up ...

Government Auditor Finds Billions in Improper Payments to Medicare Advantage Plans Coupled with Inadequate Oversight by Federal Regulator May 11, 2016

This week the General Accounting Office (GAO) issued a report entitled “Medicare Advantage: Fundamental Improvements Needed in CMS’s Effort to Recover Substantial Amounts of Improper Payments.  The report states that the Centers for Medicare & Medicaid Services (CMS) estimates that about 9.5% of its annual payments to Medicare Advantage (MA) organizations were improper – totaling ...

CMS Policy Change Allows Windfall for Medicare Advantage Plans Under Sanction March 16, 2016

On March 8, 2016, the Centers for Medicare and Medicaid Services (CMS) released a memorandum entitled “Suspension of Policy Providing for Automatic Reduction of Star Ratings for Contracts Operating Under Intermediate Sanction.” Through this memo, CMS has suspended its policy of lowering the star ratings of Medicare Advantage plans that are under sanction for violations of ...

Kaiser Family Foundation Releases Reports on MA and Part D in 2016 October 15, 2015

In a report entitled “Medicare Part D: A First Look at Plan Offerings in 2016” (October 2015), the Kaiser Family Foundation analyzed the Part D market in 2016 and found, among other things, that:In 2016, beneficiaries in each region will have a choice of 26 PDPs, on average, down by 4 from 2015. The average PDP ...

GAO Issues Report Concerning CMS Oversight of Medicare Advantage Provider Network Adequacy October 1, 2015

This week, the General Accounting Office (GAO) issued a report entitled “Medicare Advantage: Actions Needed to Enhance CMS Oversight of Provider Network Adequacy” (August 2015, publicly released September 28, 2015).  This report reviews how the Centers for Medicare and Medicaid Services (CMS) ensures adequate access to care for Medicare Advantage (MA) enrollees. The report was requested ...

Case Study: Home Health Coverage and Medicare Advantage Plan Responsibilities August 13, 2015

The Center for Medicare Advocacy received an e-mail inquiry from an individual requesting assistance advocating for her sister, Mrs. B.  Mrs. B is a Medicare beneficiary enrolled in a Medicare Advantage plan and in need of home health services.  The questions raised demonstrate several important issues that often arise with both the home health benefit ...

Reports of Import – Trustees and Kaiser Family Foundation July 23, 2015

Medicare Trustees Report – Medicare Part A Solvency Remains Stable On July 22, 2015, the Medicare and Social Security Trustees issued the 2015 Annual Report of the Boards of Trustees of the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund. Good News: In short, the projected solvency of the Part A Trust ...

Final 2016 CMS Call Letter for Medicare Parts C and D Released April 9, 2015

Every year, the Centers for Medicare and Medicaid Services (CMS) issues payment, performance and other rules that apply to Medicare Advantage (MA) and Part D plans that choose to participate in the Medicare program in the following calendar year. Commonly referred to as the “Call Letter,” this document is first released in draft form, subject ...

Center for Medicare Advocacy Co-Authors Report Published by the Kaiser Family Foundation Comparing Consumer Protections in Major Health Plans March 26, 2015

The Kaiser Family Foundation (KFF) has published a report entitled “Comparison of Consumer Protections in Three Health Insurance Markets: Medicare Advantage, Qualified Health Plans and Medicaid Managed Care Organizations.” The report is authored by Center Senior Policy Attorney David Lipschutz, former Center Policy Attorney Andrea Callow (now at Families USA) and Karen Pollitz, MaryBeth Musumeci ...

Center for Medicare Advocacy Submits Comments to Draft 2016 Call Letter for Medicare Parts C and D March 12, 2015

Every year, the Centers for Medicare and Medicaid Services (CMS) releases a draft of payment, performance and other rules that apply to Medicare Advantage (MA) and Part D plans that choose to participate in the Medicare program in the following calendar year. Commonly referred to as the “Call Letter,” this document is first released in ...

2016 Medicare Advantage (Part C) and Part D Final Rule Issued February 19, 2015

On February 12, 2015, the Centers for Medicare and Medicaid Services (CMS) published final rules entitled “Medicare Program; Contract Year 2016 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs” Applicable to the 2016 plan year ...

Update on MA and Part D Plans October 23, 2014

A Brief Survey of Recent Reports, and a New Special Enrollment Period for 2015 Medicare's Annual Coordinated Election Period (ACEP) for Medicare Advantage and Part D plans began on October 15th and runs through December 7th.  During the ACEP, often referred to as "open enrollment," Medicare beneficiaries who do not have a Part D plan can ...

Impact of ACA on Mid-term Elections; Beneficiary and Family-Centered QIOs; and More September 11, 2014

Kaiser Family Foundation Poll: Potential Impact of Affordable Care Act (ACA) on the Mid-term Elections On September 9, 2014, the Kaiser Family Foundation issued its August – September 2014 Health Tracking Poll analyzing the potential impact of voter opinion of the Affordable Care Act on the November mid-term elections. The results found that health care broadly was ...

Medicare Advantage Patient Bill of Rights Legislation Introduced in Congress August 1, 2014

Medicare Advantage (MA) plans are increasingly dropping doctors and other health care providers from their contracted networks, often in the middle of a plan year, when most plan enrollees are not permitted to change plans.  MA enrollees often get little advance warning, and some lose access to doctors they have seen for a long time, ...

Center Executive Director Judith Stein Testifies Before House Energy & Commerce Committee about Medicare Advantage Plans March 13, 2014

On March 13, 2014, Center for Medicare Advocacy Executive Director and Founder Judith Stein testified before the House Energy & Commerce Committee, Subcommittee on Health, at a hearing entitled "Keeping the Promise: Allowing Seniors to Keep Their Medicare Advantage Plans If They Like Them."   That testimony is summarized below. The Center for Medicare Advocacy recognizes that ...

Medicare Advantage Payment Reductions Are Good News for Medicare February 27, 2014

On February 21, 2014, the Centers for Medicare & Medicaid Services (CMS) issued its draft 2015 Call Letter to Medicare Advantage (MA) and Part D plan sponsors, which includes a proposed rate for MA payment for 2015.  Much anticipated, the draft Call Letter, which will be finalized in April, was preceded by an aggressive advertising ...

Dual Eligible Special Needs Plans: Considerations for Reauthorization December 5, 2013

Dual Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage (MA) plan that enrolls only individuals dually eligible for Medicare and Medicaid. Though results have been mixed, D-SNPs were created as a possible route to better integration between Medicare and Medicaid, in turn leading to better quality, higher value care. Authority for Special Needs ...

The Medicare Annual Coordinated Election Period Has Begun! October 17, 2013

During the Annual Coordinated Election Period, which runs from October 15th through December 7th, 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 Part D drug coverage. For more information and to get help reviewing ...

United Healthcare Dramatically Reducing CT Medicare Advantage Plans – Check in YOUR State October 10, 2013

For 2014, United Healthcare (UHC) is cutting 2,250 doctors from its Connecticut Medicare Advantage (MA) network. UHC is also closing one of its MA plans in New Haven County that serves 2,900 people and taking similar actions in other states.  Medicare Advantage enrollees who visit a doctor, hospital, specialist, or health center outside of UHC’s ...

Medicare Advantage “Cuts?” Don’t Believe it. March 14, 2013

The Affordable Care Act (ACA) is beginning to rein in Medicare Advantage (MA) overpayments by bringing MA payment more in line with what traditional Medicare spends on a given beneficiary.  The insurance industry is not only fighting this payment reform, but has launched a campaign against a 2.3% reduction in payment projected for 2014.   This ...

Reminder: Medicare Advantage Disenrollment Period (MADP) Ends February 14th February 7, 2013

The Medicare Advantage Disenrollment Period (MADP) lasts from January 1st through February 14th of each year.  During the MADP, a beneficiary can switch from an MA plan to traditional Medicare. The new MADP also provides an opportunity to enroll in a Part D drug plan for those who have not already done so. When disenrolling from ...

Picking a Plan During the Annual Enrollment Period? Choose Carefully October 18, 2012

As discussed in last week’s Alert, the current Medicare Annual Enrollment Period lasts until December 7th.  During this time period, Medicare beneficiaries can choose a Medicare Advantage (Part C) or Part D plan for 2013.  This Alert discusses Part C and D plan quality ratings for 2013, and special enrollment periods related to these ratings.  ...

Rewarding Mediocrity: GAO Report Concerning Medicare Advantage “Bonus” Payments April 26, 2012

On April 23, 2012, the Government Accountability Office (GAO) released a report that concludes, among other things, that a Medicare demonstration program providing bonus payments to Medicare Advantage (MA) plans mainly benefits plans whose performance is no more than average.  While the program is supposed to reward quality, in practice it largely rewards plans receiving ...

Forcing Dual Eligibles Into Private Health Plans is No Quick Fix November 22, 2011

The nearly nine million Medicare beneficiaries who are also eligible for some form of Medicaid, the so-called dual eligibles, are the subject of federal, state and local policy discussions because many of them are among the highest users of health care services in the country and thus are very costly to both Medicare and Medicaid.  ...

Medicare Advantage and Part D Changes and Enrollment Updates October 6, 2011

Once again the Medicare Advantage and Part D Annual Coordinated Election Period (ACEP) is upon us; it's time to contemplate Medicare prescription drug and Medicare Advantage choices for another calendar year.  The big news is that the ACEP, while one week longer than in the past, starts and ends much earlier this year.  The ACEP ...

Annual Enrollment Starts October 15 and Ends December 7 for Medicare Part C & Part D Plans September 22, 2011

Fall is the time for Medicare beneficiaries to explore their options regarding Part D prescription drug and Part C Medicare Advantage plans.  In years past, the annual enrollment period began in mid-November and lasted to the end of the year, with any changes or choices made effective January 1st.  Starting this year, that time period ...

New Rules for Medicare Advantage and Part D Plans June 2, 2011

On April 15, 2011, the Centers for Medicare & Medicaid Services (CMS) issued final regulations to provide policy and technical changes to the Medicare Parts C (Medicare Advantage) and D programs.  The regulations address concerns raised by Medicare beneficiary advocates, and implement provisions of the Affordable Care Act.  They also codify into regulation some existing ...

45 Day Disenrollment Period for Medicare Advantage Members January 6, 2011

Starting this year, the Medicare Advantage Open Enrollment Period (OEP) has been replaced by a new Medicare Advantage Disenrollment Period (MADP), which lasts from January 1st through February 14th. During the MADP, one can switch from an MA plan to traditional Medicare.  The new MADP also provides an opportunity to pick up Part D drug ...

Medicare Reform Articles

Information Requested on “Corporate Greed in Health Care” April 11, 2024

Private Equity ownership has been a disaster for nursing home residents, and that trend would no doubt continue in other care settings.

Advocacy Tip for Medicare Advantage Enrollees Facing Difficulty Obtaining In-Network Care January 18, 2024

The Center regularly hears from MA enrollees and those who assist them that they are unable to obtain medically necessary care from an in-network provider.

Improving Medicare by Reining in Medicare Advantage Overpayments: Policy Options January 11, 2024

Legislative and academic proposals that could use recouped MA overpayments to expand Medicare.

More Medicare Prescription Drug Help for Beneficiaries in 2024 – Including Out-of-Pocket Cap October 26, 2023

Act already helping beneficiaries, and more changes to come in 2024.

Medicare Drug Price Negotiation Program Begins After Encouraging Court Decision October 5, 2023

A federal court has rejected a bid by the pharmaceutical industry and its allies to stop the newly established Medicare drug price negotiation program before it starts.

Senate Finance Committee Confirms Medicare Home Health Coverage Can Be Long-Term September 21, 2023

Center Director Judith Stein says if we really want to fix Medicare home health care we need to enforce the law that already exists.

Inflation Reduction Act (Medicare Drug Law) Updates – Including Part D Low Income Subsidy June 15, 2023

HHS Actions to Increase LIS EnrollmentAmong other changes aimed at reducing drug costs for both Medicare beneficiaries and the Medicare program at large, a provision of the Inflation Reduction Act of 2022 (IRA) expands access to the Part D Low Income Subsidy (LIS, or “Extra Help”) to help people meet the costs of medications. Starting in ...

President Biden’s Prescription for Medicare Solvency March 9, 2023

As we review the Medicare-related provisions of the President’s proposed budget, we applaud the broad goals of shoring up the program’s solvency without cutting benefits.

Implementation of Medicare Drug Bill Proceeds – This Progress Must be Defended March 2, 2023

Inflation Reduction Act drug provisions that will help millions must be supported, even strengthened.

Center for Medicare Advocacy Statement on Recent Medicare Advantage Payment Policies and Proposals February 3, 2023

While steps taken to increase MA oversight are encouraging, the Administration must hold fast, and Congress should act to stop wasteful overspending.

Critical Provisions of Medicare Drug Bill Already Taking Effect January 19, 2023

Though already threatened by industry and their supporters in Congress, several provisions to help Medicare beneficiaries are underway.

Medicare Provisions in Year-End Spending Bill January 5, 2023

Consolidated Appropriations Act contains a number of health provisions relating to Medicare, Medicaid, and other programs.

Center for Medicare Advocacy Weighs in on IRA Implementation December 8, 2022

CMA honored to join HHS leadership to discuss implementation of the Inflation Reduction Act (IRA).

Provisions of Recently Passed Medicare Drug Bill in Effect Next Month – January 2023 December 8, 2022

Medicare-related drug provisions in the IRA starting next month will help beneficiaries nationwide.

Additional New Medicare Coverage News – Hearing Aids and Oral Health August 18, 2022

Soon a new category of hearing aids will be available at pharmacies, stores and online for adults with mild hearing loss.

President Biden Signs Inflation Reduction Act into Law – Includes Critical Medicare Prescription Drug Provisions August 18, 2022

The Medicare drug provisions in the Inflation Reduction Act are historic reform that will benefit millions of beneficiaries.

Senate Passes Historic Reconciliation Bill, House Vote Imminent August 11, 2022

We urge the House to pass the IRA and President Biden to sign it into law.

Senate Poised to Vote on Important Bill with Valuable Medicare Drug Provisions August 4, 2022

Tell the Senate to pass Medicare prescription drug reform now.

2022 Medicare Trustees Report June 9, 2022

Congress continues to ignore overpayments to private MA plans that clearly affect the Medicare trust fund.

Senate Finance Committee Holds Hearing on Medicare Solvency February 3, 2022

Medicare’s fiscal solvency can be strengthened through various means, including the simple option of reducing Medicare Advantage overpayments.

CMA Statement on Medicare Financing February 3, 2022

Statement for the Record from the Center for Medicare Advocacy “The Hospital Insurance Trust Fund and the Future of Medicare Financing” Senate Finance Committee Subcommittee on Fiscal Responsibility and Economic Growth Hearing Date: February 2, 2022The Center for Medicare Advocacy (Center) is pleased to provide a statement for the record for the above-referenced hearing. The ...

Study Published in Health Affairs Finds that Medicare Advantage Quality Bonus Program Has Not Improved Quality January 6, 2022

Higher star ratings correlate with increased beneficiary enrollment, but they did not improve quality of care.

Build Back Better Act: House and Senate Nursing Home Provisions Compared December 16, 2021

A side-by-side comparison of the House version of the Build Back Better Act’s nursing home provisions, compared with the Senate’s current version.

Pass Build Back Better — Seize the Moment to Protect Nursing Home Residents December 2, 2021

It’s time to do what is right to help protect older Americans and people with disabilities who live in our nation’s nursing homes. That means passing all five nursing home provisions in the Build Back Better Act.

CMA Statement | But for Critical Hearing Benefit, Medicare is Left Behind in Build Back Better Framework October 28, 2021

Improve the Build Back Better framework before finalizing it – add comprehensive oral health and vison coverage for all Medicare beneficiaries and end overpayments for prescription drugs and to Medicare Advantage plans.

Analysis Provides Options for Containing the Cost of a New Medicare Dental, Hearing, and Vision Benefit October 7, 2021

Policymakers must address wasteful MA overpayments, particularly if not doing so squanders this opportunity to improve Medicare.

Congress Continues to Negotiate Potential Historic Expansion of Medicare – The Time to Act Is Now September 30, 2021

Add dental, vision and hearing benefits to Part B now. Let’s not squander a rare opportunity to help millions of people on Medicare.

Reminder | Tell Congress Now is the Time to Improve Medicare September 23, 2021

Tell Congress Now is the Time to Improve Medicare

Congress Begins Debate About Adding Dental, Hearing and Vision Benefits to Medicare – Now is the Time to Act September 9, 2021

Congress is poised to strengthen our country’s safety net, including adding critical benefits to the Medicare program. Now is the time to act.

Medicare is at a Crossroads – Time to Dispel Myths Hindering an Historic Expansion of Benefits September 2, 2021

We clear up the myths and falsehoods being circulated by opponents of historic Medicare improvements.

Congress Sets the Stage for Important Medicare Improvements August 12, 2021

Reconciliation package would add oral health, hearing, and vision coverage to Medicare – goals that the Center has long sought and supported.

Advocates Call on Congress to Improve Medicare July 22, 2021

Now is the time to contact your legislators, as momentum builds for Medicare improvements.

Medicare Team Now Complete – Time to Improve the Program for Beneficiaries July 8, 2021

In addition to the current debate in Congress about expanding and improving Medicare benefits via legislation, there is much that the Administration can and should do.

Medicare and Revenue – Looking Back, Looking Forward May 3, 2021

Center for Medicare Advocacy Visiting Scholar Marilyn Moon has drafted an issue brief – “Ensuring Medicare’s Financial Health” – concerning the fiscal solvency of the Medicare program.

Changes to Health Coverage Must Include Medicare Improvements April 29, 2021

As the nation faces an historic opportunity to strengthen and expand health coverage, Medicare must remain central to the discussion.

Policy-Makers Should Review Overpayments to Medicare Advantage when Considering Medicare Fiscal Solvency March 18, 2021

Medicare payments are higher for MA enrollees than the program would spend for similar beneficiaries in traditional Medicare.

Medicare and the Dilemma of “Choice” March 11, 2021

Choice in Medicare can be both burdensome and unequal.

Study Finds Cost-Sharing Increases Can be Deadly February 25, 2021

Health care spending by patients is unlike other consumer spending. "Skin in the game" can lead to disastrous health outcomes.

Commonwealth Fund Issues Series of Articles Addressing Medicare’s Fiscal Solvency – Introductory Statement by Marilyn Moon February 11, 2021

The new Congress and Administration will soon have to address Medicare solvency issues. As Dr. Moon notes, this Commonwealth Fund series provides a good foundation for the coming debate.

Center for Medicare Advocacy and Medicare Rights Center Urge Biden Administration to Take Immediate Action on Key Issues Facing Medicare Beneficiaries February 11, 2021

Center and allies urge Biden Administration to take swift action to strengthen Medicare, Medicaid, and the ACA.

Biden Administration Withdraws Harmful Rule Re: Dropping Medicare Part A Coverage February 4, 2021

Allowing people to opt out of Medicare would undermine the universality of the Medicare program.

Consumer Groups Sign on to Letter Asking Acting HHS Secretary to Suspend Geo Direct Contracting Demo February 4, 2021

Several national non-profit organizations joined the Center for Medicare Advocacy in urging suspension of plan to turn Medicare over to private insurers.

A New Administration Begins During a “Winter of Peril and Possibility” January 21, 2021

We look forward to working with the new Administration, and are hopeful that it will address long-standing barriers to care.

COVID Relief and Omnibus Package: Overview of Medicare Provisions January 7, 2021

The recent legislation that included COVID relief also included a number of provisions that relate directly to Medicare beneficiaries.

Center for Medicare Advocacy Issues Transition Memorandum: Medicare Improvements for the Biden Administration December 18, 2020

Measures that the Biden Administration can take administratively right now to strengthen Medicare for all beneficiaries.

Center for Medicare Advocacy Urges Incoming Administration to Suspend Direct Contracting Demonstration December 17, 2020

This model will have the effect of enrolling Medicare beneficiaries into a managed care–like plan.

Center for Medicare Advocacy Comments on Harmful Proposed Rule that Would Automatically Expire Regulations Governing Medicare and Other Important Programs December 10, 2020

We strongly urge those who are willing and able to submit Medicare-related comments in opposition to this rule to do so before the 1/4/2020 deadline.

Strengthen Medicare to Build Back Better December 9, 2020

A five-part plan that will make Medicare a bulwark against the worsening health and economic challenges facing the American people.

Candidates: Don’t Forget Medicare September 24, 2020

Candidates should answer the call to preserve and improve the core Medicare program and those it serves.

Medicare’s Finances – Challenges and Solutions September 10, 2020

As demonstrated by the positive impact the Affordable Care Act had on increasing the life-span of the Medicare Trust Fund, the problem is fixable without reducing benefits.

Improve Medicare for All Beneficiaries August 13, 2020

Improve and support Medicare for all beneficiaries.

Real Medicare Matters July 30, 2020

The Medicare program must be implemented in a manner that provides better coverage and cost-sharing protections for ALL beneficiaries, not just those in wasteful private plans.

Podcast with Judy Stein: Moving Forward with COVID-19 and Medicare May 28, 2020

Center for Medicare Advocacy Executive Director Judy Stein joins journalist Mark Miller to discuss what the pandemic is teaching us about ways to improve Medicare.

House Passes Historic Medicare Expansion Bill – H.R. 3 December 12, 2019

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, ...

House to Vote on Historic Medicare Bill Next Week December 5, 2019

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 back ...

Potential Impacts of New Medicare Payment Models On Skilled Nursing Facility and Home Health Care October 31, 2019

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 ...

Center for Medicare Advocacy Board President Judith Feder Testifies at Drug Pricing Hearing October 17, 2019

On October 17, 2019, the House Ways & Means Committee held a hearing entitled “Investing in the U.S. Health System by Lowering Drug Prices, Reducing Out-of-Pocket Costs, and Improving Medicare Benefits.”  The hearing focused on H.R. 3, the Lower Drug Costs Now Act (discussed in a previous Alert), as well as current gaps in Medicare ...

Center for Medicare Advocacy Analysis of President’s Medicare Executive Order: October 10, 2019

Among Vague Language and Proposals, Real Harm to Medicare Beneficiaries On October 3, 2019, President Trump issued his “Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors” (EO). Much of the language of the EO is vague, and much is unknown about what polices might emerge from it. Some of the proposals are clear ...

Support Traditional Medicare by Leveling the Playing Field with Medicare Advantage August 15, 2019

The Center has previously written about how legislative and regulatory policy changes are tipping the scales in favor of Medicare Advantage (MA) over traditional Medicare. For example, coverage expansions such as the ability to provide new supplemental benefits have been advanced in MA but not in traditional Medicare. In recent years, this has been exacerbated ...

A First Step in an Important National Discussion: Congressional Committee Holds Hearing on “Medicare for All” May 2, 2019

Repeated efforts to repeal and undermine the Affordable Care Act (ACA) have led to growing public awareness of the importance of access to health coverage and accompanying patient protections. Recognition of the important role of the ACA and Medicare, and growing support for Medicaid, have combined to shape public support for expanding health coverage, instead ...

Medicare Trustees Issue 2019 Report: Medicare is Not Going Broke April 25, 2019

Earlier this week, the Medicare Trustees issued their 2019 annual report, which offers projections concerning the fiscal health of the Medicare and Social Security programs.  The Medicare Trustees estimate that the Part A Hospital Trust Fund will be depleted by 2026, unchanged from last year’s projection. As noted in the Report, income to the Part A ...

Home Infusion Therapy Services March 13, 2019

(The Content below is taken from the Centers for Medicare & medicaid Services: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Home-Infusion-Therapy/Overview.html) 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 . The components needed ...

Improve and Expand Medicare: CMS Should Provide Objective Information About Medicare Options February 14, 2019

Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations to improve Medicare for all beneficiaries, now and in the future, is the need to preserve and expand consumer protections and quality coverage for all Medicare Beneficiaries – including parity between traditional Medicare and private Medicare ...

Improve and Expand Medicare: Create Parity Between Medicare Advantage and Traditional Medicare February 7, 2019

Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations to improve Medicare for all beneficiaries, now and in the future, is the need to preserve and expand consumer protections and quality coverage for all Medicare Beneficiaries – including parity between traditional Medicare and private Medicare ...

Improve and Expand Medicare: Cover Long-Term Services and Supports (LTSS) January 31, 2019

Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations to improve Medicare for all beneficiaries, now and in the future, is the need to preserve and expand consumer protections and quality coverage for all Medicare Beneficiaries – including parity between traditional Medicare and private Medicare ...

Center Submits Comments on Proposed Medicare Prescription Drug Rule January 31, 2019

The Center for Medicare Advocacy recently submitted comments to a Notice of Proposed Rulemaking issued by the Centers for Medicare & Medicaid Services (CMS) entitled “Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses” (CMS-4180-P).  The Center’s comments are available at: https://www.medicareadvocacy.org/center-comments-on-modernizing-part-d-and-medicare-advantage/.   Currently, Part D prescription drug plans (PDPs) and ...

Improve and Expand Medicare: Add an Out-of-Pocket Cap January 24, 2019

Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations to improve Medicare for all beneficiaries, now and in the future, is the need to preserve and expand consumer protections and quality coverage for all Medicare Beneficiaries – including parity between traditional Medicare and private Medicare ...

Improve and Expand Medicare: Oral Health January 17, 2019

Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations for Medicare, now and in the future, is the need to expand and Improve Medicare for all current and future beneficiaries, not just those in private Medicare plans. One of the key issues faced by beneficiaries ...

Improve and Expand Medicare: Ensure Medigap Access January 10, 2019

Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations to improve Medicare for all beneficiaries, now and in the future, is the need to preserve and expand consumer protections and quality coverage for all Medicare Beneficiaries – including parity between traditional Medicare and private Medicare ...

Medicare Platform: December 20, 2018

Core Considerations for Today & Tomorrow The Center for Medicare Advocacy works for a comprehensive Medicare program and quality health coverage and care for all people. To accomplish these goals for current and future beneficiaries in the changing health care environment, we seek to:Improve Medicare for current and future beneficiaries. Support the development of the best ...

Medicare Matters for Young Americans: Expect It, Protect It! October 10, 2018

As midterm elections near, young Americans will be in the spotlight. Young Americans have been integral to a number of surprising primary victories across the country. And, for the first time, they will surpass Baby Boomers as the largest generation of Americans eligible to vote. Medicare is often at the forefront of national discourse. However, much ...

MedPAC Discusses Requiring a Three-Day Hospital Stay for All Post-Acute Care, Threatening Access to Care September 13, 2018

The Medicare Payment Advisory Commission (MedPAC) held a public meeting on September 6, 2018. Commissioners listened as staff presented on “Aligning Medicare’s statutory and regulatory requirements under a unified payment system for post-acute care.” Specifically, the presentation discussed the need to make level-of-care requirements consistent across post-acute care (PAC) settings under a unified PAC prospective ...

Tipping the Scales Toward Medicare Advantage (at the Expense of Medicare) June 21, 2018

Ranking Committee Members Echo Advocates’ Complaints to CMS about Draft 2019 Medicare & You As discussed in a previous CMA Alert, the Center for Medicare Advocacy, Justice in Aging and the Medicare Rights Center recently sent a letter to the Centers for Medicare & Medicaid Services (CMS) raising “strong objections to serious inaccuracies” in the draft ...

CMS Issues Request for Information on “Direct Provider Contracting:” Beneficiary Advocates Take Note May 10, 2018

The Affordable Care Act created the Centers for Medicare & Medicaid Innovations (CMMI), which is tasked with testing demonstration programs aimed at delivery system reform. According to a press release describing feedback to a Request for Information (RFI) on “new directions” for CMMI, the Centers for Medicare & Medicaid Services (CMS) has been engaged in ...

Choose Medicare Act Introduced – Improving Medicare, Moving Toward Universal Coverage April 19, 2018

On April 18, 2018, Senators Chris Murphy (D-CT) and Jeff Merkley (D-OR) introduced the “Choose Medicare Act.”  The Act would create a new Medicare plan, “Medicare Part E,” which would allow virtually all Americans to choose the traditional Medicare program in addition to now-available private insurance options. Medicare Part E would be available on the ...

Bill to Control Medicare Prescription Drug Costs Introduced March 8, 2018

Representative Sandy Levin recently introduced the Protecting Medicare from Excessive Price Increases Act, which would require prescription drug manufacturers to pay a rebate when the price of their Part B drug increases faster than inflation. Medicare Part B covers drugs that are usually not self-administered, such as many intravenous medications and chemotherapy drugs. Medicare Part ...

Tax Cut Bill Just Got Worse.  Health Care at Risk. November 15, 2017

 FOR IMMEDIATE RELEASE November 15, 2017 Contact: Center for Medicare Advocacy – Matt Shepard: 860-456-7790, mshepard@MedicareAdvocacy.org Medicare Rights Center – Mitchell Clark: 212-204-6286, mclark@medicarerights.org Tax Cut Bill Just Got Worse.  Health Care at Risk. As the House and Senate rush to make changes to their versions of the bill, it keeps getting worse and worse, posing an immediate threat to ...

CBO Report Confirms ACA Repeal Legislation Will Reduce Health Coverage, Care and Undermine Medicare March 15, 2017

The proposed Affordable Care Act (ACA) repeal legislation, the American Health Care Act, would cause 24 million people to lose coverage by 2026 and cut Medicaid by $880 billion over the next ten years, according to the Congressional Budget Office (CBO), a non-partisan, independent group of budget economists and analysts used to score the financial ...

American Health Care Act (AHCA): A Repeal and Regress Plan March 7, 2017

March 7, 2017, Washington, DC – Last night House Republicans presented a bill to repeal the Affordable Care Act (ACA) and cut Medicaid payments to states.  While the new bill, “America Health Care Act” (AHCA) lacks either an estimate of how many people will lose their health insurance coverage as a result of the bill ...

Health Savings Accounts and Medicare Beneficiaries March 1, 2017

Health Savings Accounts (HSAs) Defined Health Savings Accounts (HSAs) are savings accounts that allow consumers to put money aside to pay for certain “qualified health expenses” on a tax-free basis. HSAs are used in tandem with high deductible health plans (HDHPs), which are health insurance plans that require high deductibles to be paid prior to triggering ...

President Trump’s Address to Congress Brings No New News on Health March 1, 2017

Last night, President Trump, in a speech to Congress, discussed health care but offered no new insight into his Administration’s plans concerning the Affordable Care Act, Medicaid and Medicare.  A day after noting that “nobody knew health care could be so complicated”, the President stated "onight, I am also calling on this Congress to repeal ...

Back to the Future: High Risk Pools Annotated Bibliography February 22, 2017

Many Americans are greatly concerned that repeal of the Affordable Care Act (ACA) will once again leave people with pre-existing conditions without health insurance. The ACA replacement proposal released by Speaker Ryan on February 16 would move coverage from the general ACA marketplace to specific High Risk Insurance Pools. These High Risk Pools would separate ...

Repealing Medicaid Expansion Could Lead to Thousands of Deaths in the U.S. Annually February 22, 2017

According to a recent report from Vox, Congressional plans to repeal key provisions of the Affordable Care Act (ACA) will have devastating consequences for thousands of Americans each year. Vox’s Julia Belluz cites evidence to estimate that 24,000 Americans would die annually if Congress repeals vital provisions of the ACA without simultaneously enacting an appropriate ...

Affordable Care Act Replacement Proposals – Concerns and Resources February 15, 2017

The Administration and the Republican Congress threaten to repeal the Affordable Care Act (ACA), and have suggested various ideas about what a replacement to ACA would include. To better understand these proposals we’ve compiled a list of ACA replacement materials available from colleagues and partnering organizations. Though there is no consensus about what an ACA replacement ...

New Study: Uninsured Rates for Older Adults will Increase if ACA is Repealed or Medicare Eligibility Age is Raised February 1, 2017

On January 24, 2017 the Task Force on America’s Health and Retirement Security, chaired by Marilyn Moon, Ph.D. and led by Principal Investigator Peter Arno, Ph.D., released a new study showing the dramatic negative impact of raising Medicare’s eligibility age to 67 – assessing results on uninsured rates if the ACA stays in place and, what we ...

Issue Brief: Nursing Home Residents in Jeopardy if Medicaid Becomes a Block Grant February 1, 2017

If Medicaid becomes a block grant program, nearly one million nursing home residents who rely on Medicaid could immediately lose coverage for their nursing home care.  In addition, all of the federal standards that govern nursing home care today could be in jeopardy.  The United States does not have a comprehensive program to pay for long-term ...

Opening Salvo on ACA Replacement Falls Short January 25, 2017

On January 23, 2017, Senators Susan Collins (R- ME) and Bill Cassidy (R- LA) introduced the Patient Freedom Act of 2017 (S. 191) billed as a “comprehensive replacement plan for Obamacare.” According to a summary of the bill outlined on Sen. Collins’ website, it “repeals burdensome federal mandates” but “keeps essential consumer protections.”  The Bill ...

HHS Nominee Price Faced Senate HELP Committee Today – Unanswered Questions Remain January 18, 2017

Today U.S. Rep. Tom Price (R – Ga.) faced a hearing before the Senate Health, Education, Labor and Pensions (HELP) Committee to determine his qualification to become Secretary of Health and Human Services.  Next week, on January 24th, he will face an additional hearing before the Senate Finance Committee, which will vote on his nomination. Rep. ...

What’s at Stake In the Fight to Sustain Medicare, Medicaid and the Affordable Care Act (ACA) January 11, 2017

“Medicare saved my life. Without this program, I would be dead. I'm not exaggerating; it's no hyperbole when I say Medicare saved my life. I have a life threatening illness and if I had no access to doctors or medicines, I wouldn't be here. A few years ago, I had been prescribed Bactrim, which caused ...

“Cures” Act Tips the Scales Even Further in Favor of Medicare Advantage Over Traditional Medicare December 28, 2016

On December 13, 2016, President Obama signed into law the 21st Century Cures Act (Public Law No: 114-255, also known as “Cures”, H.R. 34).  The bill, which passed with overwhelming bipartisan support, addresses a wide range of issues, including medical research, the drug approval process, and, added in the final days leading up to passage, ...

Reports Highlight Devastating Effects of Repealing the Affordable Care Act and Turning Medicaid into Block Grants December 14, 2016

As we approach a new year, a new Administration and a new session of Congress, the catastrophic risks to health care coverage include threats to repeal the Affordable Care Act – without an agreed-upon replacement, turning Medicaid into a block grant or per capita cap program, and further privatizing Medicare. Several recently-issued/updated reports underscore some ...

Protect Our Health Care: It’s All Connected – ACA, Medicaid and Medicare are All Under Threat December 7, 2016

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 others in Congress also want to further privatize Medicare ...

10 Things To Be Thankful For, From the Center for Medicare Advocacy November 23, 2016

The visionaries who designed, launched and supported Medicare to help all American families. The Medicare program for its invaluable contribution to desegregating American hospitals. The Medicare program for helping to keep older Americans out of poverty. The Medicare program, for insuring people with disabilities, who, like older Americans, were left behind by private insurance. The Affordable Care Act for ...

An Open Letter to CMS About Fraud September 28, 2016

Can we talk about fraud? It exists. It’s not good for Medicare. Efforts to eliminate its damage to the program are necessary.  But CMS’ war on fraud seems to be indiscriminate, full of tactical errors and collateral damage. Rather than carefully targeting the perpetrators of fraud, a wide net is cast, resulting in legitimate claims ...

Medicare Affordability and Enrollment Act: Important Protection Introduced for Beneficiaries September 22, 2016

Senate Finance Committee Ranking Member Ron Wyden, D-Ore, introduced the Medicare Affordability and Enrollment Act on Wednesday, September 21, 2016. The Bill would improve low-income protections for beneficiaries, eliminate the two-year waiting period for people with disabilities to enroll in Medicare, and reduce late enrollment penalties. The Center for Medicare Advocacy strongly endorses the Bill. It ...

Kaiser Family Foundation Issue Brief
Turning Medicare Into a Premium Support System: Frequently Asked Questions July 26, 2016

Jul 19, 2016 by Gretchen Jacobson and Tricia NeumanThis Issue Brief, available at http://kff.org/medicare/issue-brief/turning-medicare-into-a-premium-support-system-frequently-asked-questions/, is an excellent breakdown of what a "Premium Support" structure – also referred to as "Defined Contributions" or "Vouchers"  – would mean for Medicare and Medicare beneficiaries. Topics addressed include:What is premium support? How could a premium support system for Medicare affect beneficiaries’ premiums and out-of-pocket ...

Democratic and Republican Party Platforms: Side-by-Side Comparison of Issues Important to Medicare Beneficiaries July 20, 2016

Platform Side-by-Side Suggested Medicare/Healthcare Priorities Language Originally Submitted to Platform CommitteeThe two major American political parties have released their 2016 party platforms in anticipation of their respective party conventions and the upcoming general election. Given the importance of health care in this upcoming election, the Center for Medicare Advocacy has done an initial analysis of the ...

Proper Use of Electronic Health Records Could Enhance Patient Care July 14, 2016

If properly utilized, Electronic Health Records (EHR) could increase the quality of care for Medicare’s beneficiaries and lower program costs. EHRs provide the possibility of easy transfer of information between providers, and better patient access to important information. This can mean that clinicians are apprised of changes in health status, with access to information regarding ...

President Calls On Congress to Add a Public Option to the Affordable Care Act July 13, 2016

As reported this week in The Hill, President Obama is calling on Congress to add a “public option” to the Affordable Care Act (ACA) to improve his signature health law.  “Public programs like Medicare often deliver care more cost-effectively by curtailing administrative overhead and securing better prices from providers,” Obama writes in the Journal of the ...

Center for Medicare Advocacy Submits Comments on Proposed MACRA Rule June 29, 2016

The Center for Medicare Advocacy submitted comments this week to the Centers for Medicare & Medicaid Services (CMS) concerning the proposed rule on the Medicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule (CMS–5571–P), two elements proposed in the Medicare Access and CHIP Reauthorization Act of ...

Center Comments on Proposed Rules for Medicare Skilled Nursing Facilities June 22, 2016

The Center for Medicare Advocacy’s comments on the Medicare prospective payment system for skilled nursing facilities (SNFs), submitted June 20, 2016, support the recommendation of the Medicare Payment Advisory Commission (MedPAC) not to increase reimbursement to SNFs for FY 2017.  MedPAC reports that SNFs have enjoyed Medicare margins exceeding 10% for 15 consecutive years. With respect ...

Yet Again, Value-Based Purchasing Did Not Improve Quality December 16, 2015

The federal government’s funding of a value-based purchasing (VBP) demonstration project in the Medicare Advantage (MA) program did not improve quality of care, as measured by the plans’ five-star quality ratings. The findings from this demonstration are the most recent evidence that paying health care providers more to provide better care, or to improve their ...

Solution to Medicare Part B Cost Increases? Look at “Outpatient” Observation Status October 23, 2015

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 misguided ...

Center Submits Comments to CMS Proposal Concerning Medicare Advantage Value-Based Insurance Design Model September 17, 2015

On September 1, 2015, the Centers for Medicare and Medicaid Services (CMS) issued an announcement concerning a demonstration called the Medicare Advantage (MA) Value-Based Insurance Design (VBID) model. (See: http://innovation.cms.gov/Files/x/mavbid-announcement.pdf.)  As described by CMS, Value-Based Insurance Design (VBID) “generally refers to health insurers’ efforts to structure enrollee cost-sharing and other health plan design elements to encourage ...

Reports of Import – Trustees and Kaiser Family Foundation July 23, 2015

Medicare Trustees Report – Medicare Part A Solvency Remains Stable On July 22, 2015, the Medicare and Social Security Trustees issued the 2015 Annual Report of the Boards of Trustees of the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund. Good News: In short, the projected solvency of the Part A Trust ...

Bundling Payments for Post-Acute Care May 14, 2015

The traditional Medicare program pays individual health care providers for the specific services and care they provide to beneficiaries and guarantees that patients have “freedom of choice” to select their Medicare providers.  A current focus of Congress and policymakers is changing Medicare payment policy to pay, instead, for episodes of care for beneficiaries.  One issue ...

Center Attorneys Meet with Senate Finance Committee Staff Members About Changes to Medicare Appeals Process May 7, 2015

The Medicare appeals system is not working. The success rate at the first two levels of appeal is staggeringly low for beneficiaries. It can take years to get an ALJ hearing decision – the third level of appeal, and the first real opportunity to get a coverage denial reversed. As we’ve previously reported, the Senate Finance ...

Senate Finance Committee Holds Hearing on Medicare Appeals Backlog – Proposed Solutions Are of Great Concern April 30, 2015

On April 28, 2015, the Senate Finance Committee held a hearing entitled “Creating a More Efficient and Level Playing Field: Audit and Appeals Issues in Medicare.” As noted by Chairman Hatch in his opening statement, Medicare’s hiring of contractors to conduct audits of claims submitted to Medicare “has led to a seemingly insurmountable increase in appeals, with ...

Congress Passes “Doc Fix” – Senate Unable to Improve the Bill for Medicare Beneficiaries April 16, 2015

On April 14, 2015, the Senate overwhelmingly (92 to 8) passed H.R. 2 – the Medicare and CHIP Reauthorization Act (MACRA) – which repeals and replaces the flawed Medicare physician reimbursement system known as the sustainable growth rate or SGR.  The House of Representatives passed its own bill, H.R. 2 (392 to 37), on March ...

Medicare Myths vs. Facts – “Doc Fix” Edition April 9, 2015

In the spirit of aiding the discussion concerning the budget and the SGR “Doc Fix,” we raise many of the myths surrounding Medicare and answer them with facts. Congress is working to repeal and replace the Sustainable Growth Rate (SGR) — also known as the “Doc Fix.”  The House version of the SGR bill asked too much ...

Observation Status Bills Reintroduced in Both the House and the Senate (H.R. 1571/S. 843) March 26, 2015

For the last several years, the Center has been trying to address the problem of Observation Status in the hospital, which can affect both what Medicare beneficiaries pay for hospital stays, and their coverage of subsequent care in a nursing facility.  For the last several sessions of Congress, bills have been introduced to try to ...

“Doc Fix” Package Passed by House Takes Too Much from Beneficiaries with Too Little In Return March 26, 2015

Today, March 26, the House of Representatives passed the Medicare Access and CHIP Reauthorization Act of 2015 (H.R. 2).  While the Center for Medicare Advocacy believes it’s in the best interest of Medicare beneficiaries to find a permanent solution to the broken physician payment formula called the “Sustainable Growth Rate” (SGR), this Bill is not ...

No Way to Celebrate Medicare’s 50th: Proposed Congressional Budgets Offer More of the Same, Less for Medicare and Beneficiaries March 18, 2015

Today the Senate releases its budget, which like the companion House budget released yesterday, appears to have significant cuts to the Medicare program.  Yet again, yesterday’s House budget includes a proposal to create a “premium support” – or voucher – option for future Medicare beneficiaries, starting in 2024. Medicare vouchers would convert much of Medicare ...

Ongoing “Doc Fix” Negotiations March 18, 2015

Unless Congress takes action by March 31, 2015, doctors who treat Medicare patients will see a 21% payment cut due to the current physician payment formula called the "sustainable growth rate" or "SGR."  Lawmakers have deferred the cuts prescribed by this 1997 reimbursement formula 17 times. These “patches” have been temporary because Congress has not ...

The President’s Proposed FY 2016 Budget: The Impact on Medicare February 5, 2015

On Monday, February 2nd, President Obama unveiled his Fiscal Year 2016 Budget. With respect to Medicare, this year’s proposed budget is very similar to last year’s, both good and bad, with ...

Medicaid-Medicare Dual Eligible Updates December 4, 2014

Over 9.6 million older people and people with significant disabilities are dually eligible for both Medicare and Medicaid. Dual eligible beneficiaries are among the poorest and sickest beneficiaries covered by either program. The dual eligible demonstration projects, developed pursuant to the Affordable Care Act (ACA), aim to improve coordination of services between Medicare and Medicaid, ...

Center Executive Director Judith Stein Testifies Before House Energy & Commerce Committee about Medicare Advantage Plans March 13, 2014

On March 13, 2014, Center for Medicare Advocacy Executive Director and Founder Judith Stein testified before the House Energy & Commerce Committee, Subcommittee on Health, at a hearing entitled "Keeping the Promise: Allowing Seniors to Keep Their Medicare Advantage Plans If They Like Them."   That testimony is summarized below. The Center for Medicare Advocacy recognizes that ...

The President’s Proposed FY 2015 Budget: The Impact on Medicare March 6, 2014

This week, President Obama unveiled his Fiscal Year 2015 Budget. With respect to Medicare, it is very similar to last year’s proposed budget, both good and bad. One significant improvement over last year's budget is that it no longer seeks to alter the way the federal government measures inflation for purposes of paying Social Security benefits by ...

Replacing the Broken Medicare Physician Payment Formula: At What Cost for People with Medicare? December 19, 2013

Overview The current Medicare physician payment formula, known as the "Sustainable Growth Rate" (SGR), was designed to control the growth in aggregate Medicare expenditures for physicians' services.    If implemented as intended under the law, the SGR would lead to significant cuts to physician payment (for example, if the SGR were to go into effect in 2014, ...

Medicare Prescription Drug Rebate Debate November 21, 2013

The Medicare Part D Prescription drug program is forbidden by law from getting the best prices for prescription drugs. Unlike the Veterans Administration and Medicaid, Medicare is at the mercy of drug company pricing, forbidden from seeking lower prices for its enrollees. Allowing Medicare to get fair drug prices would save billions of taxpayer dollars a year, without hurting ...

Caution: Home Health Episode Payment Caps October 10, 2013

Legislation was introduced on October 4th that could lead to a cap on the home health services available to a Medicare beneficiary.  In the midst of a government shutdown, Representatives Matheson (D-Utah) and Guthrie (R-Kentucky) introduced the "Medicare Home Health Fraud Reduction Act" (H.R. 3245).  This bill would establish maximum annual reimbursements to Medicare home ...

Happy Birthday, Medicare! July 25, 2013

Next week, Medicare celebrates its 48thbirthday.  Since 1965 Medicare has been a critical source of health and economic security for generations of Americans while evolving to meet the needs of those who rely on the successful program. Medicare brought millions of older Americans out of poverty, and continues to provide access to comprehensive health care ...

The Medicare Improvements for Patients and Providers Act: Improving Enrollment in the Medicare Savings Program Five Years Later July 11, 2013

Five years ago this month, the Medicare Improvements for Patients and Providers Act (MIPPA) became law. Since then, MIPPA has successfully increased enrollment in the Medicare Savings Program and helped ensure that thousands of Medicare beneficiaries are able to afford necessary medical care. Despite MIPPA's success, Medicare low-income programs remain under-enrolled. Federal policy makers should ...

New Report: Immigrants and Immigration Reform are Good for Medicare June 6, 2013

A new study published in Health Affairs reports that immigrant workers in the United States disproportionately contribute to the Medicare Program and help ensure its financial solvency and strength. The study's authors found that between 2002 and 2009, $115 billion of the Medicare Trust Fund was generated solely by immigrants.  The Medicare Trust Fund pays ...

Good News: Trustees Project Longer Medicare Solvency May 31, 2013

Today, the Medicare Trustees issued their annual report on Medicare's financial status.   According to this year's report, the Part A (Hospital Insurance) Trust Fund has sufficient reserves to fully pay Medicare benefits until 2026 – two more years than projected in last year's report.  Since 1970, the Trustees have projected the Medicare Trust Fund would be ...

Center for Medicare Advocacy Submits Joint Testimony to Congress on Medicare Reform Proposals May 23, 2013

This week, the House Ways and Means Subcommittee on Health held a hearing on proposals to reform Medicare at which critical issues facing the Medicare program and current and future beneficiaries were discussed. The Center for Medicare Advocacy, together with California Health Advocates and the Medicare Rights Center, submitted joint testimony to the Committee outlining ...

CMS Addresses Observation Status Again… And Again, No Help for Beneficiaries May 16, 2013

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 ...

Debunking Medicare Myths: Drug Rebates for Dual Eligibles May 8, 2013

In the midst of ongoing budget discussions, policymakers are considering a wide array of approaches for cutting spending and saving federal dollars. The Center for Medicare Advocacy recently wrote of ways to strengthen the Medicare program while achieving significant savings. Included in our analysis was a proposal that would save taxpayers billions of dollars: reinstating ...

Medicare’s Future: Letting the Affordable Care Act Work, While Learning From the Past May 7, 2013

This article is part of a NAELA Journal symposium edition that focuses on "The Future of Elder Law and Special Needs Planning." This article will provide an overview of the policy debate that led to the creation of the Medicare program.  It will identify key cost and quality problems facing the program and review solutions included ...

Privatization: Not Right for Medicaid, Not Right for Medicare April 25, 2013

The role of private managed care in Medicare and Medicaid has been growing at a rapid pace in recent years. The Center for Medicare Advocacy has written widely on the dangers of turning these successful community health care programs over to profit-driven private insurers.  Despite the efforts of the Center and other advocacy groups, however, ...

Medicare Paid $5.1 Billion to SNFs that Did Not Provide Care-Planning and Discharge-Planning (February 2013 OIG Report) April 18, 2013

In its most recent report on nursing home payments and quality, February 2013, the Office of Inspector General (OIG), Department of Health and Human Services (HHS) reports that many skilled nursing facilities (SNFs) failed to provide adequate care planning and discharge planning to residents and provided "egregious" care to some residents, yet were paid by ...

The Impact of the President’s Budget on People Who Depend on Medicare and Social Security April 11, 2013

Yesterday, President Obama unveiled his Fiscal Year 2014 Budget.   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 ...

Medicare Benefit Redesign: Proposals to Restructure Could Hurt More than Help April 4, 2013

The Medicare program can be confusing for those trying to navigate the differences between Parts A, B, C, and D.  Since the program's inception in 1965, changes made to the program have made it a more complex system for beneficiaries, particularly with the introduction of private insurance plans to the Medicare program.  Medicare beneficiaries can ...

Happy Anniversary, Affordable Care Act March 21, 2013

Since the landmark Affordable Care Act (ACA) was signed into law on March 23, 2010, it has increased access to needed health services, reduced costs and improved care for millions.  Yet, as this progress continues and the law’s most impactful provisions near implementation, threats to the law continue, through repeal efforts, budget cuts and legal ...

Medicare Advantage “Cuts?” Don’t Believe it. March 14, 2013

The Affordable Care Act (ACA) is beginning to rein in Medicare Advantage (MA) overpayments by bringing MA payment more in line with what traditional Medicare spends on a given beneficiary.  The insurance industry is not only fighting this payment reform, but has launched a campaign against a 2.3% reduction in payment projected for 2014.   This ...

Medicare and Mental Health March 14, 2013

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 ...

Protect Medicare: Reject Paul Ryan’s Budget Proposal March 14, 2013

Statement of Judith Stein, Executive Director, Center for Medicare Advocacy Nothing new. Paul Ryan’s “new” budget proposal recycles ideas that will harm older people, people with disabilities, families and Medicare. It is a plan about a governing philosophy, not about saving money, preserving Medicare, or reducing the national deficit. We know we need action to keep Medicare ...

Honor Women’s History Month: Preserve a Strong Medicare Program March 7, 2013

March is Women's History Month, honoring generations of women who have made, and are making, invaluable contributions to society. The Medicare program has been a critical lifeline for American women and their families for decades, contributing to lower poverty rates and providing health and economic security. Because women constitute the majority of beneficiaries on Medicare, ...

Center for Medicare Advocacy Testifies on Medicare Redesign February 26, 2013

In testimony submitted today to the U.S. House Committee on Ways & Means, California Health Advocates, the Center for Medicare Advocacy, Inc. and the Medicare Rights Center urged lawmakers to reject Medicare redesign proposals that burden older adults and people with disabilities with added health care costs. The joint statement pressed policy makers to adopt ...

Translating DC-Speak: What Deficit Proposals Mean for Medicare Beneficiaries February 14, 2013

As policymakers in Washington continue to debate ongoing budget issues involving federal spending and the deficit, proposals that affect Medicare beneficiaries remain on the table as targets for federal savings. However, the details and repercussions of proposals for people who rely on Medicare, Social Security, and Medicaid for health and economic security remain unknown for ...

Nursing Home Enforcement by United States Attorneys: What Happened to the Regulatory System? February 7, 2013

Two recent cases – one in Georgia and the other in Pennsylvania – enforce nursing home quality of care standards through actions by United States Attorneys.   In neither case had the regulatory agencies cited deficiencies for the significant care problems at the three facilities in question.   In addition, two of the three facilities have high ...

Study Shows High Cost-Sharing Significantly Harms Family Health and Finances February 1, 2013

A new study out this month in the Annals of Family Medicine highlights the reality facing many people with health insurance and Medicare and their families: high out-of-pocket costs and cost-sharing.  These costs have a considerable effect on their household budgets and decisions about their care. The study explored the social, medical, financial, and legal consequences ...

Medicare Facts and Fiction: Costs and Spending Edition January 10, 2013

In the past few weeks, the media spotlight on the country's fiscal issues has led to a flurry of attacks on Medicare. Pundits and some policymakers decry Medicare spending as "the largest driver of the federal debt" and argue that the program on which millions of American families rely is unsustainable and must be radically ...

Notes from the Cliff: The Deal and Its Impact on Medicare January 3, 2013

This week, the U.S. House of Representatives voted to approve legislation passed by the Senate to address  the "fiscal cliff"- the concurrent expiration of tax cuts and the beginning of automatic spending cuts (the Sequester) set to take place on January 1st. The deal, also known as the American Taxpayer Relief Act  (the Relief Act), ...

Putting a Donut Hole Back in Medicare: Proposals to Increase Medigap Costs Put Vulnerable Beneficiaries at Risk December 20, 2012

Among proposals aimed at reducing federal spending for Medicare, some are suggesting that Medigap insurance be restructured to increase the cost-sharing burden on beneficiaries and/or add a surcharge for those that choose plans offering "first-dollar" or "near first-dollar" coverage.   These proposals operate under the assumption that charging beneficiaries more in up-front, out-of-pocket costs will deter ...

Warning: Medicare Payment Limits Are Bad for Health! December 13, 2012

One of the deficit reduction proposals being discussed to achieve savings from Medicare is to introduce new cost-sharing for home health care. As a means to ward off such potential home health co-payments, some instead suggest capping Medicare payment for episodes of care, effectively limiting the duration of time individuals could access home health services. ...

Special Report – Independence of Medicare Administrative Law Judges Threatened by Office of Inspector General’s Recommendations December 6, 2012

In November, the Office of Inspector General (OIG) issued a report entitled, "Improvements are Needed at the Administrative Law Judge Level of Medicare Appeals."  The report can be found at https://oig.hhs.gov/oei/reports/oei-02-10-00340.pdf.   In the report, the OIG interprets the overall percentage of fully favorable decisions awarded to appellants by Administrative Law Judges (ALJs) as evidence that ...

Annual Medicare Payment Limits for Home Health – Even Worse Than Co-Pays for Beneficiaries December 5, 2012

The Center for Medicare Advocacy has represented Medicare beneficiaries since 1986. As one of the few advocacy organizations in the nation solely serving Medicare beneficiaries, we strongly oppose home health episodic payment caps or any other such defined payment limits. The counterpart to this notion, caps on outpatient therapy, has created significant barriers to necessary ...

Raising the Medicare Eligibility Age: A Costly and Dangerous Proposal November 29, 2012

Despite Medicare's remarkable success as a health and economic lifeline for American families, proposals to dramatically alter the program have resurfaced in the context of deficit reduction. While not a new idea, proponents of increasing Medicare's eligibility age from 65 to 67, or higher, have put the proposal in the spotlight recently as policymakers search ...

Deficit Reduction and Medicare: Save Money Without Harming Beneficiaries November 15, 2012

Although passage of the Affordable Care Act (ACA) has achieved considerable savings for the Medicare program, Medicare is still being targeted by policymakers looking to negotiate a large "grand bargain" deficit-reduction package. Many of the proposals to achieve Medicare savings would shift costs from the federal government to Medicare beneficiaries As the debt and deficit debate ...

The Affordable Care Act Moves Forward: What’s Up for 2013 November 8, 2012

Over two years after becoming law, the Affordable Care Act (ACA) continues to improve health care and lower costs for millions of Americans, including those who rely on Medicare. The recent election was key to the future of the landmark legislation, which will expand access to health care coverage and work to improve quality of ...

Medicare and ACA Facts and Updates; Jimmo Update November 1, 2012

Medicare: Just the Facts! Misinformation about Medicare and the Affordable Care Act is widespread and increasing as the election nears.  Below, we try to dispel misinformation and base discussions on a factual foundation.  Spread the word. Help set the record straight!The FactHere's WhyThe Affordable Care Act does NOT cut Medicare for beneficiaries.The Affordable Care Act achieves ...

CMA in Action: Judith Stein Testifies in Congress on the Ryan Plan to End Medicare October 4, 2012

DEMOCRATIC HOUSE STEERING AND POLICY COMMITTEE FORUM SAVING MEDICARE FOR TODAY AND IN THE FUTURE October 2, 2012 _____________________ Leader Pelosi and members of the Committee, thank you for holding this important Forum and for honoring me with the opportunity to appear before you. I am Judith Stein, founder and executive director of the Center for Medicare Advocacy, Inc.  Founded ...

Making Sense of Medicare’s Preventive Service Benefits September 20, 2012

September 20, 2012 With the Balanced Budget Act of 1997 (BBA1997), Congress began an expansion of preventive benefits and services available through Medicare.  Finally, the Patient Protection and ...

Medicaid, Long Term Care and the Ryan Budget September 10, 2012

As reported in the New York Times on Friday September 7, 2012, Center Attorney Toby Edelman writes to explain the importance of Medicaid to long-term care recipients, and how the Ryan Budget, which purports not to affect current Medicare beneficiaries, would actually have an "immediate and devastating impact" on those who rely on this vital program.In ...

How the Ryan Budget (and Republican Platform) Would Hurt Current Nursing Home Residents August 30, 2012

In March 2012, the House of Representatives passed the House Budget Committee Fiscal Year 2013 Budget Resolution, The Path to Prosperity: A Blueprint for American Renewal – called here, the Ryan Budget.   In August 2012, the Republican Party adopted the Ryan Budget's principles for Medicare and Medicaid in its Platform for 2012, We Believe in ...

We Don’t Need the Ryan Plan − Medicare Is Not Going Broke August 30, 2012

According to researchers from the Urban Institute, writing in the New England Journal of Medicine, Medicare's purported dire financial condition isn’t actually all that dire.  Given the aging of our population, increases in enrollment have obviously contributed to spending growth. But, according to the Urban Institute, “in recent years "spending growth per enrollee slowed in ...

The $700 Billion Medicare Myth August 16, 2012

Medicare has been front and center in the media and on the campaign trails this week. As part of our Medicare Truth Squad efforts to debunk myths and claims about the Medicare program, today we focus our attention on a pervasive myth that keeps going around. Some policymakers, candidates, and members of the media have been ...

Organizations Unite to Urge Caution in Demonstration Programs Serving Low-Income Medicare Beneficiaries July 26, 2012

Noting that "e are excited about the demonstrations and would like them to succeed," the Center for Medicare Advocacy (the Center), and thirty-two other national consumer advocacy and provider organizations have called on the Centers for Medicare & Medicaid Services (CMS) to scale back the scope, size, and timing of state-based demonstrations that would change ...

House Votes for 33rd Time to Repeal Health Reform July 12, 2012

Yesterday, the House of Representatives voted once again to repeal the Affordable Care Act with a 244-185 vote. Despite the Supreme Court affirming the law, House leaders proceeded in scheduling yet another vote to end it – the 33rd such attempt. Meanwhile, more data has been released showing the Affordable Care Act continues to help millions ...

Good News for Medicare: Supreme Court Upholds Affordable Care Act July 5, 2012

Last week, the Supreme Court upheld the constitutionality of the Affordable Care Act (ACA), but did place potential limits on the Medicaid expansion portion of the law. The several opinions by the Justices are lengthy (a total of 193 pages in the "slip opinion" released by the Court and 81 pages in the version published ...

Supreme Court Upholds Health Care Reform, Including Improvements to Medicare June 28, 2012

Today, the Supreme Court of the United States issued a landmark decision upholding the Affordable Care Act (ACA). The individual mandate, in addition to other provisions – including those that improve Medicare – was ruled constitutional. The law can now continue to help older and disabled Americans, children with special needs, people with pre-existing conditions, women, ...

Cut Through the Rhetoric: Questions to Ask After the Supreme Court ACA Decision June 22, 2012

Originally Published at Nieman Watchdog, in ASK THIS, June 14, 2012 (available at http://niemanwatchdog.org/index.cfm?fuseaction=ask_this.view&askthisid=00569), we offer reporters and editors a checklist for stories when the Supreme Court rules on the Affordable Care Act (ACA): 1. Did the Court strike down (or uphold) the entire law?   2. If the entire law is struck down:What will happen to the Medicare Part D Donut ...

MedPAC Reviews Blending Medicare and Medicaid June 21, 2012

Introduction In its June 2012 Report to the Congress, the Medicare Payment Advisory Commission (MedPAC) included an examination of current options and activity with respect to programs that integrate – or have the potential to integrate – Medicare and Medicaid services and financing for those individuals with coverage from both programs, often referred to as dual ...

A Reporter’s Checklist for the Impending Obamacare Ruling June 15, 2012

Originally Published at Nieman Watchdog, in ASK THIS, June 14, 2012 Health care expert Judith Stein, director of the Center for Medicare Advocacy, offers reporters and editors a checklist for stories when the Roberts Court's ruling on the Affordable Care Act is released. The Center for Medicare Advocacy suggests reporters and editors consider the following when they review ...

Center for Medicare Advocacy in Congress, Voicing Concerns on Behalf of Beneficiaries May 10, 2012

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 ...

Affordable Care Act in Action: People with Medicare Continue to See Savings May 3, 2012

New data released this week shows that families and individuals who rely on Medicare continue to see direct benefits from the Affordable Care Act by saving billions of dollars on prescription drug costs. So far in 2012, older and disabled Americans have saved an average of $837 on their drug purchases after reaching the donut-hole ...

Rewarding Mediocrity: GAO Report Concerning Medicare Advantage “Bonus” Payments April 26, 2012

On April 23, 2012, the Government Accountability Office (GAO) released a report that concludes, among other things, that a Medicare demonstration program providing bonus payments to Medicare Advantage (MA) plans mainly benefits plans whose performance is no more than average.  While the program is supposed to reward quality, in practice it largely rewards plans receiving ...

Fact vs. Fiction: Medicare is Not Going “Bankrupt” April 26, 2012

Medicare Trustees issued their annual report on Medicare's financial status on April 23, 2012.  According to this year's report, the Hospital Insurance (Part A) Trust Fund has sufficient reserves to pay out the full amount of Medicare Part A benefits until 2024 – the same projection made in last year's report.  Should nothing else change, ...

Toby Edelman Statement to Senate Committee Regarding Antipsychotic Drugs in Nursing Facilities April 19, 2012

The Future of Long-Term Care: Saving Money by Serving Seniors Senate Special Committee on Aging April 18, 2012 2:00 p.m. Statement for the Record Toby S. Edelman Senior Policy Attorney Center for Medicare Advocacy 1025 Connecticut Avenue, NW, Suite 709 Washington, DC  20036 The Center for Medicare Advocacy suggests that huge savings in the cost of care in nursing facilities could be achieved if facilities ...

Medicare Under Threat: Health Reform Versus the Ryan Budget April 5, 2012

Last week, two separate, but related, events in Washington added to the threats facing the Medicare program.  First, the Supreme Court heard oral arguments in a case challenging the constitutionality of the Affordable Care Act (ACA), otherwise known as Health Care Reform.  An adverse decision would potentially roll back Medicare improvements that have already begun. ...

Health Care Reform On Trial March 29, 2012

This week, the Supreme Court heard arguments over the constitutionality of the Affordable Care Act (ACA, or health care reform).  As we wrote last week, ACA helps millions of American families by extending health care to those who are either uninsured or underinsured. As the arguments before the Court have revealed, the path to health ...

The Second Anniversary of Health Care Reform is Good News Will There be a Third? March 21, 2012

It's been two years since President Obama signed the landmark Affordable Care Act (ACA) into law on March 23, 2010.  When fully implemented, ACA will provide access to health insurance for virtually all Americans.  Along the way to full implementation, ACA has already helped American families gain access to needed care, while reducing costs and ...

Bad Apples: Combating Medicare Fraud While Ensuring Access for Beneficiaries March 8, 2012

News and investigations of waste, fraud, and abuse in the Medicare program have made waves in the past few weeks. Recently, the Department of Justice uncovered a massive $375 million fraud scheme committed by several providers of Medicare-covered home health care services in Texas. Such an egregious case is indeed shocking and offensive, and federal ...

Congressional Subcommittee Examines Issues of Dental Health March 8, 2012

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 ...

The President’s Proposed 2013 Budget: Impact on Medicare February 17, 2012

This week, President Obama unveiled his Fiscal Year 2013 Budget.  Overall, the Center for Medicare Advocacy believes that the budget demonstrates a commitment to  keeping the Medicare program strong and keeping the program's promise to older Americans and individuals with disabilities who rely on the program to provide quality, affordable health care.  The Center is ...

Investing in Our Future: Strengthening Medicare for 2012 and Beyond February 9, 2012

This year brings another election season, another Congressional session, and another opportunity to fortify Medicare, both for those who rely on it now and for future generations. Medicare has been strengthened during the past few years.  However, dangerous rhetoric and schemes to weaken and dismantle the program threaten the health and economic security of millions ...

Payroll Tax Extension Includes Important Provisions for Medicare Beneficiaries December 29, 2011

The payroll tax extension that finally became law on December 23, 2011 includes many provisions that will help Medicare beneficiaries and lower income families (Temporary Payroll Tax Cut Continuation Act of 2011, H.R. 3765; no public law number assigned yet). The payroll tax in question is a reduction in Social Security payroll tax paid by ...

Forcing Dual Eligibles Into Private Health Plans is No Quick Fix November 22, 2011

The nearly nine million Medicare beneficiaries who are also eligible for some form of Medicaid, the so-called dual eligibles, are the subject of federal, state and local policy discussions because many of them are among the highest users of health care services in the country and thus are very costly to both Medicare and Medicaid.  ...

Supercommittee Update November 17, 2011

With six days left until their November 23rd deadline, the Supercommittee has yet to reach a deal that meets its target of achieving $1.2 trillion in federal savings. Republicans on the panel tasked with reducing the deficit have indicated their latest proposal, which seeks to lower the top tax rate in exchange for closing certain loopholes ...

Health Care Reform Update: Where Are We, and What’s Up for 2012? November 10, 2011

The Affordable Care Act (ACA), passed in March 2010, has been implemented steadily over the past two years. ThisAlert will review some of the important ...

Breaking Good News for Medicare Beneficiaries October 27, 2011

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 slightly ...

“Skin in the Game,” Health Equity and Deficit Reduction October 13, 2011

"Patients should pay more for their health care." Both Republicans and Democrats, including President Obama, promote policies to increase patients' costs as a solution to curbing the use of "inappropriate" health care services and controlling health care costs.  The President's plan for deficit reduction refers to this idea as creating incentives for the use of ...

Medigap – Fact & Fiction October 13, 2011

Nearly one in five Medicare beneficiaries rely on Medicare Supplemental insurance policies (Medigap) to fill in the gaps of some of their Medicare coverage.  As noted by the Kaiser Family Foundation, "Medigap policies help shield beneficiaries from sudden, relatively high out-of-pocket costs due to an unpredictable medical event, and also allow beneficiaries to more accurately ...

The President’s Plan for Economic Growth and Deficit Reduction: A First Look at the Impact on Medicare September 29, 2011

Last week, President Obama unveiled his recommendations to Congress's Joint Select Committee on Deficit Reduction ("Super Committee").  The proposal includes $320 billion in savings from ...

CMS to Begin Round Two of Its Competitive Bidding Program for the Provision of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) September 1, 2011

On August 19, 2011, the Centers for Medicare & Medicaid Services (CMS) announced Round 2 of its DMEPOS competitive bidding program.  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 be ...

Medicare Reimbursement For Skilled Nursing Facilities Remains High For 2012 Despite Reductions In Overpayments August 25, 2011

In final rules setting out Medicare reimbursement rates for skilled nursing facilities (SNFs) for Fiscal Year (FY) 2012 (which starts October 1, 2011), the Centers for Medicare & Medicaid Services (CMS) reduced reimbursement by $3.87 billion, or 11.1%.  The reduction was targeted, correcting the "unintended excess payments" that occurred in therapy-related reimbursement for FY 2011, ...

Raising the Medicare Eligibility Age Will Actually INCREASE Costs August 25, 2011

  Policymakers and pundits continue to propose Medicare changes that would have severe repercussions for beneficiaries and their families. These proposals will continue to make news as deficit discussions heat up.  Too often, however, they are based on false information, which is repeated as fact by the media, pundits and policymakers. We aim to correct public misinformation about Medicare.  Medicare Works. ...

Medicare Facts & Fiction: 3 More Lessons to Combat Medicare Spin August 16, 2011

Congress continues to propose Medicare changes that will have severe repercussions for beneficiaries and their families. Policymakers and pundits are feeding the media and the public misinformation about Medicare. The truth is, most people with Medicare are low-income and most pay more for health care than other insured Americans.  Nonetheless, Medicare Works. For 46 years it has ...

Amended Appeal Rules for Employer and Individual Health Plans August 11, 2011

On June 24, 2011, the Centers for Medicare & Medicaid Services (CMS), in conjunction with the Internal Revenue Service (IRS) and the Employee Benefits Security Administration (EBSA), released amendments to a set of interim final rules regarding claims and appeals review processes that were originally published in July 2010. The rules and amendments implement requirements of ...

Medicare Facts & Fiction: 3 Quick Lessons to Combat Medicare Spin August 9, 2011

  Congress continues to propose Medicare changes that will have severe repercussions for beneficiaries and their families. Policymakers and pundits are feeding the media and the public misinformation about Medicare. The truth is, most people with Medicare are low-income and most pay more for health care than other insured Americans.  Nonetheless, Medicare Works. For 46 years it has ...

What Does the Debt Ceiling Agreement Mean for Medicare? August 4, 2011

This week, Congress passed, and the President signed, the Budget Control Act of 2011.  The bill raises the nation's debt ceiling and makes debt and deficit reductions in federal spending over the next 10 years.  Between now and Thanksgiving 2011, a new Joint Committee of Congress will be tasked with seeking $1.2 to $1.5 trillion ...

New Initiatives to Improve Services for Dual Eligibles July 15, 2011

The Centers for Medicare & Medicaid Services (CMS) recently announced several new initiatives focused on improving care for people who are eligible for both Medicare and Medicaid (dual eligibles). Two initiatives relate to providing fully integrated services to dual eligibles, through both capitation and fee-for-service structures.  A third initiative addresses preventing unnecessary hospitalizations of nursing home residents, ...

House Plans Vote to Slash Medicare and Social Security through Balanced Budget Amendment July 15, 2011

Next week, the House of Representatives is scheduled to vote on a proposal that will directly impact and harm Medicare beneficiaries, Social Security recipients, and others that rely on critical safety net programs. The Goodlatte-Walsh Balanced Budget Amendment, H.J.Res.1, will come to a vote Wednesday, July 20. The bill requires Congress to pass a balanced ...

Recommendations for Beneficiary Protections In Models Approved by CMMI July 15, 2011

Introduction The Affordable Care Act includes a provision establishing a Center for Medicare and Medicaid Innovations (CMMI) that is authorized to test models to reduce Medicare and Medicaid expenditures while preserving or improving quality for beneficiaries of those two programs. The provision includes appropriations of $5 million for fiscal year 2010 and $10 billion for fiscal ...

Lower-Premium Pre-Existing Condition Insurance Plans Take Effect in Many States July 7, 2011

One year ago on July 1, 2010, Secretary of Health and Human Services Kathleen Sebelius announced the availability of new insurance coverage for individuals who were denied insurance because they had a pre-existing condition.  As required ...

Real Solutions to Save Medicare Dollars in Skilled Nursing Facilities June 30, 2011

For many years, advocates for nursing home residents have argued that when residents are denied good care, the costs of trying to treat and correct avoidable conditions and bad resident outcomes are high.  Advocates refer to this phenomenon as "the high cost of poor care."  Others identify the phenomenon as "the business case for quality."  ...

First Appellate Court Rules on Health Reform Law, Holds it Constitutional June 29, 2011

In a decision issued earlier today, the United States Court of Appeals for the Sixth Circuit issued the first appellate decision on the Patient Protection and Affordable Care Act (ACA, often referred to as Healh Care Reform) and held that it was constitutional.  Thomas More Law Center v. Obama, No. 10-2388 (6th Cir., June 29, ...

Why Medicaid Matters to People with Medicare June 16, 2011

Medicare and Medicaid, which together serve over 95 million Americans, or nearly one third of the U.S. population, are our two major national public health insurance programs offering secure and stable access to health care for beneficiaries, and peace of mind for their families. Last month's upset victory by Democrat Kathy Hochul in a traditionally Republican ...

So, What Would You Do? Real Solutions for Medicare Solvency and Reducing the Deficit June 9, 2011

Once again the House of Representatives’ leadership are proposing to change Medicare into a private voucher system. Their proposals would have severe repercussions for Medicare beneficiaries and their families. Sound solutions that would preserve Medicare coverage while reducing costs are still not being seriously addressed.  With the President on record as recommending that we lower Medicare's ...

New Rules for Medicare Advantage and Part D Plans June 2, 2011

On April 15, 2011, the Centers for Medicare & Medicaid Services (CMS) issued final regulations to provide policy and technical changes to the Medicare Parts C (Medicare Advantage) and D programs.  The regulations address concerns raised by Medicare beneficiary advocates, and implement provisions of the Affordable Care Act.  They also codify into regulation some existing ...

Many Uninsured Individuals with Pre-Existing Conditions Will Find It Easier to Obtain Coverage June 2, 2011

Individuals with pre-existing conditions who have been uninsured for six months may now find it easier to obtain coverage through the Pre-Existing Condition Insurance Plan (PCIP).  PCIP was created by the Affordable Care Act to provide interim coverage until the Health Insurance Exchanges are up and running in 2014. Twenty-seven states administer their own PCIP. ...

Combating Fraud, Waste and Abuse in Health Care May 26, 2011

Combating fraud, waste and abuse in health care and in other federal programs remains a popular refrain for reducing federal expenditures. In a survey conducted by AARP in September 2009, 80% of Medicare beneficiaries age 65 and older agreed that eliminating waste, fraud, and abuse in Medicare "should be at least one of the top ...

2011 Medicare Trustees Report May 19, 2011

The Medicare Trustees issued their annual report on Medicare's financial status on Friday, May 13, 2011.  According to this year's report, the Hospital Insurance (HI) Trust Fund has sufficient reserves to pay out the full amount of Medicare Part A benefits until 2024. Should nothing else change, and the Trust Fund reserves be depleted in ...

Send Us Medicare Summary Notices (MSNs) May 19, 2011

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 you ...

Preserve Medicaid – Share Your Story! May 19, 2011

The Center for Medicare Advocacy would like to bring to your attention this request from the National Academy of Elder Law Attorneys (NAELA) for stories about the importance of Medicaid.Do you provide time and financial support to a family member who receives Medicaid for nursing home services? Are you married to someone who is receiving ...

Proposed Notice Requirements About Quality of Care: Endorsement, with Concerns May 5, 2011

On April 4, 2011, the Center for Medicare Advocacy (the Center) filed comments on a proposal by the Centers for Medicare & Medicaid Services (CMS) to establish a new condition of Medicare participation (CoP) for certain Medicare service providers.  These providers would be required to give Medicare beneficiaries notice of the right to seek review ...

New Hospice Face-to-Face Requirement: Help or Hindrance? April 28, 2011

Eligibility for Medicare coverage of hospice care is contingent in part upon a hospice physician certifying that the beneficiary has a life expectancy of six months or less if the terminal illness runs its normal course.   In an effort to promote physician engagement in the process of certifying patients as eligible for the Medicare hospice ...

Senators Kerry and Snowe, with Representatives Courtney and Latham, Introduce Legislation to Ensure Skilled Care for Seniors April 26, 2011

Improving Access to Medicare Coverage Act of 2011 Section by Section Summary Sen. John F. Kerry & Sen. Olympia Snowe Section 1:  Short Title—"Improving Access to Medicare Coverage Act of 2011". Section 2:  Counting a Period of Receipt of Outpatient Observation Services in a Hospital towards the 3-Day Inpatient Hospital Requirement for Coverage of Skilled Nursing Facility Services under ...

Health Care Changes: Challenges to Medicare April 25, 2011

An article from NAELA Journal, Volume 7, Number 1, written by Center for Medicare Advocacy attorneys Vicki Gottlich, Patricia Nemore, and Alfred J. Chiplin Jr. Read it at: http://viewer.zmags.com/publication/4afec968#/4afec968/25 (external link)

What Happens to Current Nursing Home Residents if the House Budget Resolution Becomes Law? April 21, 2011

Under the proposed budget resolution passed by Republicans in the House of Representatives, nearly a million nursing home residents could immediately lose coverage for nursing home care.  Further, all of the standards that govern nursing home care today could disappear.  A study of the costs of nursing home care, released April 21, 2011 by John Hancock ...

25 Years of Medicare Advocacy, and Hope for 25 More April 14, 2011

In April 2011, the Center for Medicare Advocacy celebrates 25 years of advocating for, and on behalf of, older people and people with disabilities who rely on Medicare.  We started as a small organization in Connecticut, added a Data Unit in Maine, a policy office in Washington, D.C., and satellite offices in Tucson, Arizona, Massachusetts, ...

Keeping Medicare and Medicaid Strong? April 7, 2011

Medicare and Medicaid have been providing health insurance coverage to older people, people with disabilities, women, and families with children for more than 45 years.  These programs ensure that vulnerable populations who could not get health care coverage from private health insurance have access to basic health coverage. The futures of the Medicare and Medicaid programs ...

Why Medicaid Matters to Medicare Beneficiaries and Their Families April 1, 2011

Medicare and Medicaid, which together serve over 95 million Americans, are our two major national public programs offering secure and stable access to health care for beneficiaries, and peace of mind to the their families. Medicaid is under attack by proposals that would limit its scope and/or eliminate current program structures that provide important protections to ...

Happy Anniversary, Health Care Reform March 23, 2011

One year ago, on March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act, the Health Care Reform law that will provide access to health insurance for virtually all Americans. As the Center for Medicare Advocacy has reported over the past year, Health Care Reform is good for Medicare, good for ...

More Nurses in Nursing Homes Would Mean Fewer Patients Headed to Hospitals March 10, 2011

Nursing home residents are frequently hospitalized.  Residents who have recently been admitted from the hospital are frequently rehospitalized. are considered avoidable.  The 2010 National Healthcare Quality Report found that residents' hospitalization ...

The Burden of Out-of-Pocket Costs on Medicare Beneficiaries February 24, 2011

Medicare provides a vital foundation for the health and wellness of Americans who are 65 or older or have significant disabilities. The program currently covers a portion of health care costs for over 47 million individuals throughout the United States. While Medicare is critical in helping older people and people with disabilities pay for ...

New Hospice Regulations are a Mixed Bag for Beneficiaries Seeking High Quality End of Life Care January 20, 2011

Hospice care is available for Medicare beneficiaries who are certified by a hospice physician as having a life expectancy of six months or less if the terminal illness runs its normal course. In 1983, the hospice benefit was designed to cover approximately 210 days of care. There were four benefit periods: two 90 day periods, ...

New Regulations Are a Mixed Bag for Beneficiaries Seeking High Quality End-of-Life Care January 20, 2011

Hospice care is available for Medicare beneficiaries who are certified by a hospice physician as having a life expectancy of six months or less if the terminal illness runs its normal course. In 1983, the hospice benefit was designed to cover approximately 210 days of care. There were four benefit periods: two 90 day periods, ...

New Medicare Home Health Regulations: Improvement is Not Required to Obtain Coverage December 30, 2010

The Centers for Medicare & Medicaid Services (CMS) issued new regulations on November 17th regarding coverage for home health services. The new regulations clarify Medicare coverage for home health services, including physical therapy, occupational therapy and speech-language pathology services. The regulations are effective January 1, 2011; however, since they clarify rather than change coverage rules, ...

Medicare Changes Effective January 1, 2011 December 30, 2010

This Alert serves as a reminder about changes to Medicare that go into effect on January 1, 2011. 1.      The Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) competitive bidding program Beginning January 1, 2011, beneficiaries in nine areas around the country will have to get medical equipment and supplies through suppliers that have a contract with ...

Be Cautious Before Combining Medicare and Medicaid December 23, 2010

Concerned about the well-being and rights of dually eligible older and disabled people, 38 national, state and local advocacy organizations, individual advocates, and law professors sent the following letter to Secretary of Health and Human Services Kathleen Sebelius on December 13, 2010.  The letter urges her to promulgate regulations that would protect those dually eligible ...

CMA Alert: Medicare Home Health Regs: Improvement NOT Required; Also Extender Act and More December 12, 2010

CMA ALERT, DECEMBER 12, 2010New Medicare Home Health Regulations: Improvement is NOT Required to Maintain Coverage!Congress Passes the Medicare and Medicaid Extenders Act of 2010CMS Issues Corrected "Choosers" LetterRemember, You CAN Go Home for the Holidays!NEW MEDICARE HOME HEALTH REGULATIONS: IMPROVEMENT IS NOT REQUIRED TO OBTAIN COVERAGEThe Centers for Medicare & Medicaid Services ...

Health Care Reform Does Not Cut Medicare Benefits October 28, 2010

Health care reform does not cut Medicare benefits. In fact, health care reform expands Medicare coverage, by eliminating cost-sharing for preventive services, adding a yearly wellness visit, limiting some cost-sharing in private Medicare plans, and closing the Part D "Donut Hole." It also improves the solvency of the Medicare program itself. Reform does, however, change ...

Affordable Care Act Expands Medicare Coverage for Prevention and Wellness September 9, 2010

The Affordable Care Act (ACA) adds coverage for a new "Wellness Visit" and eliminates cost-sharing for almost all of the preventive services covered by Medicare, effective January 1, 2011. This Alert discusses both provisions. Wellness Visit Starting next year, Medicare will cover a new annual wellness visit and will provide payment for the creation of a personalized ...

Extended Observation Stays in Acute Care Hospitals: Criticism, Legislation and Discussion August 26, 2010

“Observation” is the term used to describe the outpatient status of a patient who is in a hospital, but not as an inpatient. Although the Medicare Manuals limit observation to 24-48 hours, many beneficiaries nationwide are experiencing extended stays in acute care hospitals under observation. A major consequence for beneficiaries of not being classified as ...

Medicare's 45th Anniversary: Promise Kept and Promises to Keep July 27, 2010

July 30th marks the 45th anniversary of Medicare. When President Johnson signed the Medicare program into law in 1965, he ushered in an era of better health and financial security for older Americans and their families. Medicare did what private insurance failed to do – provide health coverage for people age 65 and older. Over ...

The Right to Visit Partners and Others In Medicare Participating Hospitals June 22, 2010

The Centers for Medicare & Medicaid Services (CMS) has recently issued new rules for Medicare and Medicaid participating hospitals that require written policies protecting patients’ rights to choose their visitors during a stay in the hospital. The landmark rules ensure same-sex partners will have visitation rights, along with friends and other ...

Health Reform in Action: Donut Hole Rebate Checks Start Arriving June 10, 2010 June 10, 2010

Medicare beneficiaries who enter the prescription drug coverage gap (known as the "Donut Hole") anytime before the end 2010 should receive a one time $250 rebate check from Medicare.  The first checks, for people who hit the Donut Hole by March 31, 2010, should arrive around June 10, according to Secretary of the Department of ...

Don’t “Fix” Medicare Out of Existence March 19, 2008

Much of the current talk about the problems of Medicare misses the point. The proposals could end up "fixing" a successful program out of existence. Before supporting any fix, remember: Medicare has been a successMedicare assures the elderly and people with disabilities that neither they nor their families will have to bear the full burden of their ...

Myths About Nursing Home Tort Reforms April 18, 2003

The following is an executive summary. You can also view the full report here and the appendices here in .pdf form. The Center for Medicare Advocacy performed a study entitled Tort Reform and Nursing Homes that deflates the myths that pervade the nursing home industry’s discussion of tort litigation. It found that cases about nursing home abuses ...

Medicare Summary Articles

CMS Issues New “Medicare Beneficiaries at a Glance” Statistics September 28, 2022

A quick summary of who uses Medicare.

“Medicare & You” Continues to Reverse Bias Towards, and More Accurately Describe, Medicare Advantage September 28, 2022

Medicare & You handbook continues to improve, but there's room for more.

2023 Medicare Cost Sharing Released September 28, 2022

Part B Premium and deductible actually decrease for 2023.

CMS Releases Data re: Medicare and Medicaid March 17, 2022

Summary of Medicare & Medicaid enrollment numbers.

Medicare Platform: December 20, 2018

Core Considerations for Today & Tomorrow The Center for Medicare Advocacy works for a comprehensive Medicare program and quality health coverage and care for all people. To accomplish these goals for current and future beneficiaries in the changing health care environment, we seek to:Improve Medicare for current and future beneficiaries. Support the development of the best ...

2019 Medicare Cost-Sharing Announced October 18, 2018

Last week the Centers for Medicare & Medicaid Services released the Medicare premium, deductible and co-pay amounts for 2019.  Below are the 2019 cost-sharing amounts. Part A Premium (For those not automatically enrolled)0-29 qualifying quarters of employment: $437.00 30-39 quarters: $240.00Inpatient HospitalDeductible, Per Spell of Illness: $1,364.00 Co-pay, Days 1 – 60: $0 Co-pay, Days 61 – 90: ...

CMA Alert – You CAN Leave the Nursing Home; 2018 Cost-Sharing; Enrollment Reminder; Talk Turkey About Taxes November 21, 2017

Home for the Holidays: Leaving the Nursing Home During a Medicare-Covered Stay 2018 Medicare Cost Sharing REMINDER: Medicare Enrollment Continues through December 7th Tax Bill Facing Vote in the Senate Next Week – Time to Talk Turkey!Home for the Holidays: Leaving the Nursing Home During a Medicare-Covered Stay Late November begins a time for gatherings with family and friends ...

Medicare Annual Enrollment Period Has Begun – Ends December 7 October 19, 2016

Fall is the time for Medicare beneficiaries to explore their options regarding traditional Medicare, Part D prescription drug plans and Part C Medicare Advantage plans.  The Annual Coordinated Election Period (ACEP) starts on October 15th and ends on December 7th. This means that Medicare beneficiaries have to analyze their options and make choices by December ...

Minimal Social Security COLA Increase Will Likely Lead to Dramatic Part B Premium Increases for Some, Large Deductible Increase for All, Unless Congress Intervenes October 19, 2016

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 statute ...

People with Medicare Beware: COBRA Is Not Coverage as a “Current” Employee November 24, 2015

Caution Advocates have seen an increase in the number of Medicare beneficiaries who have delayed enrolling in Medicare Part B, thinking, erroneously, that because they are paying for and receiving continued health coverage under COBRA, they do not have to enroll in Medicare Part B.  COBRA-qualified beneficiaries who have delayed enrollment in Medicare Part B do ...

2016 Cost-Sharing Announced November 12, 2015

This week the Centers for Medicare & Medicaid Services released the Medicare premium, deductible and co-pay amounts for 2016.  As the Center for Medicare Advocacy has extensively reported, the Part B Premium, which was feared to spike outrageously for many beneficiaries, will instead remain the same for most, and increase far less for the rest.  ...

2015 Medicare Cost Sharing October 9, 2014

Hospital Deductible: $1,260.00 / Benefit period Hospital Coinsurance:Days 0-60: $0 Days 61-90: $315 / Day Days 91-150: $630/ DaySkilled Nursing Facility Coinsurance:Days 1-20: $0 Days 21-100: $157.50/ DayPart A Premium (For voluntary enrollees only)With 30-39 quarters of Social Security coverage: $224.00 / Month With 29 or fewer quarters of Social Security coverage: $407.00 / MonthPart BDeductible: $147.00 / Year Standard Premium: ...

Annual Enrollment for Medicare Advantage & Part D: October 15 – December 7 September 18, 2014

Fall is the time for Medicare beneficiaries to explore their options regarding Part D prescription drug plans and Part C Medicare Advantage plans.  The Annual Coordinated Election Period (ACEP) for Medicare Advantage and Medicare Part D prescription drug plans will start on October 15th and end on December 7th. This means that Medicare beneficiaries have to ...

Good News: Trustees Project Longer Medicare Solvency May 31, 2013

Today, the Medicare Trustees issued their annual report on Medicare's financial status.   According to this year's report, the Part A (Hospital Insurance) Trust Fund has sufficient reserves to fully pay Medicare benefits until 2026 – two more years than projected in last year's report.  Since 1970, the Trustees have projected the Medicare Trust Fund would be ...

Medicare’s Future: Letting the Affordable Care Act Work, While Learning From the Past May 7, 2013

This article is part of a NAELA Journal symposium edition that focuses on "The Future of Elder Law and Special Needs Planning." This article will provide an overview of the policy debate that led to the creation of the Medicare program.  It will identify key cost and quality problems facing the program and review solutions included ...

Reminder: Medicare Advantage Disenrollment Period (MADP) Ends February 14th February 7, 2013

The Medicare Advantage Disenrollment Period (MADP) lasts from January 1st through February 14th of each year.  During the MADP, a beneficiary can switch from an MA plan to traditional Medicare. The new MADP also provides an opportunity to enroll in a Part D drug plan for those who have not already done so. When disenrolling from ...

2013 Medicare Cost-Sharing December 27, 2012

Hospital Deductible: $1,184 per spell of illness Hospital Coinsurance:Days 0-60: $0 Days 61-90: $296 / day Days 91-150: $592 / daySkilled Nursing Facility CoinsuranceDays 0-20: $0 Days 21-100: $148 / dayPart A Premium (for voluntary enrollees only)With 30-39 quarters of Social Security coverage: $243 / month (no change) With 29 or fewer quarters of Social Security coverage: $441 / monthPart ...

Making Sense of Medicare’s Preventive Service Benefits September 20, 2012

September 20, 2012 With the Balanced Budget Act of 1997 (BBA1997), Congress began an expansion of preventive benefits and services available through Medicare.  Finally, the Patient Protection and ...

CMS Clarifies When the Advance Beneficiary Notice of Non-Coverage (ABN) Must be Issued August 16, 2012

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.  The new transmittal is part of an ongoing effort by CMS to provide additional information ...

New Medicare Summary Notice March 8, 2012

On March 7, 2012, the Centers for Medicare & Medicaid Services (CMS) announced the redesign of the Medicare Summary Notice (MSN), the statement that informs Medicare beneficiaries about their claims for Medicare services and benefits.  The Medicare Summary Notice (MSN) generally sets out what Medicare has or hasn't covered, provides information about a beneficiary's payment ...

The Medicare Advance Beneficiary Notice of Non-Coverage (ABN): A Tool for Limiting Beneficiary Liability January 26, 2012

Medicare's limitation on liability (LOL) protections In order to shift liability to the beneficiary, a provider is required to notify a beneficiary in advance ...

Annual Enrollment Starts October 15 and Ends December 7 for Medicare Part C & Part D Plans September 22, 2011

Fall is the time for Medicare beneficiaries to explore their options regarding Part D prescription drug and Part C Medicare Advantage plans.  In years past, the annual enrollment period began in mid-November and lasted to the end of the year, with any changes or choices made effective January 1st.  Starting this year, that time period ...

2011 Medicare Trustees Report May 19, 2011

The Medicare Trustees issued their annual report on Medicare's financial status on Friday, May 13, 2011.  According to this year's report, the Hospital Insurance (HI) Trust Fund has sufficient reserves to pay out the full amount of Medicare Part A benefits until 2024. Should nothing else change, and the Trust Fund reserves be depleted in ...

Send Us Medicare Summary Notices (MSNs) April 25, 2011

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 you ...

Quick Medicare Facts & Statistics February 9, 2011

"…Medicare has been a boon to the elderly and their children. Surveys show that beneficiaries are overwhelmingly satisfied with their care. Before Medicare, only 56 percent of the elderly had hospital insurance; the program has contributed to an increase in life expectancy and a sharp reduction in poverty among the elderly." Robert Pear, Walt Bogdanich, Some ...

Medicare Annual Enrollment Period Started November 15, 2010: Time to Review Coverage Options November 18, 2010

The Annual Coordinated Election Period for Medicare Advantage and Medicare Part D drug coverage started November 15, 2010 and goes through December 31, 2010. During this period, Medicare beneficiaries who do not have a Part D plan can enroll in one, and those who do have Part D coverage can change plans. Beneficiaries can also ...

2011 Medicare Cost Sharing Details November 10, 2010

On November 9, 2010, the Centers for Medicare and Medicaid Service (CMS) released three notices detailing the Medicare Part A and Part B premiums and Deductibles for calendar year 2011. See, 75 Fed. Reg. 68790-68802 (Nov. 9, 2010). Advocates need to be aware of changes and complications for 2011 with regard to premiums in order to ...

CMS Issues Final Rules for Medicare Appeals January 14, 2010

On December 9, 2009, the Centers for Medicare & Medicaid Services (CMS) issued final regulations for the Medicare Claims Appeals Process (Parts A & B combined) and for the application of certain appeals provisions to the Medicare prescription drug appeals process (Medicare Part D). Both sets of rules were effective on January 8, 2010. Appeal ...

Medicare Coverage Appeals Articles

Medicare Coverage for People with Disabilities Articles

Medicare and Mental Health Services Articles

Issue Brief on Substance Use Disorder Treatment for Duals Released February 1, 2024

People eligible for both Medicare & Medicaid face unique barriers to treatment.

New Substance Use Disorder Coverage in Medicare in 2024 November 30, 2023

November 2, 2023 rules include new coverage options for substance use disorder treatment that will close gaps for beneficiaries.

New Studies on Mental Health and Substance Use Disorder Access Highlight the Need for Parity in Medicare August 24, 2023

Increasing access to mental health and substance use disorder treatment must be a significant priority for policymakers.

Equity Impacts of Mental Health & Substance Abuse Cost-Sharing January 19, 2023

Cost-sharing parity for Mental Health and Substance Use Disorders increased white patients access, but had less impact on minority patients.

Medicare Provisions in Year-End Spending Bill January 5, 2023

Consolidated Appropriations Act contains a number of health provisions relating to Medicare, Medicaid, and other programs.

Reminder from CMS – May is Mental Health Awareness Month May 7, 2020

  May is Mental Health Awareness Month, and The Centers for Medicare & Medicaid services (CMS) wants to remind people with Medicare that the program covers mental health services to support them during these stressful times including:Telehealth counseling services during the COVID-19 public health emergency – learn more here: https://www.medicare.gov/coverage/telehealth Other outpatient mental health services, including depression ...

Medicare Can Help People In Rural Areas Access Mental Health Care August 13, 2015

Medicare pays for a limited number of Part B services furnished by a physician or practitioner to an eligible beneficiary via a telecommunications system. For eligible telehealth services, the use of a telecommunications system substitutes for an in-person encounter. Cognitive Behavioral Therapy (CBT) as psychotherapy via telemental health is covered by Medicare for certain eligible beneficiaries.  ...

Medicare and Mental Health March 14, 2013

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 ...

Medicare and Hospice Care Articles

Study: People with Dementia Receive Less Home Health and Hospice Care in Their Final Months February 23, 2023

Study: "current health models are not always equipped for the sustained burdens of dementia, resulting in inadequate end-of-life care, or even none at all."

Gaps in Hospice Abuse and Neglect Reporting January 12, 2023

CMS should ensure hospice reporting requirements are at least as stringent as other providers.

NAHC and CMA Announce New Hospice Resource for Consumers December 12, 2022

“Questions to Ask When Choosing a Hospice.”

Recent Rules and Guidance Address Transparency in Hospice Coverage November 12, 2020

For hospice elections beginning on or after October 1, 2020, Medicare beneficiaries are entitled to greater transparency.

Government Watchdog Agency Issues Report Highlighting “Significant Vulnerabilities” in Medicare’s Hospice Benefit July 11, 2019

Following up on earlier work analyzing the Medicare hospice benefit, the Department of Health and Human Services (DHSS) Office of Inspector General (OIG) issued two reports this week “which found that from 2012 through 2016, the majority of U.S. hospices that participated in Medicare had one or more deficiencies in the quality of care they provided ...

Inspector General Reports Concerns About Medicare Hospice Care August 9, 2018

Last week, the Office of Inspector General (“OIG”) published a report of its study on the growth in hospice utilization and reimbursement since 2005.  The Report summarizes key vulnerabilities in the Medicare hospice program affecting quality of care and program integrity, and presents recommendations to the Department of Health and Human Services for protecting beneficiaries ...

Observation Status Impedes Access to End-of-Life Skilled Nursing Facility Care November 3, 2016

Mr. P. has been hospitalized after having a heart attack. He also has terminal cancer for which he wants to continue treatment. If Mr. P. is admitted as an inpatient for a total of three days while in the hospital, he can qualify for Medicare Part A coverage of subsequent Skilled Nursing Facility (SNF) stay ...

Medicare Hospice Care: Palliative vs. Curative July 26, 2016

Hospice care is holistic care for the dying.  Medicare coverage of hospice care is available for beneficiaries who have been certified as terminally ill, for services that are “reasonable and necessary for the palliation or management of the terminal illness as well as related conditions.”  Prior to receiving Medicare coverage for hospice care, beneficiaries must ...

The Center for Medicare Advocacy Submits Comments on Proposed Rule for Hospice June 22, 2016

The Center for Medicare Advocacy submitted comments this week to the Centers for Medicare & Medicaid Services (CMS) concerning its proposed rule titled “Medicare Program; FY 2017 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements” (81 Fed. Reg. 25498), which was published on April 28, 2016.  The Center’s comments focused on ...

National Healthcare Decisions Day: April 16, 2016 January 20, 2016

Be a Resource for National Healthcare Decisions Day on April 16. There are numerous ways to participate at no cost, and the goal is simple: "To inspire, educate & empower the public & providers about the importance of advance care planning."  The easiset thing you can do is draw attention to your existing resources about advance care planning on ...

Husband Reimbursed for Dying Wife’s Medication After Trying to Appeal Hospice Denial for Nearly Eight Years November 18, 2015

When Emily Back was dying in early 2008, her treating physician prescribed a medication to help relieve her excruciating pain.  After the hospice provider refused to furnish the medication, her husband, in desperation, purchased it from the pharmacy, spending almost $6,000 of their own funds.  Mr. Back thought there must be some way to appeal ...

Hospice Quick Reference November 17, 2015

Hospice Quick Reference Hospice care is compassionate end-of-life care that includes medical and supportive services intended to provide comfort to individuals who are terminally ill. Care is provided by a team. Hospice is often called “palliative care,” because it aims to manage a patient’s illness and pain, but does not treat the underlying terminal illness. Hospice care is ...

26. Medicare Needs a Timely Way for Patients to Appeal Hospice Denials June 22, 2015

By Howard Back, a Medicare Beneficiary from California Medicare funding for hospice services is a wonderful thing. But there is a missing element in the system: there is no timely way a hospice patient can appeal failure of a hospice to provide a drug, or piece of equipment or other service that the patient’s physician prescribes. Many hospices, ...

Hospice Patients’ Rights Enhanced by New Medicare Rule October 2, 2014

Hospice care is specialized, compassionate care for those diagnosed with a limited life expectancy.  Good hospice care should enhance quality of life for the patient and should support caregivers.  The Medicare Conditions of Participation afford hospice patients certain enumerated rights including the right to choose one's own attending physician.  A new rule promulgated in the ...

Hospice and Access to Medications Update: CMS Replacement Guidance July 24, 2014

Quick Summary When Medicare beneficiaries elect the hospice benefit, they waive Medicare coverage for all care and services related to the terminal illness that are not on the hospice plan of care and provided through the hospice provider.  This means that when a terminally ill beneficiary elects hospice, all of the medications needed to control the ...

The Center Joins 26 Other Organizations in Calling for Suspension of Hospice and Part D Guidance June 12, 2014

Research suggests that medications that should be covered by the Medicare Hospice Benefit are sometimes paid for by Medicare Part D plans. In March, to prevent this from happening, the Centers for Medicare & Medicaid Services (CMS) issued a memorandum to Part D Plan Sponsors and Medicare Hospice Providers entitled, "Part D Payment for Drugs for ...

Tinkering With Hospice: The Medicare Care Choices Model April 24, 2014

Some croon, "Everyone wants to go to Heaven, but nobody wants to die."  As a general rule, Americans not only don't want to die, we also don't want to talk about death and dying.  As a consequence of this reticence, many Americans are dying without the benefits of hospice care.  In an attempt to grapple with ...

Hospice and Access to Medications – New CMS Guidance April 10, 2014

On March 10, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a memorandum to Part D Plan Sponsors and Medicare Hospice Providers entitled, "Part D Payment for Drugs for Beneficiaries Enrolled in Hospice – Final 2014 Guidance" (Guidance).   The Guidance identifies a billing problem related to medications after Medicare beneficiaries elect hospice, and ...

Medicare Hospice Care: We Want Your Stories! January 9, 2014

Hospice is a program of care and support for people who are terminally ill.  To qualify for Medicare hospice coverage, a doctor certifies that a person is terminally ill, with an expectation of six months or less to live.  Once a person enters hospice, all their medical needs related to the terminal illness for pain ...

Hospice – Care When It’s Needed Most October 20, 2011

November is National Hospice Month.  The first White House proclamation honoring hospice month was signed by President Jimmy Carter in 1978. Access to care has improved significantly in the three decades since November has been celebrated as National Hospice Month.  At that time, hospices in the US served several thousand individuals and their family members ...

New Hospice Face-to-Face Requirement: Help or Hindrance? April 28, 2011

Eligibility for Medicare coverage of hospice care is contingent in part upon a hospice physician certifying that the beneficiary has a life expectancy of six months or less if the terminal illness runs its normal course.   In an effort to promote physician engagement in the process of certifying patients as eligible for the Medicare hospice ...

New Hospice Regulations are a Mixed Bag for Beneficiaries Seeking High Quality End of Life Care January 20, 2011

Hospice care is available for Medicare beneficiaries who are certified by a hospice physician as having a life expectancy of six months or less if the terminal illness runs its normal course. In 1983, the hospice benefit was designed to cover approximately 210 days of care. There were four benefit periods: two 90 day periods, ...

Hospice News: the Good, the Bad, the Ugly October 20, 2009

The Good: Connecticut Will Cover Hospice Care for Medicaid Recipients Medicaid recipients in Connecticut will soon have access to hospice care.  The new benefit closely resembles the Medicare hospice benefit.  To obtain hospice care, Medicaid clients must be certified as having a life expectancy of six months or less if the ...

Medicare Part B Articles

Medicare Will Cover Seat Elevation Systems for Eligible Wheelchair Users May 18, 2023

Coverage for the devices in certain wheelchairs is guarantied, others at CMS discretion.

Wheelchair Seat Elevation Systems Should be Covered by Medicare August 25, 2022

Seat elevation systems for wheelchairs are primarily medical in nature and should be covered as durable medical equipment.

Beneficiary Access to Complex Rehabilitation Wheelchair Accessories Protected August 5, 2021

Advocates had feared beneficiaries would lack options to obtain the necessary items.

New Opioid Treatment Program Benefit in Part B January 23, 2020

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 Drug Administration ...

CMS Extends “Equitable Relief” from Part B Late Enrollment Penalties for People Moving from ACA Marketplace Plans to Medicare October 31, 2019

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 ...

Medicare Coverage for Genetic Tests: Know the Facts May 2, 2019

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 ...

Home Infusion Therapy Services March 13, 2019

(The Content below is taken from the Centers for Medicare & medicaid Services: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Home-Infusion-Therapy/Overview.html) 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 . The components needed ...

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Updates January 24, 2019

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) for DME suppliers. ...

Don’t Fall for the Distraction: The President’s Prescription Drug Proposal is Much Ado About Much Too Little October 30, 2018

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 ...

Congress DID Repeal Outpatient Therapy Caps Despite Lack of Information on Medicare.gov March 1, 2018

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 ...

Congress Repeals Medicare Outpatient Therapy Caps, Strengthening the Jimmo Settlement Agreement February 14, 2018

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. Pursuant to the Balanced Budget Act of 1997, Medicare Part ...

Outpatient Therapy Caps: What Now? January 31, 2018

Since the Balanced Budget Act of 1997, outpatient therapy under Medicare Part B has been subject to dollar limits, or caps.  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 ...

Minimal Social Security COLA Increase Will Likely Lead to Dramatic Part B Premium Increases for Some, Large Deductible Increase for All, Unless Congress Intervenes October 19, 2016

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 statute ...

CMS Proposes Changes in How It Pays for Part B Drugs March 23, 2016

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 pays ...

Time for Medicare to Cover Audiology Care March 16, 2016

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 ...

House Passes Budget Agreement That Would Reduce Dramatic Rise in Part B Costs for Beneficiaries – Bill Moves to Senate; Advocates Remain Concerned About Underlying Causes October 28, 2015

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. On ...

Solution to Medicare Part B Cost Increases? Look at “Outpatient” Observation Status October 23, 2015

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 misguided ...

Part B and the Cost of Living Adjustment (COLA) October 15, 2015

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 ...

Advocacy Organizations Support Legislation to Mitigate Huge Part B Premium/Deductible Increases October 8, 2015

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 ...

Center Urges Action on Drastic Part B Premium Increase October 1, 2015

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 ...

The Medicare Dental Exclusion: Is it Being Used to Deny Vulnerable Beneficiaries Needed Care? May 28, 2015

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. The decayed and infected teeth, when left untreated, place these cancer patients at increased risk for infection, thereby decreasing ...

Medicare Takes a Big Step Forward to Help People Communicate – But There’s More to Do April 30, 2015

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) proposed ...

Welcome Reprieve for People Who Need Speech Generating Devices (SGDs) To Communicate November 7, 2014

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 announced ...

Medical Equipment Suppliers’ Ongoing Opposition to the Competitive Bidding Program and Consequences for Beneficiaries November 6, 2014

Report prepared by Mario Ramsey, Center for Medicare Advocacy Summer Health Policy FellowI.                   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 successful in ...

Medicare and Telemedicine (or Telehealth) August 7, 2014

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 ...

The DMEPOS Competitive Bidding Process: Is It Working? June 26, 2014

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 the ...

Medicare’s Reluctance to Embrace Technology: Effects on the Coverage of Speech Generating Devices June 5, 2014

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 ...

Medicare Physician Payment – Another One-Year Fix Passes Congress, With Usual “Extenders” and Some New, Permanent Payment Policies April 3, 2014

On Tuesday, April 1st, President Obama signed into law the "Protecting Access to Medicare Act of 2014" (H.R. 4302). 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 ...

Medicare Therapy Caps: A Call for Repeal January 16, 2014

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 ...

New Report: Expanded Dental Coverage Needed to Confront Health Crisis October 24, 2013

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 ...

Medicare’s National Mail Order Program for Diabetic Testing Supplies June 20, 2013

On July 1, 2013, Medicare Part B will implement a national mail-order competitive bidding program specifically for diabetic testing supplies. will purchase diabetic ...

Let DMEPOS Competitive Bidding Proceed While Addressing Identified Problems and Concerns June 13, 2013

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 ...

Medicare and Mental Health March 14, 2013

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 ...

Making Sense of Medicare’s Preventive Service Benefits September 20, 2012

September 20, 2012 With the Balanced Budget Act of 1997 (BBA1997), Congress began an expansion of preventive benefits and services available through Medicare.  Finally, the Patient Protection and ...

Center for Medicare Advocacy in Congress, Voicing Concerns on Behalf of Beneficiaries May 10, 2012

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 ...

Congressional Subcommittee Examines Issues of Dental Health March 8, 2012

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 ...

Reminder: Medicare Covers Obesity Prevention with No Cost-Sharing January 5, 2012

On November 29, 2011, CMS announced its decision to include coverage for obesity screening and counseling services for Medicare beneficiaries. An ...

Breaking Good News for Medicare Beneficiaries October 27, 2011

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 slightly ...

CMS to Begin Round Two of Its Competitive Bidding Program for the Provision of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) September 1, 2011

On August 19, 2011, the Centers for Medicare & Medicaid Services (CMS) announced Round 2 of its DMEPOS competitive bidding program.  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 be ...

FAQs on Preventive Services August 17, 2011

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 http://www.CMS.gov/MLNProducts/35_PreventiveServices.asp and select “Preventive Services FAQs.”  Or, find the answer to an individual FAQ below. Annual Wellness Visit ...

Medicare Coverage of Power Mobility Devices: Tips and Reminders March 28, 2011

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 ...

Medicare Coverage of Power Mobility Devices: Tips and Reminders April 3, 2008

When it comes to obtaining Medicare coverage for Mobility Assistive Equipment (MAE), 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 ...

Medicare Part D Articles

Medicare Drug Pricing Updates from HHS March 28, 2024

41 drugs available through Medicare Part B will have a lowered Part B coinsurance rate from April 1 – June 30, 2024, if the drug company raises prices faster than inflation.

Good Progress in Litigation Against Medicare Drug Price Negotiations March 21, 2024

Inane suits to stop negations seem to be failing thus far.

Implementation of Medicare Drug Law Proceeds March 14, 2024

The prescription drug expansions and controls in the IRA benefit millions, and the administration wants to help even more - yet the industry continues to fight it.

Center for Medicare Advocacy Submits Comment on Proposed 2025 Medicare Advantage and Part D Rule January 11, 2024

While positive, there is room for more MA oversight .

New Medicare Drug Provisions Now in Effect – Including Out-of-Pocket Changes January 4, 2024

Effectively caps Out-of-pocket costs at $3250 for 2024, dropping to $2000 in 2025.

Center Joins Fight Against Drug Manufacturer Seeking to End Medicare Price Negotiations November 9, 2023

Case is one of many brought by drug manufacturers to strike down the negotiation program created by the Inflation Reduction Act (IRA).

More Medicare Prescription Drug Help for Beneficiaries in 2024 – Including Out-of-Pocket Cap October 26, 2023

Act already helping beneficiaries, and more changes to come in 2024.

Medicare Drug Price Negotiation Program Begins After Encouraging Court Decision October 5, 2023

A federal court has rejected a bid by the pharmaceutical industry and its allies to stop the newly established Medicare drug price negotiation program before it starts.

CMS Releases Notices Regarding LIS October 5, 2023

Certain Low Income Subsidy-eligible individuals will be automatically reassigned to new plans for 2024.

One-Year Anniversary of Medicare Prescription Drug Law: Beneficiaries Already Saving Money but Drug Industry Fights Progress August 17, 2023

Drug companies and business interests have already sued to stop money-saving, cost-lowering changes.

CMS Request for Information Regarding Self-Administered Drugs – Center for Medicare Advocacy Calls for Reform August 17, 2023

CMA calls attention to the risk of beneficiary liability and the inherent violation of due process baked into the Self Administered Drug list determination process.

Inflation Reduction Act (Medicare Drug Law) Updates – Including Part D Low Income Subsidy June 15, 2023

HHS Actions to Increase LIS EnrollmentAmong other changes aimed at reducing drug costs for both Medicare beneficiaries and the Medicare program at large, a provision of the Inflation Reduction Act of 2022 (IRA) expands access to the Part D Low Income Subsidy (LIS, or “Extra Help”) to help people meet the costs of medications. Starting in ...

Lawsuit Settlement Allows Medicare Coverage for “Off-Label” Medication June 8, 2023

"Support" for effective use does need to be hyper-specific.

Special Report | Recent Medicare Advantage (MA) and Part D Rule – Important Consumer Protections re: MA Prior Authorization and Marketing May 4, 2023

Rule includes improvements to prior authorization process and consumer protections re: marketing.

Implementation of Medicare Drug Bill Proceeds – This Progress Must be Defended March 2, 2023

Inflation Reduction Act drug provisions that will help millions must be supported, even strengthened.

Center for Medicare Advocacy Comments on Proposed Part C & D Rule February 16, 2023

After years of administrations letting the MA program do as it will, we applaud the proposals in this rule,

Critical Provisions of Medicare Drug Bill Already Taking Effect January 19, 2023

Though already threatened by industry and their supporters in Congress, several provisions to help Medicare beneficiaries are underway.

CMS Issues Proposed Rules Impacting Medicare Advantage – Part C & D Rule for 2024, and Separate Prior Authorization Rule December 15, 2022

Rules address several advocate concerns, but there is more work to do.

Provisions of Recently Passed Medicare Drug Bill in Effect Next Month – January 2023 December 8, 2022

Medicare-related drug provisions in the IRA starting next month will help beneficiaries nationwide.

Center for Medicare Advocacy Sues, Again, for Coverage of “Off-label” Prescription Drug December 1, 2022

Center recently won a similar case in Florida.

President Biden Signs Inflation Reduction Act into Law – Includes Critical Medicare Prescription Drug Provisions August 18, 2022

The Medicare drug provisions in the Inflation Reduction Act are historic reform that will benefit millions of beneficiaries.

Senate Poised to Vote on Important Bill with Valuable Medicare Drug Provisions August 4, 2022

Tell the Senate to pass Medicare prescription drug reform now.

CMS Needs to Rein in Medicare Advantage Overpayments and Heighten Oversight of Insurance Industry March 10, 2022

CMS fails to use their discretion to address wasteful Medicare Advantage (MA) overpayments, or increase oversight of MA plans.

CMS Releases Proposed 2023 Rule for Medicare Advantage and Part D Plans January 13, 2022

A number of provisions will considerably help consumers, but, in other ways, the proposed rule falls short of providing needed protections.

Study Finds Cost-Sharing Increases Can be Deadly February 25, 2021

Health care spending by patients is unlike other consumer spending. "Skin in the game" can lead to disastrous health outcomes.

Final 2022 Rule for Medicare Parts C and D Released By Trump Administration February 4, 2021

Rather than focus on plan sponsor “burden,” CMS should focus on consumer education and access to care.

Dismantling the Affordable Care Act Would Harm Medicare and Medicare Beneficiaries October 22, 2020

Undoing the ACA would jeopardize drug coverage for millions of Medicare beneficiaries.

Senators Release Report Concerning Postal Service Problems and Delays in Receipt of Mail-Order Drugs September 10, 2020

Senators' report on postal service cuts and mail order drugs cites the Center for Medicare Advocacy.

Center Letter Re: Impact of Postal Service Delays on Medicare Beneficiaries September 10, 2020

September 3, 2020VIA ELECTRONIC SUBMISSIONThe Honorable Robert P. Casey, Jr.United States Senate393 Russell Senate Office BuildingWashington, D.C. 20510The Honorable Elizabeth WarrenUnited States Senate309 Hart Senate Office BuildingWashington, DC 20510Re: Potential Impact on Medicare Beneficiaries Due to Recent Changes at the United States Postal Service (USPS) Causing Delays in DeliveryDear Senators Casey and Warren:The Center for ...

Final Rule for Medicare Parts C and D Includes Weakened Standards for Medicare Advantage Networks May 28, 2020

On May 22, 2020, the Centers for Medicare & Medicaid Services (CMS) published a final rule regarding Medicare Advantage (Medicare Part C) and Part D prescription drug plans (“C & D Rule”). The rule is entitled “Medicare Program; Contract Year 2021 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, ...

CMS Announces Voluntary Part D Program to Reduce Insulin Out-of-Pocket Costs for Some Enrollees May 28, 2020

In a May 26, 2020 press release, the Centers for Medicare & Medicaid Services (CMS) “announced that over 1,750 standalone Medicare Part D prescription drug plans and Medicare Advantage plans with prescription drug coverage have applied to offer lower insulin costs through the Part D Senior Savings Model for the 2021 plan year. Across the ...

Center for Medicare Advocacy Submits Comments on Proposed Medicare Parts C and D Rule April 9, 2020

On February 18, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule entitled Medicare and Medicaid Programs; Contract Year 2021 and 2022 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicaid Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (CMS-4190-P). The ...

House Passes Historic Medicare Expansion Bill – H.R. 3 December 12, 2019

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, ...

House to Vote on Historic Medicare Bill Next Week December 5, 2019

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 back ...

House Companion to Part D Extra Help Bill Introduced October 3, 2019

This week Rep. Brad Schneider (D-IL) introduced a House companion to the Senate Medicare Extra Rx HELP Act (S. 691, H.R. 4583) introduced by Sen. Bob Casey (D-PA) in March 2019.  The bill would expand Part D Low Income Subsidy/ Extra Help by eliminating the asset test, streamlining program administration, and providing full benefits to those living on the ...

Speaker Pelosi Unveils Bill Authorizing Negotiation of Drug Prices and Capping Out-of-Pocket Costs September 26, 2019

On September 19, 2019, Representative Frank Pallone, Jr., Chairman of the U.S. House Committee on Energy & Commerce, introduced the Lower Drug Costs Now Act (H.R. 3). As noted in The New York Times, the bill addresses the problem of skyrocketing prescription drugs costs. In a press release, Speaker Nancy Pelosi stated that “he soaring ...

Part D Legislation Markup Today: Improve Beneficiary Appeals July 25, 2019

On Tuesday, July 23, the Senate Finance Committee released draft drug pricing legislation, the Prescription Drug Pricing Reduction Act (PDPRA) of 2019. This sweeping bill would make a number of changes aimed at addressing the high and rising costs of prescription drug prices. However, the legislation currently does not contain important changes to the Medicare Part ...

Center for Medicare Advocacy Submits Comments to House Ways & Means and Energy & Commerce Committees on Draft Part D Legislation June 13, 2019

On May 23, 2019, Ways & Means Committee Chairman Richard E. Neal (D-MA) and Energy & Commerce Committee Chairman Frank Pallone, Jr. (D-NJ), along with Ranking Members Kevin Brady (R-TX) and Greg Walden (R-OR) announced a solicitation for comments on draft legislation to reform the Medicare Part D program that would establish an out-of-pocket cap ...

Center for Medicare Advocacy Submits Comments to CMS’ Draft 2020 Call Letter for Medicare Advantage and Part D March 7, 2019

On January 30, 2019, the Centers for Medicare & Medicaid Services (CMS) issued Part II of its draft 2020 Call Letter, an annual set of proposed rules, guidelines and clarifications for Part C Medicare Advantage (MA) and Part D plans that want to participate in Medicare in the following calendar year. In collaboration with several ...

State of the Union: Want More Affordable Prescription Drugs? Start with Medicare. February 7, 2019

While the President’s State of the Union Address was short on substance concerning health care, he did mention a desire to work with Congress to “lower the cost of health care and prescription drugs.” While the President focused on “global freeloading” there is one common sense solution that would make drugs more affordable for individuals, ...

Center Submits Comments on Proposed Medicare Prescription Drug Rule January 31, 2019

The Center for Medicare Advocacy recently submitted comments to a Notice of Proposed Rulemaking issued by the Centers for Medicare & Medicaid Services (CMS) entitled “Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses” (CMS-4180-P).  The Center’s comments are available at: https://www.medicareadvocacy.org/center-comments-on-modernizing-part-d-and-medicare-advantage/.   Currently, Part D prescription drug plans (PDPs) and ...

Congressional Hearings Explore Rising Prescription Drug Costs January 31, 2019

On January 29, 2019, the Senate and House held separate hearings on prescription drug prices. The Senate Finance Committee’s hearing, Drug Pricing in America: A Prescription for Change, Part 1, explored the rising cost of prescription drugs and potential solutions to the ongoing crisis. In his opening testimony, Ranking Member Ron Wyden stated that “ore ...

Don’t Fall for the Distraction: The President’s Prescription Drug Proposal is Much Ado About Much Too Little October 30, 2018

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 ...

Dual Eligibles and Access to Part D Drugs: Pretty Good News from the OIG July 26, 2018

The Office of the Inspector General for the Department of Health and Human Services released a report recently regarding Part D coverage of prescription drugs used by people dually eligible for Medicare and Medicaid. The June report, Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles: 2018, found that most Part D plan ...

The Right Way to Lower Medicare Prescription Drug Costs June 7, 2018

Robert Pear wrote last week in the New York Times (“Trump Plan to Lower Drug Prices Could Increase Costs for Some Patients”) that the President’s plan to “inject more competition into the market” and switch coverage of some expensive drugs from Medicare Part B Medicare Part D could significantly increase out-of-pocket costs for some of ...

The Center for Medicare Advocacy and Florida Health Justice Project Sue to Obtain “Off-label” Part D Prescription Drug Coverage for Beneficiary April 19, 2018

On April 6, 2018 the Center for Medicare Advocacy and Florida Health Justice Project filed a lawsuit in U.S. District Court for the Southern District of Florida on behalf of a 49-year-old beneficiary seeking Medicare coverage for his “off-label” (non-FDA-approved) use of a critically needed medication (Dobson v. Azar, 4:18-cv-10038-JLK).  The beneficiary’s Medicare Part D ...

Center for Medicare Advocacy Submits Comments to CMS’ Draft 2019 Call Letter for Medicare Advantage and Part D March 8, 2018

On February 1, 2018, the Centers for Medicare & Medicaid Services (CMS) issued its draft 2019 Call Letter, an annual set of proposed rules, guidelines and clarifications for Part C Medicare Advantage (MA) and Part D plans that wish to participate in Medicare in the following calendar year.  In collaboration with several other advocacy organizations, ...

Bill to Control Medicare Prescription Drug Costs Introduced March 8, 2018

Representative Sandy Levin recently introduced the Protecting Medicare from Excessive Price Increases Act, which would require prescription drug manufacturers to pay a rebate when the price of their Part B drug increases faster than inflation. Medicare Part B covers drugs that are usually not self-administered, such as many intravenous medications and chemotherapy drugs. Medicare Part ...

Center Urges CMS to Preserve and Strengthen Consumer Protections in Medicare Advantage and Part D April 26, 2017

As noted in a previous Alert, the Center for Medicare & Medicaid Services (CMS) recently finalized their 2018 Call Letter.  In the same document, CMS issued a Request for Information regarding ideas for “regulatory, sub-regulatory, policy, practice and procedural changes to better accomplish” the goals of “using transparency, flexibility, program simplification and innovation to transform ...

Preview – 2017 Part D Standard Benefit & Other Threshold Amounts September 20, 2016

Note:  The amounts in this table do not apply to beneficiaries who have the Part D Low Income Subsidy (“Extra Help”)Annual Deductible Maximum$400Initial Coverage Period Cost sharing during this period may be a flat 25% co-insurance OR the plan may have a tiered system of co-pays and co-insurance that is actuarially equivalent to 25%Initial Coverage Limit (Once ...

The Center’s Long-Time Concerns Gain Attention August 31, 2016

Prescription Drug Pricing An excellent and well-timed (given #Epi-gate) article appeared in this week’s Journal of the American Medical Association discussing the reason drug costs are so high in the U.S. According to the article, the major cause is the “granting of government-protected monopolies to drug manufacturers, combined with restriction of price negotiation at a level ...

Medicare Part D and Off-Label Rx Denials June 29, 2016

In the last 18 months, the Center for Medicare Advocacy, and other advocates around the country, have received many, many calls from older and disabled beneficiaries who can no longer obtain coverage for the Lidocaine Patch 5% from their Part D plans. Many have been using the Patch for at least a decade and are ...

Federal Court Issues Favorable Off-label Part D Drug Coverage Decision May 18, 2016

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 ...

Attention Patients and Prescribers of Part D Drugs March 2, 2016

March 2016 Update: CMS is now delaying enforcement of the Part D Prescriber Enrollment Requirements until February 1, 2017. Nevertheless, prescribers of Part D drugs should submit their Medicare enrollment applications or opt-out affidavits to their Part B Medicare Administrative Contractors (MACs) by January 1, 2016, or earlier, to ensure that MACs have sufficient time to ...

Remove Barriers to Obtaining Medicare Covered Drugs January 20, 2016

Low income racial and ethnic minority beneficiaries are adversely affected by prescription drug pricing, a problem that has a negative impact on overall Medicare program costs.  A 2011 International Journal of Health Services study estimates that the economic costs of health disparities due to race for African Americans, Asian Americans, and Latinos from 2003 thru ...

Office of Inspector General Authorizes Hospitals to Discount or Waive Certain Drug Charges for Patients Classified as “Outpatients” December 10, 2015

The Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS) released a statement on October 30, 2015 that advises hospitals that it will not administratively sanction them if they discount or waive charges for an outpatient’s self-administered drugs. Thus, hospitals now have the option, and a greater incentive, not ...

Assistance with Paying for Prescription Drugs November 30, 2015

This page focuses on programs that help Medicare beneficiaries acquire necessary medications, although many of the programs discussed are not limited to that population.  Many Americans who are still feeling the effects of the recession are struggling to find ways to save money and pay for their medications. Unfortunately, some have been forced to make ...

Department of Health and Human Services Forum on Drug Pricing and Innovation November 24, 2015

On November 20, 2015, Center staff attended a one day symposium hosted by the federal Department of Health and Human Services (HHS) entitled “HHS Pharmaceutical Forum: Innovation, Access, Affordability & Better Health.”  The forum featured HHS Secretary Burwell, Acting Administrator for the Centers for Medicare and Medicaid Services (CMS), Andy Slavitt, consumer advocates, pharmaceutical company ...

Kaiser Family Foundation Releases Reports on MA and Part D in 2016 October 15, 2015

In a report entitled “Medicare Part D: A First Look at Plan Offerings in 2016” (October 2015), the Kaiser Family Foundation analyzed the Part D market in 2016 and found, among other things, that:In 2016, beneficiaries in each region will have a choice of 26 PDPs, on average, down by 4 from 2015. The average PDP ...

Final 2016 CMS Call Letter for Medicare Parts C and D Released April 9, 2015

Every year, the Centers for Medicare and Medicaid Services (CMS) issues payment, performance and other rules that apply to Medicare Advantage (MA) and Part D plans that choose to participate in the Medicare program in the following calendar year. Commonly referred to as the “Call Letter,” this document is first released in draft form, subject ...

Center for Medicare Advocacy Submits Comments to Draft 2016 Call Letter for Medicare Parts C and D March 12, 2015

Every year, the Centers for Medicare and Medicaid Services (CMS) releases a draft of payment, performance and other rules that apply to Medicare Advantage (MA) and Part D plans that choose to participate in the Medicare program in the following calendar year. Commonly referred to as the “Call Letter,” this document is first released in ...

2016 Medicare Advantage (Part C) and Part D Final Rule Issued February 19, 2015

On February 12, 2015, the Centers for Medicare and Medicaid Services (CMS) published final rules entitled “Medicare Program; Contract Year 2016 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs” Applicable to the 2016 plan year ...

Update on MA and Part D Plans October 23, 2014

A Brief Survey of Recent Reports, and a New Special Enrollment Period for 2015 Medicare's Annual Coordinated Election Period (ACEP) for Medicare Advantage and Part D plans began on October 15th and runs through December 7th.  During the ACEP, often referred to as "open enrollment," Medicare beneficiaries who do not have a Part D plan can ...

2015 Medicare Cost Sharing October 9, 2014

Hospital Deductible: $1,260.00 / Benefit period Hospital Coinsurance:Days 0-60: $0 Days 61-90: $315 / Day Days 91-150: $630/ DaySkilled Nursing Facility Coinsurance:Days 1-20: $0 Days 21-100: $157.50/ DayPart A Premium (For voluntary enrollees only)With 30-39 quarters of Social Security coverage: $224.00 / Month With 29 or fewer quarters of Social Security coverage: $407.00 / MonthPart BDeductible: $147.00 / Year Standard Premium: ...

Hospice and Access to Medications Update: CMS Replacement Guidance July 24, 2014

Quick Summary When Medicare beneficiaries elect the hospice benefit, they waive Medicare coverage for all care and services related to the terminal illness that are not on the hospice plan of care and provided through the hospice provider.  This means that when a terminally ill beneficiary elects hospice, all of the medications needed to control the ...

The Center Joins 26 Other Organizations in Calling for Suspension of Hospice and Part D Guidance June 12, 2014

Research suggests that medications that should be covered by the Medicare Hospice Benefit are sometimes paid for by Medicare Part D plans. In March, to prevent this from happening, the Centers for Medicare & Medicaid Services (CMS) issued a memorandum to Part D Plan Sponsors and Medicare Hospice Providers entitled, "Part D Payment for Drugs for ...

Submitting Claims to Part D for Prescription Drugs Administered in the Hospital During an Observation Status Stay May 1, 2014

The use of Medicare observation status in hospitals has increased dramatically over the past several years. However, many of the beneficiaries the Center assists also find themselves facing large hospital bills for drugs ...

Hospice and Access to Medications – New CMS Guidance April 10, 2014

On March 10, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a memorandum to Part D Plan Sponsors and Medicare Hospice Providers entitled, "Part D Payment for Drugs for Beneficiaries Enrolled in Hospice – Final 2014 Guidance" (Guidance).   The Guidance identifies a billing problem related to medications after Medicare beneficiaries elect hospice, and ...

2014 Income and Resource Information for Medicare Low-Income Programs February 6, 2014

Programs that help low-income people afford their Medicare, including the Medicare Savings Programs and the Part D Low Income Subsidy (also called LIS or Extra Help) have income and resource eligibility guidelines that change yearly. The Federal poverty level (FPL) guidelines for 2014 were published in the Federal Register on January 22, 2014.  These guidelines provide ...

Medicare Prescription Drug Rebate Debate November 21, 2013

The Medicare Part D Prescription drug program is forbidden by law from getting the best prices for prescription drugs. Unlike the Veterans Administration and Medicaid, Medicare is at the mercy of drug company pricing, forbidden from seeking lower prices for its enrollees. Allowing Medicare to get fair drug prices would save billions of taxpayer dollars a year, without hurting ...

The Medicare Annual Coordinated Election Period Has Begun! October 17, 2013

During the Annual Coordinated Election Period, which runs from October 15th through December 7th, 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 Part D drug coverage. For more information and to get help reviewing ...

Debunking Medicare Myths: Drug Rebates for Dual Eligibles May 8, 2013

In the midst of ongoing budget discussions, policymakers are considering a wide array of approaches for cutting spending and saving federal dollars. The Center for Medicare Advocacy recently wrote of ways to strengthen the Medicare program while achieving significant savings. Included in our analysis was a proposal that would save taxpayers billions of dollars: reinstating ...

Reminder: Medicare Advantage Disenrollment Period (MADP) Ends February 14th February 7, 2013

The Medicare Advantage Disenrollment Period (MADP) lasts from January 1st through February 14th of each year.  During the MADP, a beneficiary can switch from an MA plan to traditional Medicare. The new MADP also provides an opportunity to enroll in a Part D drug plan for those who have not already done so. When disenrolling from ...

Deficit Reduction and Medicare: Save Money Without Harming Beneficiaries November 15, 2012

Although passage of the Affordable Care Act (ACA) has achieved considerable savings for the Medicare program, Medicare is still being targeted by policymakers looking to negotiate a large "grand bargain" deficit-reduction package. Many of the proposals to achieve Medicare savings would shift costs from the federal government to Medicare beneficiaries As the debt and deficit debate ...

Picking a Plan During the Annual Enrollment Period? Choose Carefully October 18, 2012

As discussed in last week’s Alert, the current Medicare Annual Enrollment Period lasts until December 7th.  During this time period, Medicare beneficiaries can choose a Medicare Advantage (Part C) or Part D plan for 2013.  This Alert discusses Part C and D plan quality ratings for 2013, and special enrollment periods related to these ratings.  ...

Impact of Budget Control Act and Sequestration on Aids Drug Assistance Programs September 24, 2012

As a result of the Budget Control Act, which outlined mandatory cuts to both defense and non-defense discretionary programs in the event a Congressional committee could not agree to a deficit-reduction package, programs impacting the HIV community and funding are expected to be affected. According to the AIDS Institute, over $500 million would be cut ...

Increased Funding for AIDS Drugs Assistance Program Responds to Need for Additional HIV/AIDS Services August 23, 2012

On July 19, 2012, the Secretary of Health & Human Services (HHS), Kathleen Sebelius, announced the availability of roughly $80 million dollars in grant money to increase access to HIV/AIDS care, including eliminating waiting lists, which have been a challenge in operating the Aids Drug Assistance Program. A Global Pandemic HIV/AIDS remains a global pandemic that affects ...

Affordable Care Act in Action: People with Medicare Continue to See Savings May 3, 2012

New data released this week shows that families and individuals who rely on Medicare continue to see direct benefits from the Affordable Care Act by saving billions of dollars on prescription drug costs. So far in 2012, older and disabled Americans have saved an average of $837 on their drug purchases after reaching the donut-hole ...

New Medicare Part D Pharmacy Notice Rule In Effect; Stay Tuned for Final Model Notice January 5, 2012

Effective January 1, 2012, Medicare Part D plan enrollees who are unable to obtain a prescription drug at the pharmacy are now, in most instances, entitled to a written notice explaining how they can contact their Part D plan in order to initiate an appeal.  On February 2, 2012, CMS announced that the final model ...

Medicare Advantage and Part D Changes and Enrollment Updates October 6, 2011

Once again the Medicare Advantage and Part D Annual Coordinated Election Period (ACEP) is upon us; it's time to contemplate Medicare prescription drug and Medicare Advantage choices for another calendar year.  The big news is that the ACEP, while one week longer than in the past, starts and ends much earlier this year.  The ACEP ...

Annual Enrollment Starts October 15 and Ends December 7 for Medicare Part C & Part D Plans September 22, 2011

Fall is the time for Medicare beneficiaries to explore their options regarding Part D prescription drug and Part C Medicare Advantage plans.  In years past, the annual enrollment period began in mid-November and lasted to the end of the year, with any changes or choices made effective January 1st.  Starting this year, that time period ...

New Rules for Medicare Advantage and Part D Plans June 2, 2011

On April 15, 2011, the Centers for Medicare & Medicaid Services (CMS) issued final regulations to provide policy and technical changes to the Medicare Parts C (Medicare Advantage) and D programs.  The regulations address concerns raised by Medicare beneficiary advocates, and implement provisions of the Affordable Care Act.  They also codify into regulation some existing ...

CMS Sends Out Reminders to LIS-Eligible Medicare Beneficiaries May 26, 2011

The Centers for Medicare & Medicaid Services (CMS) announced that it is sending "Choosers Reminder Notices" to approximately 944,000 Medicare beneficiaries who are eligible for the Part D low-income subsidy (LIS).  The notices, which are being mailed from May 26 – May 31, are designed to remind these individuals that the drug plan in which ...

Help Someone Retain Part D Extra Help March 17, 2011

The Social Security Administration (SSA) has released state by state information on numbers of individuals whose Part D low income subsidy (extra help) will end March 31 if they do not respond to SSA’s request for information concerning their continued eligibility.  Nationwide, 86,789 low-income Medicare beneficiaries subject to routine redeterminations had not responded to SSA ...

Extension of Time to Enroll In a Prescription Drug Plan for Medicare Beneficiaries Who Lost Coverage February 10, 2011

Some Medicare beneficiaries lost prescription drug coverage at the end of 2010 because their Medicare Advantage (MA) plan or prescription drug plan (PDP) either did not renew its contract with the Centers for Medicare & Medicaid Services (CMS) or reduced the service area it served, and they did not enroll in a new plan.  These ...

2011 Poverty Levels Affect Eligibility for Many Federal Programs January 27, 2011

Federal poverty level (FPL) guidelines for 2011 were published in the Federal Register January 20, 2011. 76 FR 3637 (January 20, 2011).  The guidelines provide the baseline for eligibility levels for many public benefits, including health benefits for older people and people with disabilities. The published poverty levels merely state a dollar figure for different-sized family ...

45 Day Disenrollment Period for Medicare Advantage Members January 6, 2011

Starting this year, the Medicare Advantage Open Enrollment Period (OEP) has been replaced by a new Medicare Advantage Disenrollment Period (MADP), which lasts from January 1st through February 14th. During the MADP, one can switch from an MA plan to traditional Medicare.  The new MADP also provides an opportunity to pick up Part D drug ...

Court Emphatically Rejects Beneficiaries’ Right to Sue a Part D Plan When the Plan Delays Enrollment September 30, 2010

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. The decision, which was issued on August 31, 2010, makes clear the Court's view that Congress did not intend beneficiaries ...

CMA REPORT: MEDICARE COVERAGE FOR OFF-LABEL DRUG USE September 16, 2010

September, 2010 While the Medicare prescription drug benefit provides assistance for many people with their drug costs, the requirements for coverage of the off-label use of a drug are onerous and often result in beneficiaries not being able to get the drug coverage they need.  Unfortunately, the information the law requires beneficiaries to submit to substantiate ...

Health Reform in Action: Donut Hole Rebate Checks Start Arriving June 10, 2010 June 10, 2010

Medicare beneficiaries who enter the prescription drug coverage gap (known as the "Donut Hole") anytime before the end 2010 should receive a one time $250 rebate check from Medicare.  The first checks, for people who hit the Donut Hole by March 31, 2010, should arrive around June 10, according to Secretary of the Department of ...

LI NET: More Help for Dually-Eligible People December 24, 2009

In 2006 the Centers for Medicare & Medicaid Services (CMS) created the “Point-of-Sale Facilitated Enrollment” (POS) process, administered by WellPoint.  The purpose of the POS is to assist people who are dually eligible for Medicare and Medicaid (dual eligibles) in filling their prescriptions at the pharmacy if they have not ...

Part Covered, Part Not: "Straddle Claims" in Medicare Part D July 24, 2008

Medicare Part D coverage is complex, particularly when a prescription drug claim crosses multiple phases of the benefit.  These “straddle claims” make it particularly challenging to determine what a beneficiary owes, but it is important to be accurate, particularly when the claim straddles a coverage gap, resulting in expense to ...

Medicare Savings Programs Articles

Simplified Access to Medicare Savings Programs February 22, 2024

Programs provide crucial assistance to low-income Medicare beneficiaries, but many eligible people do not enroll.

2024 Federal Poverty Guidelines Released February 1, 2024

Updated guidelines affect eligibility for many programs.

New Medicare Rule Increases Access to Medicare Savings Programs September 28, 2023

MSPs provide critical support for low-income Medicare beneficiaries Currently, only about half of those eligible are enrolled in these programs.

MSP/LIS Updates February 9, 2023

Medicaid.gov has updated their MSP table for 2023 but states might not apply these criteria until March or April 1.

Helpful News for Some Lower Income Medicare Beneficiaries July 19, 2018

The Social Security Administration (SSA) has released revisions to the Program Operations Manual System (POMS) regarding how to process Part A enrollments that are conditional to a state’s determination of a beneficiary as a Qualified Medicare Beneficiary (QMB).  The update is intended to address inconsistencies and confusion in SSA field offices and includes important clarifications, ...

2018 CT Medicare Savings Programs January 10, 2018

If you have Medicare, Social Security deducts money from your check each month to pay for your Medicare Part B premium.  If you qualify for one of Connecticut’s three Medicare Savings Programs (MSP), the State of Connecticut will pay this monthly Part B premium on your behalf.  Your Social Security check will then increase each month. In addition to ...

CMA Alert – The REST of the Tax Cut Plan; “Jimmo” Improvement Standard Update; QMB News; Enrollment Periods End Soon November 30, 2017

The Plan: Pass a Devastating Tax Bill, Balloon the Deficit, then Gut the Social Programs We Rely On Jimmo Update: Court Orders CMS to Modify Special Jimmo Webpage ACA and Medicare Enrollment Periods End Soon Changes to Notice of Qualified Medicare Beneficiary (QMB) StatusThe Plan: Pass a Devastating Tax Bill, Balloon the Deficit, then Gut the Social Programs ...

CMA Alert – Changes to Help QMBs; Home Health Updates; ACA Sabotage October 4, 2017

CMS Changes Will Help Ensure Low Income Beneficiaries Are Not Illegally Billed CMS Reissues Improved Medicare Home Health Booklet Dispelling a Myth: Medicare Home Health Coverage is NOT a Short Term, Post-Acute Care Benefit The ACA Sabotage ContinuesCMS Changes Will Help Ensure Low Income Beneficiaries Are Not Illegally Billed The Centers for Medicare and Medicaid Services (CMS) is changing ...

Medicare General Enrollment Period Runs January through March 31; Offers Opportunities for Help Paying Medicare Cost-Sharing February 17, 2016

The 2016 Medicare Part A and B General Enrollment Period runs from January 1 through March 31, 2016. As detailed below, this enrollment period is especially important for many individuals who are not eligible for premium-free Medicare Part A. Most people do not pay a premium for Medicare Part A because they have sufficient work history. ...

CMS Report Finds Access to Care Problems for Low-Income Medicare Beneficiaries August 27, 2015

A recent Centers for Medicare & Medicaid Services (CMS) report, Access to Care Issues Among Qualified Medicare Beneficiaries (QMB), revealed several access to care problems for low-income Medicare beneficiaries enrolled in the QMB program. The report analyzed two studies focused on access to care for low-income beneficiaries. The first study utilized qualitative interviews with beneficiaries to ...

Medicare Physician Payment – Another One-Year Fix Passes Congress, With Usual “Extenders” and Some New, Permanent Payment Policies April 3, 2014

On Tuesday, April 1st, President Obama signed into law the "Protecting Access to Medicare Act of 2014" (H.R. 4302). 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 ...

2014 Income and Resource Information for Medicare Low-Income Programs February 6, 2014

Programs that help low-income people afford their Medicare, including the Medicare Savings Programs and the Part D Low Income Subsidy (also called LIS or Extra Help) have income and resource eligibility guidelines that change yearly. The Federal poverty level (FPL) guidelines for 2014 were published in the Federal Register on January 22, 2014.  These guidelines provide ...

The Medicare Improvements for Patients and Providers Act: Improving Enrollment in the Medicare Savings Program Five Years Later July 11, 2013

Five years ago this month, the Medicare Improvements for Patients and Providers Act (MIPPA) became law. Since then, MIPPA has successfully increased enrollment in the Medicare Savings Program and helped ensure that thousands of Medicare beneficiaries are able to afford necessary medical care. Despite MIPPA's success, Medicare low-income programs remain under-enrolled. Federal policy makers should ...

Medicare Cost-Sharing for Qualified Medicare Beneficiaries January 19, 2012

Balance Billing is Prohibited.  Period. New Guidance released jointly by the Center for Medicaid and CHIP Services (CMCS) and the Medicare-Medicaid Coordination Office (MMCO) once again highlights and advises about an issue that has created hardships for low-income people using Medicare and challenges for advocates trying to help them. The jointly-issued Guidance includes a link to ...

Help Someone Retain Part D Extra Help March 17, 2011

The Social Security Administration (SSA) has released state by state information on numbers of individuals whose Part D low income subsidy (extra help) will end March 31 if they do not respond to SSA’s request for information concerning their continued eligibility.  Nationwide, 86,789 low-income Medicare beneficiaries subject to routine redeterminations had not responded to SSA ...

Pennsylvania Lawsuit Increases Access to Medicare for Low-Income Beneficiaries February 14, 2011

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. The Garcia settlement will lower the cost of Medicare ...

2011 Poverty Levels Affect Eligibility for Many Federal Programs January 27, 2011

Federal poverty level (FPL) guidelines for 2011 were published in the Federal Register January 20, 2011. 76 FR 3637 (January 20, 2011).  The guidelines provide the baseline for eligibility levels for many public benefits, including health benefits for older people and people with disabilities. The published poverty levels merely state a dollar figure for different-sized family ...

Recommendations for a Beneficiary-Centered Office for Dual Eligibles July 22, 2010

The Affordable Care Act creates an office within the Centers for Medicare & Medicaid Services (CMS) whose focus is beneficiaries who are eligible for both Medicare and Medicaid (dual eligibles). Specifically, the Federal Coordinated Health Care Office (CHCO) is created for the purposes of:more effectively integrating benefits under Medicare and Medicaid for those dually ...

The Centers for Medicare & Medicaid Services Advises States About Medicare Savings Program Enrollment March 1, 2010

Introduction Long-awaited guidance from the Centers for Medicare & Medicaid Services (CMS) concerning implementation of various provisions of the Medicare Improvements for Patients and Protections Act of 2008 (MIPPA), Pub. L. 110-275, was released on February 18, 2010. The guidance, in the form of a State Medicaid Director Letter (SMDL # 10-003), signed by Center ...

LI NET: More Help for Dually-Eligible People December 24, 2009

In 2006 the Centers for Medicare & Medicaid Services (CMS) created the “Point-of-Sale Facilitated Enrollment” (POS) process, administered by WellPoint.  The purpose of the POS is to assist people who are dually eligible for Medicare and Medicaid (dual eligibles) in filling their prescriptions at the pharmacy if they have not ...

Medicare Cost-Sharing for Dual Eligibles: Who Pays What for Whom? April 24, 2008

Guidance released recently by the Centers for Medicare & Medicaid Services (CMS) sheds new light on an issue that has created hardships for beneficiaries and challenges for advocates trying to help them. The guidance addresses two issues: balance billing of Qualified Medicare Beneficiaries (QMBs)and payment of Medicare cost-sharing for dually eligible beneficiaries enrolled in Medicare ...

Medicare Secondary Payer Programs Articles

MSP Reporting Threshold Change – 2/18/2014 February 20, 2014

On February 18, 2014, CMS’s Financial Services Group announced in an Alert an important change in the reporting threshold for certain liability settlements, judgments awards or other payments required by Section 202 of the Strengthening Medicare and Repaying Tax Payers Act of 2012 (SMART Act). CMS is increasing its current reporting threshold from $300 to $1000. ...

Medicare Secondary Payer: Web Portal to Collect Data on Conditional Payment Amounts and Claims Detail October 3, 2013

The Medicare Secondary Payer (MSP) program is designed to reduce costs to the Medicare program by requiring other insurers of health care for beneficiaries to pay primary to Medicare. It applies in three situations: where there is liability insurance, e.g. for an accident; where there is workers compensation coverage, e.g., for a job related injury; ...

New CMS Website: Medicare Secondary Payer Conditional Payment Information February 21, 2013

On January 10, 2013, President Obama signed legislation for the establishment of a website to provide information to beneficiaries about their Medicare Secondary Payer (MSP) obligations.  While there are exceptions, Medicare generally expects to be reimbursed if it makes a conditional payment for which a third party, such as other insurance or a personal injury ...

Medicare Secondary Payer (MSP) Program: Proposed Rules for the Treatment of Funds Intended for Future Medical Expenses August 2, 2012

Advocates have long awaited clarification from the Centers for Medicare & Medicaid Services (CMS) about its rules and procedures for the treatment of future medical expenses related to an accident or injury for which there is third party liability and Medicare has made a conditional payment.  This is because there has been very little guidance ...

CMS Revises Its Medicare Secondary Payer Collection Letters Following Haro v. Sebelius Decision July 28, 2011

The Medicare Secondary Payer (MSP) program authorizes the Centers for Medicare & Medicaid Services (CMS) to recover compensation payments from beneficiaries who have private insurance that should be primarily responsible for their medical expenses. In a class action lawsuit brought by Medicare beneficiaries and their attorney to challenge certain harsh MSP collection practices, a federal district ...

Medicare Secondary Payer Practices that Harm Medicare Beneficiaries May 12, 2011

A group of organizations has identified collection practices in the Medicare Secondary Payer (MSP) program that are unnecessarily harmful to beneficiaries.  On April 28, 2011, the Center for Medicare Advocacy, together with the American Bar Association Commission on Law and Aging, the Medicare Rights Center, and the Center for Health Care Rights, wrote to the ...

Medicare Secondary Payer Collection Requirements for Insurers Threaten Beneficiary Rights February 17, 2011

The Medicare Secondary Payer (MSP) program seeks to conserve funds by prohibiting Medicare payment for health care that could be covered by another insurer.  Thus, when a Medicare beneficiary experiences an injury that might be covered by liability, no-fault, or workers’ compensation (hereinafter “liability”) insurance, Medicare will pay conditionally for her medical services, but recovers ...

Limits on Medicare’s Recovery Health Care Payments When the Beneficiary Has Liabaility or Workers’ Compensation Insurance September 17, 2009

The Medicare Secondary Payer (MSP) law was enacted by Congress to assure that Medicare does not pay for medical expenses that could be covered by private insurance. When beneficiaries are injured, Medicare will pay for care related to the injury if payment by these private insurances cannot be expected promptly, but it expects to recover ...

Medigap Articles

Spotlight on the Importance of Medigap September 14, 2023

We spotlight the importance of Medigap coverage.

Traditional Medicare or Medicare Advantage? February 9, 2023

Don't just be tempted by minor extras - think about overall needs - and remember what "Insurance" means.

CMA Senior Policy Atty. Kata Kertesz Publishes Article on Need for Medigap Protections July 18, 2022

This article explores how expansions of consumer protections for private Medigap supplemental insurance are necessary to promote health equity in the Medicare program.

Connecticut Expands Medigap Options for Medicare Beneficiaries Under Age 65 July 1, 2021

Connecticut has one of the country's most robust Medigap programs.

Article Raises Concerns about Medicare Advantage and Calls Attention to Limited Medigap Access April 25, 2019

A recent Bloomberg News article highlighted an important issue for Medicare beneficiaries: limited access to Medigap plans. The Center for Medicare Advocacy has long advocated for improved access to Medigap plans for all Medicare beneficiaries. Medigap plans are private plans that provide supplemental health insurance for beneficiaries in Traditional Medicare to assist with out-of-pocket medical expenses, ...

Improve and Expand Medicare: Ensure Medigap Access January 10, 2019

Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations to improve Medicare for all beneficiaries, now and in the future, is the need to preserve and expand consumer protections and quality coverage for all Medicare Beneficiaries – including parity between traditional Medicare and private Medicare ...

CMS to Clarify Medigap Section of the Medicare.gov Plan Finder Tool November 20, 2018

Concerned that Medicare beneficiaries could reject proper consideration of Medigap supplement plans because of undefined and significantly high costs listed in an “Estimated Annual Cost” column for Medigaps in the Medicare.gov CMS Plan Finder tool, the Center for Medicare Advocacy (the Center) requested CMS define costs that are included in the “Estimated Annual Cost” column. ...

Medigap News: Disparities in Enrollment Rights; Bill Introduced to Strengthen Medigap Access and Protections July 19, 2018

Kaiser Family Foundation Report A report recently issued by the Kaiser Family Foundation, “Medigap Enrollment and Consumer Protections Vary Across States” (July 2018), “provides an overview of Medigap enrollment and analyzes consumer protections under federal law and state regulations that can affect beneficiaries’ access to Medigap. In particular, brief examines implications for older adults with ...

Barriers to Medigap Coverage for Beneficiaries Under Age 65 October 26, 2016

Medicare is commonly known for providing health insurance for older people; however, a significant portion of the program’s beneficiaries are under age 65. Individuals with permanent disabilities and End Stage Renal Disease (ESRD) qualify for Medicare before turning 65. This subset of Medicare beneficiaries, who often deal with multiple chronic conditions and serious health complications, ...

Putting a Donut Hole Back in Medicare: Proposals to Increase Medigap Costs Put Vulnerable Beneficiaries at Risk December 20, 2012

Among proposals aimed at reducing federal spending for Medicare, some are suggesting that Medigap insurance be restructured to increase the cost-sharing burden on beneficiaries and/or add a surcharge for those that choose plans offering "first-dollar" or "near first-dollar" coverage.   These proposals operate under the assumption that charging beneficiaries more in up-front, out-of-pocket costs will deter ...

Medigap Rates December 1, 2011

 Connecticut as of 11/15/2011: http://www.ct.gov/cid/lib/cid/Medicare_Supplement_Insurance_Rates.pdf   Find policies in your area at: http://www.medicare.gov/find-a-plan/questions/medigap-home.aspx

Medigap – Fact & Fiction October 13, 2011

Nearly one in five Medicare beneficiaries rely on Medicare Supplemental insurance policies (Medigap) to fill in the gaps of some of their Medicare coverage.  As noted by the Kaiser Family Foundation, "Medigap policies help shield beneficiaries from sudden, relatively high out-of-pocket costs due to an unpredictable medical event, and also allow beneficiaries to more accurately ...

Health Reform Mandates Changes for Medigap Policies January 7, 2011

Medigap insurance (Medicare supplemental health insurance) is meant to work in tandem with the original Medicare program by paying for beneficiary cost-sharing and some other services not usually covered by Medicare. Thus, Medigap insurance serves as a key component of health insurance protection for individuals who rely upon the original Medicare program to finance their ...

Observation Status Articles

Advocates Join Center in Comments on Observation Status Appeals March 28, 2024

Offer general support, but with recommendations to improve procedures.

Organizational Sign-On Letter Commenting on Proposed Rule on Observation Status Appeals February 8, 2024

Would implement appeal rights for Medicare beneficiaries admitted to hospitals as inpatients then reclassified as outpatients receiving observation services.

Congressman Joe Courtney and Bipartisan Colleagues Reintroduce Observation Status Bill August 10, 2023

Only time in the hospital classified as “inpatient” counts toward the 3-days needed for nursing home coverage. Many patients are called “outpatients in observation,” instead, even though their care is indistinguishable from “inpatients” care.

Increased Use of Observation Stays Undermined Hospital Readmissions Reduction Program December 8, 2022

Hospital readmissions are not good when factoring in so-called "outpatient" observation.

Reminder: Questions or Comments on Proposed Clarification in Hospital “Observation Status” Case Due November 25 November 17, 2022

A clarification on addressing retroactive claims has been proposed and is out for review.

Medicare Announces Development of Appeal Process for Certain Hospital “Observation Status” Patients July 28, 2022

Medicare.gov website acknowledges Observation Status appeal rights, but says process is still underway.

It’s Time: Repeal the 3-Day Inpatient Hospital Requirement for Medicare Skilled Nursing Facility Coverage February 10, 2022

The outdated requirement of a 3 Day stay hasn't changed since 1965, when average stays were 13 days.

Court Upholds Right to Appeal for Certain Medicare Beneficiaries on “Observation Status” January 27, 2022

Medicare must provide appeal procedures for hospitalized beneficiaries who are reclassified from inpatients to “outpatients” receiving “observation services.”

HHS Inspector General Calls on CMS to Address Medicare Observation Status November 11, 2021

OIG calls on CMS to analyze counting time spent as an outpatient toward the 3-night requirement for SNF services.

Appeals Court Temporarily Pauses Implementation of Observation Status Decision While Considering Government’s Request for a Stay July 22, 2021

Government’s appeal of the trial decision remains pending. The Center and co-counsel continue to oppose the appeal and the stay.

Hospital Readmissions Reduction Program Misses Nearly 20% of Hospital Stays in “Observation Status” June 24, 2021

Observation stays described as “often clinically indistinguishable from inpatient hospitalizations billed under Medicare Part A.”

Senators Introduce Bipartisan Observation Status Bill to Help Vulnerable Medicare Beneficiaries June 17, 2021

A Medicare billing technicality should not prevent beneficiaries from getting the post-hospital care they need.

Observation Status Bill Reintroduced June 10, 2021

Bill would count time spent by a patient in a hospital under outpatient “observation status” towards satisfying the three-day stay required for Medicare Part A coverage of a nursing home stay.

It’s Time to Repeal the 3-Day Inpatient Hospital Requirement for Medicare Skilled Nursing Facility Coverage February 11, 2021

Times have changed. Congress should repeal the three-day inpatient requirement for multiple reasons.

Government Seeks to Stop Implementation of Court Order in Hospital Observation Status Case January 21, 2021

The Center and co-counsel will oppose the stay and continue to press for relief for class members.

“Observation Status” May Disproportionately Burden Medicare Beneficiaries in the Most Vulnerable Neighborhoods December 17, 2020

Medicare’s observation status policies have a disproportionate impact on those who can least afford it.

Federal Court Orders Appeal Rights for Some Observation Status Patients: More Advocacy is Needed April 16, 2020

In order to qualify for Medicare-covered skilled nursing facility (SNF) care, Medicare beneficiaries must be an inpatient of a hospital for at least three consecutive days, not including the day of discharge. Unfortunately, beneficiaries are too often either admitted to hospitals as outpatients on observation status or have their status changed to outpatient observation after ...

Frequently Asked Questions about Observation Status Court Decision April 9, 2020

On March 24, 2020, a federal court issued a decision in a nationwide class action, Alexander v. Azar, finding that certain Medicare beneficiaries who are admitted as “inpatients” and then changed to “observation status” at hospitals have the right to appeal to Medicare to challenge that status.The Center has posted answers to frequently asked questions about ...

Frequently Asked Questions about the “Observation Status” Court Decision April 7, 2020

On March 24, 2020, a federal court issued a decision in a nationwide class action, Alexander v. Azar, finding that certain Medicare beneficiaries who are admitted as hospital “inpatients” but then switched to “observation status” have the right to appeal to Medicare for coverage as hospital inpatients.Note: On October 31, 2022, the parties jointly proposed a ...

CMS Temporarily Waives Medicare Access Barriers for Skilled Nursing Facility Care March 26, 2020

On March 13, 2020, President Trump proclaimed the COVID-19 pandemic a national emergency. As a result, the U.S. Department of Health and Human Services (HHS) now has the authority under Section 1135 of the Social Security Act to waive or modify certain requirements of public health programs, including Medicare. The Centers for Medicare & Medicaid ...

Federal Court Orders Appeal Rights on “Observation Status” Issue for Certain Medicare Hospital Patients March 24, 2020

For Immediate Release March 24, 2020 Contact: Matthew Shepard: 202-293-5760, MShepard@MedicareAdvocacy.org In a decision issued today, Judge Michael P. Shea of the U.S. District Court in Hartford, Connecticut found that certain Medicare beneficiaries who are placed on “observation status” at hospitals, rather than being admitted as “inpatients,” have the right to appeal to Medicare. The case, Alexander v. Azar, ...

Accountable Care Organizations and Observation Status January 30, 2020

One of the ongoing problems that Medicare beneficiaries face is so-called “outpatient” hospital observation status. When a hospital classifies a patient as an outpatient, rather than as an inpatient, the result is that the patient is ineligible for Medicare Part A coverage of the post-hospital stay in a skilled nursing facility (SNF) (because the Medicare ...

Administrator Verma’s Tweet Sparks Support for Addressing Observation Status September 12, 2019

On August 4, CMS Administrator Seema Verma tweeted that beneficiaries wanting Medicare to pay for their stay at a skilled nursing facility (SNF) should make sure they are first admitted to the hospital for at least three days. Writing, “Govt doesn’t always make sense,” she concludes, “We’re listening to feedback.” Posted feedback supports addressing the issue ...

Alexander v. Azar Trial Update – Seeking an Appeal of Outpatient Observation Status August 22, 2019

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 was ...

CMS Administrator Acknowledges that Prior Inpatient Hospital Rules Do Not Make Sense August 8, 2019

Medicare requires beneficiaries to have a three-day inpatient hospital stay in order to qualify for skilled nursing facility (SNF) care. Unfortunately, too many beneficiaries continue to be classified as hospital outpatients on observation status, thereby eliminating their ability to receive Medicare-covered SNF care. In a recent Tweet, Centers for Medicare & Medicaid Services (CMS) Administrator ...

More Doors to Medicare Home Health Closing, More Harm for Observation Status Patients July 18, 2019

Many Medicare hospital patients classified as observation status “outpatients” currently forego necessary skilled nursing facility (SNF) care and head home to continue care through Medicare’s home health care benefit. This is because they lack a 3-day inpatient hospital stay, which is required for Medicare coverage of most beneficiaries’ post-acute care in a SNF. Beginning January ...

Observation Status and Surprise Medical Bills July 11, 2019

The Center for Medicare Advocacy frequently hears from Medicare beneficiaries and their families about patients who receive treatment, tests, and services for multiple days while they are in a hospital bed but who are called “outpatients.” If these patients need post-hospital care in a skilled nursing facility (SNF), Medicare Part A will not pay for ...

Congressional Hearing on Surprise Medical Bills; Center for Medicare Advocacy Submits Statement on Observation Status May 23, 2019

“Protecting Patients from Surprise Medical Bills” – a hearing held on May 21 by the House Ways and Means’ Subcommittee on Health – considered the bills for health care services that patients get after they received care from health care providers who were not in the patients’ health insurance network. Typically, patients receive these bills ...

Observation Status Deprives Medicare Beneficiaries of their Skilled Nursing Facility Benefit. Period. April 11, 2019

The facts are in: The ever-increasing use of observation status deprives many Medicare beneficiaries of care and coverage in skilled nursing facilities (SNFs).  In 2018, research by Avalere Health confirmed that the use of SNFs by beneficiaries in the traditional Medicare program declined each year between 2009 and 2016. Avalere identified the cause as “fewer hospital ...

Observation Status: Physicians Challenge the Inspector General March 28, 2019

A group of physicians has challenged a recent audit report from the Inspector General for the Department of Health & Human Services Like the ...

Members of Congress Reintroduce Legislation to Fix Outpatient Observation Status March 14, 2019

Medicare requires a three-day inpatient hospital stay in order to qualify for care at a skilled nursing facility. Sadly, and all too often however, beneficiaries are classified as hospital outpatients on observation status. While outpatients on observation status and inpatients may receive the same care and services, for the same number of days or weeks, ...

Improve and Expand Medicare: End the Use of Outpatient Observation Status – A Billing Issue that Restricts Needed Care February 28, 2019

Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations to improve Medicare for all beneficiaries, now and in the future, is the need to end ongoing barriers to care. One of the most common barriers about which the Center receives inquiries is the continued overuse ...

Improve Medicare: Correct Medicare Hospital Observation Status January 3, 2019

Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations to improve Medicare for all beneficiaries, now and in the future, is the need to reduce ongoing barriers to coverage and care. One of the key issues impeding access to Medicare coverage is the continued, and ...

Study: Three-Day Hospital Requirement for Post-Hospital Care In a Skilled Nursing Facility Increases Medicare Costs October 4, 2018

In order to qualify for Medicare Part A coverage of a post-hospital stay in a skilled nursing facility, the traditional Medicare program requires that the beneficiary first be hospitalized as an inpatient for three consecutive days, not counting the day of discharge.  This requirement has been in place since the Medicare program was enacted more ...

Does Observation Status Undercut Claims that Hospital Readmissions Have Been Reduced?  MedPAC Says No, Research Says Yes. June 21, 2018

As required by the Affordable Care Act, the Medicare Hospital Readmissions Reduction Program (HRRP) reduces Medicare payment rates, by up to 3%, to hospitals that readmit patients with certain specified conditions within 30 days.  The financial penalty is applied only when the patient’s initial hospital stay and subsequent hospital stay are both identified as inpatient.  ...

NPR Observation Status Story: How Medicare’s Conflicting Hospitalization Rules Cost Me Thousands Of Dollars April 26, 2018

On April 20, 2018, Alison Kodjak of NPR published the story of trying to navigate her own Mother’s “Outpatient” Observation Status and follow-up care.  After four nights in the hospital, all coded as observation, Alison’s Mother, Catherine Fitzgerald, was discharged, still unable to walk, and in need of follow-up care at a skilled nursing facility, ...

Hospitalists Continue to Oppose Observation Status and Call for Significant Change March 1, 2018

Patients in “outpatient” observation status often receive care in acute care hospitals that is indistinguishable from the care patients receive when they are formally admitted to hospitals as inpatients.  Nevertheless, the financial consequences of outpatient status are considerable, particularly for patients who need post-acute care in a skilled nursing facility (SNF).  Medicare Part A does ...

Annotated Bibliography: Observation Status September 13, 2017

Abbey, Duane. “Inpatient Versus Outpatient: The Real Issue.” RAC Monitor. 06 March 2014. http://www.racmonitor.com/rac-enews/1618-inpatient-versus-outpatient-the-real-issue.html (site visited September 21, 2016). The author writes that there aren’t any well-established guidelines for Recovery Audit Contractors (RACs) when they review observation-related Medicare appeals. When there are disagreements, RACs can be directed to specific criteria. Unfortunately, Medicare RACs lack such ...

CMA Alert – Critical Issue Roundup: MA Overpayment; HH Payment; Observation; More August 16, 2017

Former CMS Administrator Comments on Medicare Advantage Overpayments Proposed Home Health Rules – Payments Drive Delivery of Care, Harming Beneficiaries Observation Status Harms Low-Income Medicare Beneficiaries Poll: Americans Favor Making the ACA WorkFormer CMS Administrator Comments on Medicare Advantage Overpayments In Austin Frakt’s August 7, 2017 The Upshot blog in the New York Times (“Medicare Advantage Spends Less on ...

Look for the Moon! March 1, 2017

Beginning no later than March 8, 2017, hospitals are required to give written and oral notice to Medicare patients when they are placed in “outpatient” observation status for 24 hours and are not formally admitted as inpatients. Although hospitals can provide all the care that ...

CMS Issues Instructions Regarding the Medicare Outpatient Observation Notice (MOON) February 15, 2017

Beginning no later than March 8, 2017, and as required by the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act),  Hospitals must use the written notice ...

HHS Inspector General: Observation Status is a Growing Problem for Patients January 4, 2017

HHS Inspector General: Observation Status is a Growing Problem for Patients In a new report, Vulnerabilities Remain Under Medicare’s 2-Midnight Hospital Policy, the HHS Inspector General documents and confirms what Medicare beneficiaries and their advocates have seen: long outpatient stays in hospitals are increasing. How hospitals bill the Medicare program – Part A for inpatient status, ...

Hospitals Must Give Patients Notice of Their Observation Status, Beginning March 8, 2017 December 14, 2016

Effective August 6, 2016, the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) requires acute care hospitals to provide oral and written notification to patients who are classified as outpatients or observation status patients for more than 24 hours.  Notice of non-inpatient status must be provided within 36 hours.  On August ...

Observation Status Impedes Access to End-of-Life Skilled Nursing Facility Care November 3, 2016

Mr. P. has been hospitalized after having a heart attack. He also has terminal cancer for which he wants to continue treatment. If Mr. P. is admitted as an inpatient for a total of three days while in the hospital, he can qualify for Medicare Part A coverage of subsequent Skilled Nursing Facility (SNF) stay ...

Stop Calling Inpatients Outpatients: Medicare Created Observation Status – Ask Them to Change It! September 23, 2016

This summer, the New York Times article “New Medicare Law to Notify Patients of Loophole in Nursing Home Coverage”* told the story of one of many people who contact the Center for Medicare Advocacy for help with hospital “outpatient” Observation Status. These patients stayed in the hospital for multiple days receiving skilled care, but were ...

Submit Your Observation Status Story August 29, 2016

<a data-cke-saved-href="https://www.eSurveysPro.com/Survey.aspx?id=8588f152-de28-42a0-82fd-09d8b0aff1ff" href="https://www.eSurveysPro.com/Survey.aspx?id=8588f152-de28-42a0-82fd-09d8b0aff1ff" target=_blank>Click here to take the survey now</a>. The survey was created with eSurveysPro.com <a data-cke-saved-href="https://www.eSurveysPro.com" href="https://www.eSurveysPro.com" target='_blank' title='Online survey software'>survey software</a>.

Observation Status Hurts Medicare Beneficiaries – Whether they have NOTICE or Not August 10, 2016

An August 7, 2016 New York Times article once again highlighted the problem of hospital Observation Status, including issues with the NOTICE Act, which is supposed to help Medicare beneficiaries understand their status. The article, New Medicare Law to Notify Patients of Loophole in Nursing Home Coverage, featured a Center For Medicare Advocacy client's story. In the piece, Center Executive Director Judith ...

CMS Delays Implementation of NOTICE Act Until Fall 2016 August 4, 2016

Beginning August 6, 2016, the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) requires hospitals to provide written and oral notice, within 36 hours, to patients who are in observation or other outpatient status for more than 24 hours.  The notice must explain the reason that the patient is an outpatient ...

A Model to Waive the Three-Day Inpatient Hospital Stay Requirement for Care in a Skilled Nursing Facility July 20, 2016

In order for Medicare Part A to pay for a patient’s stay in a skilled nursing facility (SNF), the patient must first have spent at least three consecutive days as an inpatient in an acute care hospital.  For many Medicare beneficiaries, Part A SNF coverage is denied because the hospital classifies the stay as Outpatient ...

More on Observation Status: CMS Halts Review of Hospitals’ Compliance with Two-Midnight Rule May 25, 2016

The controversial issue of Observation Status continues.  The latest news is that the Centers for Medicare & Medicaid Services (CMS) told Quality Improvement Organizations (QIOs) on May 4 that they should temporarily pause their reviews of hospitals’ compliance with the two-midnight rule.  The pause was reported by Livanta, one of the two QIOs nationwide (the ...

Observation Status and the NOTICE Act: Advocates Not Over the MOON April 27, 2016

In proposed rules updating Medicare reimbursement to acute care hospitals,  Effective August 6, 2016, the NOTICE Act requires that hospitals provide written and oral notice, within 36 hours, ...

CMS Hosts Tele Town Hall on Hospital Observation NOTICE Act; Comments Accepted until January 4, 2016 December 23, 2015

The Centers for Medicare & Medicaid Services (CMS) hosted a Tele Town Hall on December 21, 2015 to solicit comments on the Notice of Observation Treatment and Implications for Care Eligibility (NOTICE) Act, Public Law 114-42.  Beginning in August 2016, the NOTICE Act requires hospitals to inform patients who are hospitalized for more than 24 ...

Office of Inspector General Authorizes Hospitals to Discount or Waive Certain Drug Charges for Patients Classified as “Outpatients” December 10, 2015

The Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS) released a statement on October 30, 2015 that advises hospitals that it will not administratively sanction them if they discount or waive charges for an outpatient’s self-administered drugs. Thus, hospitals now have the option, and a greater incentive, not ...

Revisions to “Two-Midnight Rule” Do Not Help Hospitalized Medicare Patients in Observation Status December 2, 2015

In 2013, the Centers for Medicare & Medicaid Services (CMS) promulgated the Two-Midnight Rule, which, for the first time in the Medicare program’s 50-year history, determined patient status in a hospital by reference to time.  Specifically, CMS’s new rule provided that a patient would be considered an inpatient, and the hospital stay would be covered ...

Solution to Medicare Part B Cost Increases? Look at “Outpatient” Observation Status October 23, 2015

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 misguided ...

Observation Status Again! August 20, 2015

Hospitals often classify hospitalized Medicare patients as outpatients, even though their hospital care may be indistinguishable from the care they would receive if they were formally admitted as inpatients.  This issue – called Observation Status – has been a serious problem for Medicare beneficiaries for many years, chiefly because patients who do not have at ...

Observation Status: The NOTICE Act Will Soon Be Law August 6, 2015

An increasing number of patients in hospitals are not formally admitted as inpatients, but as “outpatients” on “observation status.”  Although they receive whatever medical and nursing care, diagnostic tests, medications, and food they need, their status as “outpatients” means that they do not satisfy the three-day inpatient hospital prerequisite for Medicare coverage of post-acute care ...

Proposed Revisions to “Two-Midnight” Rule Provide Little, If Any, Relief for Medicare Beneficiaries Stuck in the Hospital in Observation Status July 9, 2015

In the annual update to Medicare reimbursement of acute care hospitals for outpatient care (July 8, 2015) the Centers for Medicare & Medicaid Services (CMS) includes proposed revisions to the “Two-Midnight Rule” and its enforcement. If the proposed changes lead to an increased number of patients being formally admitted as inpatients (rather than, as now, placed ...

Observation Status: Virginia Requires Hospitals to Notify Patients of their Observation Status July 9, 2015

Effective July 1, 2015, Virginia has become the fifth state to enact legislation requiring hospitals to inform patients when they are in Observation or other outpatient status, and the consequences of not being admitted as inpatients.  Senate Bill 750 requires hospitals to provide oral and written notice to patients who are receiving “onsite services” (including ...

Saga of an Inpatient Hospital Appeal: Notice and Use of Lifetime Reserve Days and Comments on Observation Status May 21, 2015

This CMA Alert highlights a recent individual ALJ decision that sets out an important but often unrecognized beneficiary right to a written notice when he or she is about to use hospital “Lifetime Reserve Days.”  A hospital’s failure to provide appropriate notice in this context can lead to the waiver of a beneficiary’s liability for ...

Observation Status Update April 23, 2015

Observation Status – hospital patients’ classification as outpatients, which makes them ineligible for Medicare Part A coverage of their subsequent stay in a skilled nursing facility (SNF) when they do not have “inpatient” status for at least three consecutive midnights – is an ongoing issue that the Center for Medicare Advocacy has discussed many times.  ...

Observation Status and the Medicare Payment Advisory Commission January 22, 2015

At its January 16, 2015 public meeting, the Medicare Payment Advisory Commission (MedPAC), the government agency that advises Congress on Medicare payment policy, addressed observation status as part of its discussion of hospital short stay policy issues.  MedPAC Commissioners preliminarily, but unanimously, voted to move forward on a recommendation to count time in observation status ...

Appeals Court Allows Hospital Patients in “Observation Status” to Continue Court Case January 22, 2015

Medicare patients considered hospital outpatients on Observation Status may be helped by a decision issued on January 22, 2015 by a federal appeals court.  A three-judge panel of the U.S. Court of Appeals for the Second Circuit decided that Medicare patients who are placed on “Observation Status” in hospitals may have an interest, protected by ...

Observation Status: Hospitals May Begin Rebilling Medicare Patients Who Were Hospitalized After October 1, 2013 September 4, 2014

Medicare patients need to be aware that if they were hospitalized after October 1, 2013, hospitals may be contacting them about their bills. Final rules that were published in August 2013 and became effective October 1, 2013 created a new regulatory provision, 42 C.F.R. 414.5, "Hospital services paid under Medicare Part B when a Part A ...

Observation Status: Mixed Messages from Federal Government as Beneficiaries Continue to be Hurt August 14, 2014

The use of “Observation Status” – treating certain hospitalized Medicare patients as outpatients when their care is indistinguishable from that of formally admitted inpatients – continues to garner considerable public and Congressional attention. It remains an unresolved problem that has serious financial consequences for Medicare patients and their families.   On July 30, 2014, the Senate Special ...

CMS has Authority Under Existing Law to Define Inpatient Care July 16, 2014

Under a 2008 decision of the Second Circuit Court of Appeals, the Secretary of HHS has authority under the Medicare statute to include a hospital patient’s time in observation as part of inpatient time in the hospital for purposes of determining whether the patient qualifies for Part A coverage of a subsequent stay in a ...

Observation Status – Notice and Appeal June 19, 2014

Connecticut Passes Observation Notice Law On June 12, 2014, Connecticut Governor Dannel P. Malloy signed into law a requirement that, starting October 1, 2014, Connecticut hospitals give oral and written notice to patients placed on observation status for 24 hours or more.  Similar laws already exist in New York and Maryland.  Specifically, Connecticut's law requires:A statement ...

Harm from Medicare’s Hospital Observation Status Debated In Congressional Hearing – Center for Medicare Advocacy Presents Beneficiary Perspective May 21, 2014

May 21, 2014 The May 20, 2014 hearing on "Current Hospital Issues in the Medicare Program," held by the Health Subcommittee of the House Committee on Ways and Means, was the first Congressional hearing to consider the impact of observation status on hospitalized Medicare patients.  At the hearing, the Center for Medicare Advocacy's Senior Policy Attorney, ...

Senior Policy Attorney Toby S. Edelman Testifies about Observation Status before Congress May 15, 2014

Center for Medicare Advocacy Senior Policy Attorney Toby S. Edelman will testify before the House Ways and Means Health Subcommittee on Tuesday, May 20, 2014 at 9:30 AM regarding current hospital issues in the Medicare program, specifically the ongoing problem of observation status. The hearing, announced on May 13th, is the first Congressional hearing to consider ...

Submitting Claims to Part D for Prescription Drugs Administered in the Hospital During an Observation Status Stay May 1, 2014

The use of Medicare observation status in hospitals has increased dramatically over the past several years. However, many of the beneficiaries the Center assists also find themselves facing large hospital bills for drugs ...

New Study: CMS’s New 2-Midnight Rule Increases Hospital’s Use of Observation Status February 20, 2014

Final rules published in August 2013 by the Centers for Medicare & Medicaid Services (CMS) created time-based rules for determining inpatient status in an acute-care hospital.  Under the rules' two-midnight presumption, a physician should order an inpatient admission if the physician expects that the patient's stay in the acute care hospital will be at least ...

Center and “Observation Status” on NBC Nightly News January 10, 2014

As our client, Ms. Bricout states in this video, Observation Status is simply "illogical."  But there is a sound, viable solution! Congressman Joe Courtney has a bill pending in Congress that would fix the observation status problem for good: the Improving Access to Medicare Coverage Act of 2015 (H.R. 1571 and S. 843).

Three Observation Status Bills Have Been Introduced; Only Congressman Courtney’s Has Immediate Promise November 27, 2013

>Hospitals' increasing use of observation status harms more Medicare beneficiaries daily as patients hospitalized for multiple days are denied coverage of subsequent care in a skilled nursing facility because their time in the hospital was labeled "outpatient," not "inpatient."  Since the enactment of the Medicare program nearly 50 years ago, Medicare has limited payment for ...

New CMS Rules Do NOT Change Requirement for 3-Day Qualifying Inpatient Hospital Stay October 31, 2013

The Center for Medicare Advocacy has heard that some Medicare beneficiaries believe that new federal rules authorize Medicare to pay for their nursing home care if they are inpatients in a hospital for two midnights.  This belief is NOT CORRECT.  New rules published by the Centers for Medicare & Medicaid Services (CMS) in August 2013, ...

Disappointing Decision from Court in Challenge to “Observation Status” Highlights Need to Pass Legislation September 26, 2013

On September 23, a federal judge in Connecticut dismissed a lawsuit filed by the Center for Medicare Advocacy and the National Senior Citizens Law Center on behalf of Medicare beneficiaries who have been placed on "observation status."  When hospital patients are placed on observation status they are labeled "outpatients," even though they are often on ...

Observation Status Round Up September 5, 2013

While Observation Status continues, recent weeks have seen a great increase in awareness of the problem.  In addition, support for legislation to end Observation Status has grown rapidly.What is Observation Status?Observation Status refers to the classification of hospital patients as "outpatients," even though, like inpatients, observation patients may stay for many days and nights in ...

Observation Status: New Final Rules from CMS Do Not Help Medicare Beneficiaries August 29, 2013

Effective October 1, 2013, new rules for inpatient hospital reimbursement under the Medicare program  Neither set resolves the ...

Observation Status: OIG Provides an Analysis and CMS Issues Final Regulations August 8, 2013

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 ...

Observation Status: “Morphed Into Madness” August 1, 2013

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 ...

CMS Addresses Observation Status Again… And Again, No Help for Beneficiaries May 16, 2013

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 ...

End Observation Status! May 7, 2013

$30,000 – that’s Mrs. Kauffman’s nursing home bill for care she received following a three-day hospitalization. Although she was in the hospital for three full days, Mrs. Kauffman was never admitted as an inpatient. Instead, she was classified as an outpatient on "observation status."  Because Medicare coverage for nursing home care is only available after ...

CMS’ Proposed Rules on Observation Status Would Not Help Beneficiaries March 28, 2013

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).  These actions address some financial concerns of hospitals about “observation status;” but they do not ...

Bills Concerning Hospital Observation Status Reintroduced March 21, 2013

Increasingly, hospital patients throughout the country are learning they are considered outpatients, on "observation status," not inpatients, although they have stayed many days and nights and been treated IN a hospital. The Center has written extensively about this practice and is pursuing litigation to challenge it in federal court.  Among the harmful consequences of observation ...

Déjà Vu All Over Again: CMS Decides (Again) Not to Decide About Observation Status November 20, 2012

On July 30, 2012, as part of proposed rulemaking on the outpatient prospective payment system, the Centers for Medicare & Medicaid Services (CMS) asked for public comment on potential policy options related to "observation status." What is Observation Status? Observation status refers to the classification of a patient in an acute care hospital as an outpatient, even ...

CMS Invites Public Comment on Observation Status August 9, 2012

August 9, 2012 Note to Alert readers: This Posted version contains additional information beyond that in the emailed version.As part of a notice of proposed rulemaking published in the Federal Register on July 30, 2012, the Centers for Medicare & Medicaid Services (CMS) is asking for public comments on potential policy changes related to observation status.  ...

More Concerns About Observation Status: Hospitals Join the Chorus July 12, 2012

Hospital case managers and the hospital industry have joined the chorus of those opposed to observation status – a designation that renders a beneficiary ineligible for Medicare-covered skilled nursing facility (SNF) care.  This Alert discusses a recent survey by the American Case Management Association and an amicus brief filed by the American Hospital Association in ...

Brown University Confirms Observation Continues to Replace Hospital Admission Status June 7, 2012

Since 2008, the Center for Medicare Advocacy (the Center) has been reporting that an increasing number of Medicare beneficiaries are being placed in acute care hospital beds for multiple days – receiving medical and nursing care, diagnostic tests, treatments, medications, and food – but are being called “outpatients” in observation status, rather than admitted “inpatients.”  ...

Reducing Rehospitalizations… The Right Way March 1, 2012

For several years, reducing rehospitalizations of Medicare beneficiaries has been a key public policy goal, the intent of which is to improve quality of care for beneficiaries and reduce costs for the Medicare program.  Studies have shown that rehospitalizations are common and expensive.  In 2006, for example, nearly one-quarter of nursing home residents (23.5%) were ...

Preserving Access to Necessary Care: Ending Hospital “Observation Status” November 3, 2011

The Center for Medicare Advocacy has heard increasingly about beneficiaries throughout the country whose entire stays in a hospital, including stays as long as 14 days, are classified by the hospital as outpatient observation.  In some instances, the beneficiaries' physicians order their admission, but the hospital retroactively reverses the decision.  As a consequence of the classification of ...

Congressman Joe Courtney and Center for Medicare Advocacy Hold Congressional Briefing on Observation Status October 24, 2011

Coalition Urges Congress to Pass Legislation Safeguarding Medicare Beneficiaries' Skilled Nursing CareFor Immediate Release October 21, 2012 Terry Berthelot 860-456-7790 Toby Edelman 202-293-5760Washington, DC. – A Congressional briefing on "observation status," sponsored by Congressman Joe Courtney (D. CT), was held yesterday afternoon to examine Medicare beneficiaries' being denied Medicare coverage for care in a skilled nursing facility (SNF) when their ...

Study Finds that Use of Hospitalists Shifts Costs from Inpatient Care to Post-Discharge Setting September 8, 2011

Hospitalists are defined as physicians who are based full-time in acute care hospitals and who provide care to hospitalized patients.  The past decade has witnessed a rapid growth in hospitals' use of hospitalists, who have been shown to lead to reduced lengths of inpatient hospital stays.  A new study, however, finds that decreased inpatient costs ...

CMA And Others Support Legislation to End “Observation Status” June 21, 2011

Max Richtman, Chair May 20, 2011 The Honorable John Kerry The Honorable Olympia Snowe United States Senate Washington, DC 20510 The Honorable Joe Courtney The Honorable Tom Latham United States House of Representatives Washington, DC 20515 Dear Senators Kerry and Snowe and Representatives Courtney and Latham: The Leadership Council of Aging Organizations (LCAO) – a coalition of national not-for-profit organizations representing 60 million older Americans – ...

Senators Kerry and Snowe, with Representatives Courtney and Latham, Introduce Legislation to Ensure Skilled Care for Seniors April 26, 2011

Improving Access to Medicare Coverage Act of 2011 Section by Section Summary Sen. John F. Kerry & Sen. Olympia Snowe Section 1:  Short Title—"Improving Access to Medicare Coverage Act of 2011". Section 2:  Counting a Period of Receipt of Outpatient Observation Services in a Hospital towards the 3-Day Inpatient Hospital Requirement for Coverage of Skilled Nursing Facility Services under ...

Extended Observation Stays in Acute Care Hospitals: Criticism, Legislation and Discussion August 26, 2010

“Observation” is the term used to describe the outpatient status of a patient who is in a hospital, but not as an inpatient. Although the Medicare Manuals limit observation to 24-48 hours, many beneficiaries nationwide are experiencing extended stays in acute care hospitals under observation. A major consequence for beneficiaries of not being classified as ...

Overcoming Barriers to Medicare Coverage of Skilled Nursing Facility Care March 10, 2010

On March 10, 2010 NCCCNHR, The National Consumer Voice for Quality Long-Term Care, along with the Center for Medicare Advocacy hosted a web seminar on overcoming barriers to skilled nursing care, presented by Center Senior Policy Attorney Toby S. Edelman. Recorded copies are still available! Medicare pays for more residents in nursing homes than ever before, and ...

Observation Services: What Can Beneficiaries and Advocates Do? February 18, 2010

What are Observation Services? CMS Brochure Favorable DecisionsWhat Should Beneficiaries and their Advocates Do? Continuing WorkBeing in a hospital bed in a Medicare-participating hospital is no guarantee that a Medicare beneficiary is an inpatient.  In our December 11, 2008 Alert, the Center for Medicare Advocacy described the increasingly common practice of placing Medicare beneficiaries in acute care hospital beds ...

Keeping Hospital Patients on “Observation Status” Rather Than Admitting Them Harms SNF Patients As Well As Hospital Patients April 19, 2001

Advocates at the Center for Medicare Advocacy recently settled a case involving an individual who was in a hospital bed for four days but was never "formally admitted ". Instead, the hospital accorded her "observation status ". Although Medicare Part B covered her, she was not only not unable to obtain a determination of Part ...

Lormore v. Shalala – Center Successfully Settles "Observation" Case April 19, 2001

No. 3:00CV563(AVC), filed March 24, 2000 Updated: April 19, 2001 Issue: (1) Whether a four-day stay in a hospital can be considered “outpatient observation” status and thus preclude meeting the 3-day qualifying condition for post-hospital skilled nursing facility care; (2) whether a hospital’s refusal to submit a Part A claim, and thus to keep the plaintiff out ...

Quality of Care Articles

Information Requested on “Corporate Greed in Health Care” April 11, 2024

Private Equity ownership has been a disaster for nursing home residents, and that trend would no doubt continue in other care settings.

Study Examines Health Equity Differences between Medicare and Medicare Advantage April 4, 2024

"MA plans’ care management strategies do not provide appropriate care to all patients"

CMS Must Strengthen Federal Criteria for Certifying Nursing Homes for Medicare and Medicaid Reimbursement February 22, 2024

Keeping poorly performing operators from operating additional facilities would dramatically improve quality of care.

Sufficient Nursing Facility Staffing Saves Lives, Insufficient Staffing Harms and Kills July 20, 2023

Recent analyses find what all studies of staffing have consistently found for decades – higher staffing levels mean better care for residents and lower staffing levels mean resident harm and death.

CMS to Review Five Medicare Claims from Each Skilled Nursing Facility July 6, 2023

Doubling of Improper payment rate findings leads to review.

CMS Report Highlights Quality of Care Concerns in MA June 22, 2023

Dually eligible beneficiaries with disabilities fare worse on several quality measures, and inequities exist among all duals compared to non-duals.

Gaps in Hospice Abuse and Neglect Reporting January 12, 2023

CMS should ensure hospice reporting requirements are at least as stringent as other providers.

Study Finds Relationship Between Religiously Affiliated Nursing Homes and Standard of Care Complaints and Violations April 21, 2022

Religious affiliation often fosters a “cognitive and emotional link between the organization and its members.”

Second State Report Recommends Barring Medicaid Payments to Chronically Poor-Performing Nursing Facilities February 10, 2022

Facilities that fail or refuse to provide acceptable levels of care to residents should be barred from receiving public funding. 

Elder Justice Newletter, Vol. 3 Issue 8 Now Available July 8, 2021

In the Elder Justice Newsletter, we highlight citations, that have been identified as not causing any resident harm.

Elder Justice Newsletter – Vol 3, Issue 6 Now Available April 29, 2021

The Elder Justice Newsletter highlights SNF citations that have been identified as not causing any resident harm - despite causing great harm.

Oscar Nominated Documentary Goes Undercover in Chilean Nursing Home April 22, 2021

Film illustrates how even a simple phone call to a loved one can make a meaningful difference.

Special Report – Nursing Homes Cited with Infection Control Deficiencies During the Pandemic: Poor Results In Health Inspections, Low Staffing Levels June 17, 2020

We analyzed the information on Nursing Home Compare for the 160 facilities that were cited with infection control deficiencies during the pandemic. By various measures, these facilities provide poor quality care.

CDC’s Report on Coronavirus in a Seattle Nursing Facility: What it Tells Us About Staffing Problems Nationwide; What We Must Do to Address Lessons Learned April 9, 2020

The Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Weekly Report for March 18, 2020 describes, as of March 9, coronavirus and the Life Care Center at Kirkland (Washington State): “Introduction of COVID-19 into a long-term residential care facility in Washington resulted in cases among 81 residents, 34 staff members, and 14 visitors; ...

Changes Coming to CMS Websites for Consumers February 13, 2020

A recent blogpost by Administrator Seema Verma of the Centers for Medicare & Medicaid Services (CMS) announces CMS’s plan to “combine and standardize” the eight Compare websites into a Medicare Compare website. At the same time, an unidentified spokeswoman wrote to McKnight’s Long-Term Care News, an on-line trade publication, that “‘CMS is interested in evaluating ...

Study Finds Nursing Home Compare Data about Patient Falls with Major Injuries Underreported and “Highly Inaccurate” January 30, 2020

In the first “national-level assessment of how nursing homes self-report major injury fall rates, which are used by CMS for quality measurement and public reporting,” researchers “found substantial underreporting on the specific Minimum Data Set (MDS) item (J1900C) used by NHC .”  Prachi Sanghav, Shengyuan Pan, Daryl Caudry, “Assessment of nursing home reporting ...

Medicare SNF Payment Model Creates Changes in Care and Admissions – What about Facility Assessments? January 30, 2020

The new Medicare reimbursement system for skilled nursing facilities (SNFs) – the Patient-Driven Payment Model (PDPM) – fundamentally changes the financial incentives for facilities. With PDPM, Medicare now pays lower rates for residents needing therapy and higher rates for residents needing complex nursing care. Responding to these financial incentives, SNFs laid off therapists across the ...

Quality Care for Nursing Home Residents Act of 2019 December 5, 2019

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 22, ...

Poorly Performing Skilled Nursing Facilities: What Happens to Them? November 7, 2019

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, ...

Nursing Home Compare’s Abuse Icon is Now Live October 24, 2019

On October 23, 2019, the Centers for Medicare & Medicaid Services (CMS) began use of a new “abuse icon” on Nursing Home Compare. Consumers using the website will now be alerted when a nursing home has been cited for an abuse violation in the past year or over each of the past two years, depending ...

Nursing Home Deregulation Continues, Despite Substantial Risk to Residents September 5, 2019

September 2019 Background Under the Trump Administration, the Centers for Medicare & Medicaid Services (CMS) has been advancing efforts to deregulate the nursing home industry by rolling back the rights and protections of nursing home residents. These efforts include reducing accountability for substandard care, such as by shifting the default financial penalty for the most serious health ...

Federal Reports Find Incidents of Nursing Home Resident Abuse Are on the Rise but also Underreported August 1, 2019

                      Joint statement from the Center for Medicare Advocacy and the Long Term Care Community Coalition. On July 23, 2019, the U.S. Government Accountability Office (GAO) published a report on nursing home resident abuse, Improved Oversight Needed to Better Protect Residents from Abuse. The GAO found ...

Nursing Home “Quality Measures” Do Not Reflect Quality of Nursing Home Care July 3, 2019

The federal website for information about nursing homes, Nursing Home Compare, reports information for each Medicare-certified and Medicaid-certified nursing facility in three categories – health inspections, staffing, and quality measures – as well as an overall score that combines the three domains. The health inspections domain reflects the findings of standard (annual) and complaint surveys ...

Special Report – “Graduates” From the Special Focus Facility Program Provide Poor Care June 20, 2019

The Centers for Medicare & Medicaid Services (CMS) identifies about 88 nursing facilities – generally one to two facilities per state – that are among the most poorly performing facilities in the country. These nursing facilities, which CMS calls Special Focus Facilities (SFFs), have “more problems” than other facilities, “more serious problems” than other facilities, ...

Senators Release Secret List of Poor Quality Nursing Homes June 6, 2019

At present, only 88 nursing facilities nationwide (0.6% of the nation’s total number of facilities) are identified as Special Focus Facilities (SFFs). The Centers for Medicare & Medicaid Services (CMS) describes SFFs as having “more problems” than other facilities, “more serious problems” than other facilities, and “ pattern of serious problems that has persisted over ...

Nursing Home Compare Inaccurately Reports Civil Money Penalties Imposed Against Nursing Facilities May 30, 2019

Public information about enforcement actions imposed and upheld against nursing facilities is inaccurate and limited, or missing.The Center for Medicare Advocacy (the Center) analyzed whether the federal website Nursing Home Compare to determine if it accurately reports civil money penalties (CMPs) that were imposed against nursing facilities and upheld by Administrative Law Judges (ALJs).  The Center identified 18 decisions by ALJs ...

Protecting Nursing Home Residents from Reckless Operators May 16, 2019

Last year, New Jersey-based Skyline Healthcare abandoned more than 100 nursing facilities nationwide, forcing multiple states to seek receiverships in court in order to protect residents and make sure they received food, medications, and care. States had allowed Skyline to take over the facilities, many from the nursing home chain Golden Living, even as Skyline’s ...

Latest Issue – Elder Justice Newsletter April 18, 2019

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 ...

Transfer and Discharge Deficiencies Cited Since 2017: Surveyors Focus On paperwork, Not Residents’ Rights September 20, 2018

The involuntary transfer and discharge of nursing home residents is the top complaint received by nursing home ombudsman programs nationwide.  In December 2017, the Centers for Medicare & Medicaid Services (CMS) announced an initiative “to examine and mitigate facility-initiated discharges that violate federal regulations.”  While recognizing the seriousness of involuntary transfer and discharge for residents ...

House Committee Holds Hearing on Nursing Home Quality Issues September 13, 2018

For the first time in many years, Congress held a hearing on nursing home quality of care on September 6, 2018.  The hearing of the Subcommittee on Oversight and Investigations of the House Energy and Commerce Committee, entitled “Examining Federal Efforts to Ensure Quality of Care and Resident Safety in Nursing Homes,” featured three witnesses: ...

Elder Justice: What “No Harm” Really Means for Residents – Latest Issue August 16, 2018

Elder Justice: What "No Harm" Really Means for Residents is a monthly 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 to nursing ...

Special Focus Nursing Facilities that “Have Not Improved:” Poor Care for Residents, Overall Ratings Artificially Boosted by 5-Star Ratings in Self-Reported Quality Measures August 15, 2018

The Centers for Medicare & Medicaid Services (CMS) identifies some of the most poorly performing nursing facilities in the country as Special Focus Facilities (SFFs).  In this Second Report on SFFs, the Center for Medicare Advocacy looks at one of four categories of SFFs – those that “have not improved” – and how they game ...

Nursing Facilities’ “Quality Measures” Do Not Reflect Actual Quality of Care Provided to Residents August 9, 2018

The Center for Medicare Advocacy wanted to determine whether nursing facilities that had one-star in their health survey ratings on Nursing Home Compare were able to boost their overall ratings from one star to two stars through the designation of five stars in the self-reported quality measure domain.  The finding – that many facilities in ...

CMS Reverses Obama Policy on Nursing Home Quality Enforcement June 21, 2018

The Centers for Medicare & Medicaid Services (CMS) issued a Survey and Certification Letter on October 27, 2017, which outlined proposed changes to Chapter 7 of the State Operations Manual (SOM), and invited public comment. As the Center for Medicare Advocacy noted in a previous alert, the proposed changes sought to reverse surveyor guidance issued ...

Take a Moment to Acknowledge World Elder Abuse Awareness Day June 14, 2018

A message from the Center for Medicare Advocacy and the Long Term Care Community Coalition: June 15th is World Elder Abuse Awareness Day. According to the Administration for Community Living (ACL), about five million – one in ten – older adults are abused, neglected, or exploited every year. Elder abuse can take many forms and may even ...

Corporate Integrity Agreements and Nursing Homes May 10, 2018

In their April 2, 2018 letter to CMS Administrator Seema, Republican leaders of the House Energy and Commerce Committee express serious concern about “recent media reports describing horrific instances of abuse, neglect, and patient harm allegedly occurring at SNFs and NFs across the country.”  They focus particular attention on Dr. Jack Michel, an owner of ...

Nursing Home Roundup April 12, 2018

Nurse Staffing in Nursing Homes: CMS Transition to Payroll-Based Journal Staffing Data on Nursing Home Compare Will Provide Better Information for the Public Beginning in April 2018, the Centers for Medicare & Medicaid Services (CMS) will begin using Payroll-Based Journal (PBJ) staffing data to determine each facility’s staff rating on Nursing Home Compare. All facilities must ...

Alert – Tax Cut Harm Just Got Worse; This Week in Sabotage; CMS Pushing MA Plans; SNF Deregulation November 15, 2017

Tax Cut Bill Just Got Worse. Health Care at Risk. This Week in Sabotage CMS Steering to Medicare Advantage Administration And Nursing Home Industry: Lockstep in Deregulating Nursing Facilities & Reducing Resident ProtectionsTax Cut Bill Just Got Worse.  Health Care at Risk.Free Webinar Series Next Webinar: Hospital Observation Status Update January 24, 2018 3:00 p.m. ET  Presenters: Center for Medicare Advocacy Litigation Director, attorney ...

CMA Alert – OIG Warns of Abuse in SNFs; Ted Kennedy, Jr. Joins CMA Advisory Board; “Jimmo” Corrective Action Plan August 30, 2017

HHS OIG Warns of Potential Elder Abuse in Skilled Nursing Facilities Connecticut State Senator Ted Kennedy, Jr. Joins Center for Medicare Advocacy Advisory Board Jimmo Corrective Action Plan CompletedHHS OIG Warns of Potential Elder Abuse in Skilled Nursing Facilities Last week, the HHS Office of Inspector General (OIG) issued an Early Alert, warning of the Centers for Medicare ...

CMA Alert – Joint Replacement Model Undermines Care; OTC Hearing Aids Legislation Passed; More August 23, 2017

Care is Compromised Under CMS’s Comprehensive Care for Joint Replacement (CJR) Model: A Case In Point Over-the-Counter (OTC) Hearing Aid Act Signed into Law Severe Harm if ACA Cost-Sharing Payments EndCare is Compromised Under CMS’s Comprehensive Care for Joint Replacement (CJR) Model: A Case In Point On a Friday this past March, “Ms. T”, a 70-year old Medicare ...

Nursing Home “Advancing Excellence” Quality Program Ends after a Decade November 16, 2016

Advancing Excellence in America’s Nursing Homes, a voluntary program promoted as an effort to improve quality of care in nursing homes, has ended after a decade.  Unfortunately, the Centers for Medicare & Medicaid Services (CMS) will continue the website (“New name, new logo, same GREAT website!”), which it has funded since 2006, in a new ...

Don’t be Fooled by the Federal Nursing Home Five-Star Quality Rating System October 5, 2016

In 2014, The New York Times reported that nursing facilities were gaming the Five-Star Quality Rating System on Nursing Home Compare and that “even nursing homes with a history of poor care rate highly in the areas that rely on self-reported data."  The Times reported that nearly two-thirds of 50 facilities on CMS's watch list ...

Proper Use of Electronic Health Records Could Enhance Patient Care July 14, 2016

If properly utilized, Electronic Health Records (EHR) could increase the quality of care for Medicare’s beneficiaries and lower program costs. EHRs provide the possibility of easy transfer of information between providers, and better patient access to important information. This can mean that clinicians are apprised of changes in health status, with access to information regarding ...

Medicare’s Value-Based Purchasing Program for Hospitals: Paying More to Low-Cost Hospitals That Provide Low Quality Care July 6, 2016

In 2012, the Centers for Medicare & Medicaid Services (CMS) announced expansion of Medicare’s Value-Based Purchasing (VBP) Program for acute care hospitals.  Beginning in Fiscal Year 2015, and as mandated by Congress in the Affordable Care Act, CMS would incorporate a new measure for “Medicare Spending Per Beneficiary.”  CMS suggested this efficiency measure would reward ...

New Report Highlights National Epidemic of Medical Errors May 25, 2016

By Cynthia Ronzio, Public Health Consultant The British Medical Journal (BMJ) recently published a highly controversial and alarming study that claims that medical errors are the third leading cause of death in the US.  The authors used crude statistics (for example, they do not describe their method of extrapolation nor is there mention of weights, case-mix ...

Reducing Hospital Readmissions by Addressing the Causes April 18, 2016

Reports that 20% or more of unplanned hospital readmissions are avoidable has led to considerable interest in policymakers in reducing readmissions.  Actively reducing hospital readmissions is seen as a route to lower Medicare spending and improved patient care. The Affordable Care Act (ACA) established a penalty program for preventable readmissions.  Under the Hospital Readmissions Reduction Program, ...

International Study: Privatization of Long-Term Care Facilities Does Not Lead to Greater Transparency or More Care March 23, 2016

A comparison of the long-term care industry in California, Ontario (Canada), England, and Norway evaluates the extent to which ownership of nursing facilities has shifted from the public sector to private for-profit and not-for-profit companies, and how this shift affects the transparency of information and accountability for public reimbursement. While privatization has been a recent ...

RNs and CNAs Work Fewer Hours in Nursing Facilities that Serve Predominately Ethnic and Racial Minority Residents January 27, 2016

A December 2015 Health Affairs study of freestanding Skilled Nursing Facilities (SNFs) from 2001 thru 2011 found that registered nurses (RNs) were less likely to work at nursing homes with high concentrations of racial and ethnic minorities. This study reports on significant health disparities for racial and ethnic minority SNF residents. In the Health Affairs study, ...

Yet Again, Value-Based Purchasing Did Not Improve Quality December 16, 2015

The federal government’s funding of a value-based purchasing (VBP) demonstration project in the Medicare Advantage (MA) program did not improve quality of care, as measured by the plans’ five-star quality ratings. The findings from this demonstration are the most recent evidence that paying health care providers more to provide better care, or to improve their ...

Discharge Planning: Tips for Evaluating a Hospital’s Skilled Nursing Facility Placement Choices November 17, 2015

Medicare beneficiaries often need care in a Medicare- participating skilled nursing facility (SNF) after an inpatient hospitalization.  For these patients, hospitals are responsible for identifying skilled nursing facilities within the geographic region that can meet the patient’s medical needs.  Until such a placement is found, the beneficiary will not be responsible for her hospital stay.  ...

Advancing Excellence: Very Few Nursing Homes are “Full Active Participants” and Nearly Half of Them Provide Poor Care June 18, 2015

In September 2006, the nursing home industry announced a voluntary quality improvement campaign – Advancing Excellence in America’s Nursing Homes.  The Center for Medicare Advocacy (Center) was skeptical about the campaign ...

Center for Medicare Advocacy Co-Authors Report Published by the Kaiser Family Foundation Comparing Consumer Protections in Major Health Plans March 26, 2015

The Kaiser Family Foundation (KFF) has published a report entitled “Comparison of Consumer Protections in Three Health Insurance Markets: Medicare Advantage, Qualified Health Plans and Medicaid Managed Care Organizations.” The report is authored by Center Senior Policy Attorney David Lipschutz, former Center Policy Attorney Andrea Callow (now at Families USA) and Karen Pollitz, MaryBeth Musumeci ...

Changes to Nursing Home Compare and the Five Star Quality Rating System February 26, 2015

Two-Thirds of Nursing Facilities Nationwide Will See Decline In their Quality Measures; One-Third of Facilities Will See Decline in Their Overall Score As promised in October 2014, the Centers for Medicare & Medicaid Services (CMS) has made significant changes to Nursing Home Compare, effective February 20, 2015.  The changes recalibrate the Quality Measures (QMs), add antipsychotic drug ...

Changes to Nursing Home Compare: Some Good, Some Bad November 20, 2014

The Centers for Medicare & Medicaid Services (CMS) announced plans to expand its focused surveys on resident assessments and nurse staffing for nursing facilities nationwide (but not in all facilities), beginning in early fiscal year 2015.  Expanded surveys should lead to more accurate reporting of quality measures and staffing data on the federal website Nursing ...

CMS Restructures Quality Improvement Organization (QIO) Program July 17, 2014

Separating Beneficiary Complaint Review Functions from Quality Improvement Functions On May 9, 2014, the Centers for Medicare & Medicaid Services (CMS) announced the first phase of its restructuring of the QIO functions.  In the first phase, CMS has contracted with Livanta LLC (for geographic areas 1 and 5), located in Annapolis Junction, Maryland, and KePRO (for ...

The Myth of Improved Quality in Nursing Home Care: Setting the Record Straight Again April 17, 2014

April 17, 2014 A recent report by the Department of Health and Human Services' Inspector General found that one third-of nursing home residents in a Medicare-nursing home stay suffered an adverse event or other harm in August 2011 and that most of the events were preventable and caused by problems in staffing.  Yet the nursing home ...

CMA Report: Examining Inappropriate Use of Antipsychotic Drugs in Nursing Facilities December 12, 2013

The misuse of antipsychotic drugs by nursing homes has been the subject of Congressional hearings and Government reports for many decades.  With funding from the Commonwealth Fund of New York and in cooperation ...

Debunking Nursing Home Myths about Quality of Care and Enforcement of Federal Care Standards September 12, 2013

As policymakers in Washington, DC and beyond continue a national discussion about the state of long-term care in the United States, a critical component of the discussion is the quality of care provided in nursing homes across the country. The nursing home industry argues that nursing home quality is improving, pointing to higher ratings on the Centers ...

Medicare Paid $5.1 Billion to SNFs that Did Not Provide Care-Planning and Discharge-Planning (February 2013 OIG Report) April 18, 2013

In its most recent report on nursing home payments and quality, February 2013, the Office of Inspector General (OIG), Department of Health and Human Services (HHS) reports that many skilled nursing facilities (SNFs) failed to provide adequate care planning and discharge planning to residents and provided "egregious" care to some residents, yet were paid by ...

Nursing Home Enforcement by United States Attorneys: What Happened to the Regulatory System? February 7, 2013

Two recent cases – one in Georgia and the other in Pennsylvania – enforce nursing home quality of care standards through actions by United States Attorneys.   In neither case had the regulatory agencies cited deficiencies for the significant care problems at the three facilities in question.   In addition, two of the three facilities have high ...

The Worst-Performing Nursing Facilities Are Seldom Sanctioned; Self-Reporting is Not an Accurate Quality Measurement January 24, 2013

According to an analysis by the Center for Medicare Advocacy (the Center) few sanctions are imposed for the poor care provided by nursing facilities identified by the Federal Government as among those providing the poorest quality of care and quality of life to residents – Special Focus Facilities (SFFs).  The Center's analysis documents an enforcement ...

Picking a Plan During the Annual Enrollment Period? Choose Carefully October 18, 2012

As discussed in last week’s Alert, the current Medicare Annual Enrollment Period lasts until December 7th.  During this time period, Medicare beneficiaries can choose a Medicare Advantage (Part C) or Part D plan for 2013.  This Alert discusses Part C and D plan quality ratings for 2013, and special enrollment periods related to these ratings.  ...

New Procedures for Review of Quality of Care Complaints September 27, 2012

On April 6, 2012, the Centers for Medicare & Medicaid Services (CMS) issued Transmittal 17, which revises and creates new procedures for the review of quality of care concerns Effective May 7, 2012, the new procedures apply to QIO review of the quality of services "among different cases and settings ...

Compare Hospitals or Nursing Homes Using Medicare’s Online Tools July 20, 2012

Two websites that help Americans make informed choices about hospitals and nursing homes have been redesigned and will make more information available to the public, CMS announced on July 19, 2012.The two sites – Hospital Compare and Nursing Home Compare – have been enhanced to make navigation easier by users, and have added important new ...

National Alzheimer’s Plan: A Step Forward, More Work Ahead May 17, 2012

This week, the Obama Administration launched a National Alzheimer's Plan to help the more than 5 million Americans with Alzheimer's disease and their 15 million caregivers. Consisting of funding for clinical research, provider education and outreach, data collection, a public awareness campaign, and proposed funding for caregiver support, the plan provides needed investment and vision ...

Low Staffing in Nursing Homes Leads to More Deaths May 3, 2012

When research conducted a decade ago documented that mortality rates actually increased when employment rates increased, health economists sought to identify the cause.  Focusing on employed workers did not explain the increased mortality rates.  A new analysis by the Center for Retirement Research at Boston College – focused on who was actually dying when employment ...

Medicare Hospital Readmissions May 2, 2012

Reducing hospital readmissions is generating lots of confusion.  The rules are complicated.  In addition, some hospitals, facilities, and health care networks have adopted protocols, and have in place some level of procedures for reduction in hospital readmissions in advance of the requirements set forth in the Affordable Care Act (ACA). In general, the Centers for Medicare & ...

Voluntary Nursing Home Improvement Campaign Does Not Work January 11, 2012

Nursing Facilities Participating in Advancing Excellence Still Among Worst Performers Many nursing facilities that are identified by the federal government as among the facilities providing the poorest quality of care to residents in the country – the Special Focus Facilities (SFFs) – participate in the nursing home industry's voluntary quality improvement campaign, Advancing Excellence in America's ...

Special Focus Facility Study: Nursing Facilities’ Self-Regulation Cannot Replace Independent Surveys December 22, 2011

Each month, the Centers for Medicare & Medicaid Services (CMS) identifies nursing facilities that are among the facilities providing the poorest care to their residents, as determined by federal deficiencies cited in the prior three years.   These facilities, called Special Focus Facilities (SFFs), receive special attention from state survey agencies – at least two surveys ...

Toby Edelman Testifies Before Senate Special Committee Regarding Antipsychotics In Nursing Homes December 1, 2011

UNITED STATES SENATE SPECIAL COMMITTEE ON AGING OVERPRESCRIBED: THE HUMAN AND TAXPAYERS' COSTS OF ANTIPSYCHOTICS IN NURSING HOMES November 30, 2011 Testimony of Toby S. Edelman Senior Policy Attorney Center for Medicare Advocacy The misuse of antipsychotic drugs as chemical restraints is one of the most common and longstanding, but preventable, practices causing serious harm to nursing home residents today.   We ...

Study Finds that Use of Hospitalists Shifts Costs from Inpatient Care to Post-Discharge Setting September 8, 2011

Hospitalists are defined as physicians who are based full-time in acute care hospitals and who provide care to hospitalized patients.  The past decade has witnessed a rapid growth in hospitals' use of hospitalists, who have been shown to lead to reduced lengths of inpatient hospital stays.  A new study, however, finds that decreased inpatient costs ...

Proposed Notice Requirements About Quality of Care: Endorsement, with Concerns May 5, 2011

On April 4, 2011, the Center for Medicare Advocacy (the Center) filed comments on a proposal by the Centers for Medicare & Medicaid Services (CMS) to establish a new condition of Medicare participation (CoP) for certain Medicare service providers.  These providers would be required to give Medicare beneficiaries notice of the right to seek review ...

Private Medicare Plans Do Not Offer Better Health Outcomes August 28, 2010

For more than a year, the Center for Medicare Advocacy has been outspoken about the overpayments made to the private insurance plans in the subsection of the Medicare program called "Medicare Advantage." During this same time period, the proponents of Medicare Advantage (MA) have operated what can best be described as a fierce campaign against ...

Accountable Care Organizations Should Increase Care Coordination in Traditional Medicare July 1, 2010

By January 1, 2012, the Secretary of Health and Human Services (the Secretary) must establish a Medicare Shared Savings Program (MSSP) that promotes accountability for a defined patient population, coordinates items and services under traditional Medicare Parts A and B, and encourages investment in infrastructure and redesigned care processes for high quality and efficient service ...

Health Reform: Linking Medicare Payment to Quality Outcome June 24, 2010

This is the seventh in a series of Alerts by Center for Medicare Advocacy regarding the Patient Protection and Affordability Care Act of 2010 (PPACA) and the Health Care and Education Reconciliation Act of 2010 (HCERA). This Alert focuses on changes in PPACA that address measuring the quality of care that is received by Medicare ...

New GAO Report Demonstrates Need for Stronger Enforcement of Nursing Home Quality Standards: Health Reform Provisions Could Help May 20, 2010

The Patient Protection and Affordable Care Act of 2010 (PPACA), the health care reform legislation enacted earlier this year, provides a new opportunity to strengthen and improve federal oversight mechanisms for nursing homes. Implementation of new statutory requirements for public reporting of nursing home ownership information and for Ethics and Compliance Programs in all facilities ...

A New Entity from Health Reform: The Center for Medicare & Medicaid Innovation May 6, 2010

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 ...

Establishing A Coordinated Care Benefit In The Traditional Medicare Program April 9, 2009

The Center for Medicare Advocacy is pleased that there is renewed interest in the Congress for establishing a coordinated care benefit in the traditional Medicare program. Any health care reform, including Medicare reform, must embrace a coordinated care benefit. The absence of such a benefit has been detrimental to Medicare beneficiaries for too long. In ...

Consumer Assessment of Health Care Providers and Systems (CAHPS) July 31, 2008

Beneficiary Satisfaction Measure is Not Used to It's Fullest Extent Unlike report cards that use clinical measures, The Consumer Assessment of health care Providers and Systems (CAHPS) reports patient ratings of their experience with care.  The CAHPS surveys were designed to provider consumers of health care with more information and to enable the consumer to make ...

Addressing Concerns about Quality of Care For Medicare Beneficiaries August 30, 2007

When beneficiaries receive Medicare coverable health care, there is an expectation that the provider will listen to their concerns and assess and provide appropriate medical care. What can beneficiaries do if they believe that the prescribed medical care is inadequate or incorrect in some way? In Medicare, beneficiaries can request a “quality of care review” ...

Myths About Nursing Home Tort Reforms April 18, 2003

The following is an executive summary. You can also view the full report here and the appendices here in .pdf form. The Center for Medicare Advocacy performed a study entitled Tort Reform and Nursing Homes that deflates the myths that pervade the nursing home industry’s discussion of tort litigation. It found that cases about nursing home abuses ...

Rehabilitation Care Articles

CMS Revises Inpatient Rehabilitation Facility “Review Choice Demonstration” – Confirming Individual Assessments Must be Used to Adjudicate Claims July 27, 2023

CMS addressed the CPR Coalition’s concerns relating to reviewers utilizing “rules of thumb” to improperly and categorically deny claims, which is barred under the Hooper v. Sullivan case.

Patients Need Therapy – Medicare Payment Systems Create Barriers December 12, 2019

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 ...

New Fact Sheet Available – Medicare Inpatient Rehabilitation Hospital/Facility Coverage In Light of Jimmo v. Sebelius April 11, 2019

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy has produced a new Fact Sheet to help Medicare beneficiaries and their families respond to unfair Medicare denials for care at inpatient rehabilitation hospitals/facilities (IRH/F). The Fact Sheet outlines the coverage criteria for IRH/Fs and emphasizes language from the Jimmo Settlement Agreement. ...

CMS Clarifies 3-Hour “Rule” Should Not Preclude Medicare-Covered Inpatient Rehabilitation Hospital Care March 15, 2018

Inpatient rehabilitation hospitals (IRHs, also known as Inpatient Rehab Facilities/IRFs) provide intensive rehabilitation services to patients on an inpatient basis.  Over time, a myth developed – based on a discredited CMS Policy – that patients are appropriate for Medicare-covered IRH care only if they can participate in at least three hours a day of rehabilitative ...

Value of Inpatient Rehabilitation Hospital Care Reaffirmed May 18, 2016

American Heart Association/American Stroke Association Recommends That Patients Who Have Strokes Receive Rehabilitation at Inpatient Rehabilitation Hospitals, not Skilled Nursing Facilities For the first time, the American Heart Association/American Stroke Association has issued a Scientific Statement and guidelines strongly recommending that, “whenever possible,” “stroke patients be treated at an in-patient rehabilitation hospital (now often referred to as Inpatient ...

Saga of an Inpatient Hospital Appeal: Notice and Use of Lifetime Reserve Days and Comments on Observation Status May 21, 2015

This CMA Alert highlights a recent individual ALJ decision that sets out an important but often unrecognized beneficiary right to a written notice when he or she is about to use hospital “Lifetime Reserve Days.”  A hospital’s failure to provide appropriate notice in this context can lead to the waiver of a beneficiary’s liability for ...

No Site Neutral Payments for Inpatient Rehabilitation Facilities and Skilled Nursing Facilities December 11, 2014

The Medicare Payment Advisory Commission (MedPAC), the nonpartisan government agency that advises Congress on Medicare policy, indicated at its November 7, 2014 public meeting that, at its next public meeting in December, it would recommend (1) phasing-in site-neutral payments for inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) for 17 conditions, which it has ...

Inpatient Rehabilitation Facilities and Skilled Nursing facilities: Vive La Difference! July 31, 2014

A study assessing the outcomes of patients who were treated in inpatient rehabilitation facilities (IRFs) with clinically and demographically similar patients who received their post-acute rehabilitation in skilled nursing facilities (SNFs) finds that IRFs provide better care to their patients over a number of outcome measures – IRF patients live longer, spend more days at ...

Skilled Nursing Facilities Articles

CMS Seeks Comments on Consolidated Billing Exclusions April 25, 2024

Comments on this request and on the proposed rule in general are due by May 28, 2024.

CMS Must Preserve Standard Surveys for All Nursing Facilities April 11, 2024

Advocates for residents have little confidence in designations of “consistently higher-quality facilities.”

CMS Proposes Major Changes to Civil Money Penalties for Nursing Homes April 4, 2024

A more complex system and lower penalties will not help residents.

MedPAC Report Undermines Nursing Home Industry Claims March 28, 2024

Recommends 3% payment reduction for FY 2025

Reports: Nursing Facilities’ “Financial Shenanigans” Divert Reimbursement to Private Gain, Jeopardizing Resident Care March 21, 2024

Basically, money for care is funneled into profits by any shady means possible.

A Model for Nursing Home Enforcement March 21, 2024

Stronger sanctions, barring from Medicaid might actually lead to improvement for patients.

Nursing Homes Hide Profits March 14, 2024

That's it. It's that simple. Nursing homes aren't losing money, they're shifting it and hiding it.

New From the House Ways & Means Committee: No Nursing Home Staffing Standards Ever March 7, 2024

House Ways & Means Committee proposes to abandon all nursing home standards.

Two Courts Reject Nursing Home Industry Challenges to New York Law Requiring Minimum Spending on Care and Caps on Profit February 29, 2024

Advocates support requirements to spend a specified portion of revenue on actual care - obviously.

Know Jimmo | Skilled Nursing Facility Policy February 22, 2024

Skilled maintenance services are covered in a nursing home.

CMS Must Strengthen Federal Criteria for Certifying Nursing Homes for Medicare and Medicaid Reimbursement February 22, 2024

Keeping poorly performing operators from operating additional facilities would dramatically improve quality of care.

When Should Medicare Coverage Be Available For Skilled Nursing Facility (SNF) Care? February 22, 2024

A quick Guide to Medicare coverage of nursing home

Studies Show Nursing Home Closures Have Declined January 24, 2024

Nursing home closures have actually declined - and most facilities that close provide very poor care to residents.

Nursing Facilities Spend More on Administration, Capital, and Profits Than Nursing: 2019 Medicare Cost Reports January 11, 2024

Report also finds that while half of facilities reported a net loss, 79% actually had a profit.

KFF: Increased Numbers of Deficiencies Cited at Nursing Facilities May Reflect Insufficient Staffing January 11, 2024

Report suggests that, possibly as the result of insufficient staffing levels, deficiencies have increased.

A Poster Child for Meaningful, Corporate-Wide Enforcement of Nursing Facilities January 4, 2024

Nursing Home has a record for poor care and is affiliated with six other facilities that also have exceptionally poor records for resident care.

Improving Nursing Home Quality through Current Law December 21, 2023

Four approaches that are currently available to improve quality of care for residents.

Enforcement Provisions of President Biden’s Nursing Home Reform Agenda Being Ignored December 14, 2023

CMS has largely ignored Biden's directive to strengthen the enforcement of standards of care for nursing facilities.

Immigrant Nurses – Be Wary of Staffing Agencies that Violate Federal Law December 7, 2023

Employment contracts provisions flagrantly violate federal labor law.

CMS Issues Final Rule on Nursing Home Transparency November 30, 2023

Regulations to to monitor and hold nursing homes accountable effective January 16, 2024.

Center for Medicare Advocacy Comments About Proposed Rule to Mandate Nurse Staffing Standards in Nursing Homes – Comment Period Now Closed November 9, 2023

The 60-day public comment period ended November 6, 2023; 46,341 comments were submitted.

Reminder – Add Your Voice! Comment on CMS’ Proposed Rule About Nurse Staffing Standards for Nursing Homes November 2, 2023

Comments must be received by CMS by November 6, 2023.

Center Senior Policy Attorney Toby S. Edelman Receives Brian Capshaw Rock Star Award October 19, 2023

Award for resident advocacy honors the memory of Brian Capshaw, a tireless, brilliant, and effective resident and resident-advocate.

Proposed Nursing Home Staffing Rule Described as “Dangerously Inadequate” September 28, 2023

Rule described as "so minimal and with such huge exceptions that many nursing home residents will see no benefit at all.”

COVID-19 Is Increasing Among Nursing Home Residents and Staff September 21, 2023

Alarming increase in infections among residents and staff demands strong and firm action - Higher nurse staffing levels mean fewer COVID-19 cases and deaths.

Gallup Poll Finds Americans Give Nursing Homes a “D+” Grade for Quality September 14, 2023

There is clearly much work to do to make the public confident about nursing home care.

Meaningful Nurse Staffing Ratios in Nursing Homes: If Not Now, When? September 7, 2023

Proposed Rule would set lower staffing standard than needed. Comments due November 6, 2023.

A Chaotic Week in Nursing Home Reform August 31, 2023

Leaked, then retracted, report indicates lower staffing threshold than 20 years ago. Advocates continue to fight.

Nursing Facilities: Are Conditions Improving or Is the Sky Falling? August 31, 2023

AHCA’s gloom and doom predictions are both typical for the trade association and not credible.

CMS Reimbursement Rules for Skilled Nursing Facilities Disappoint Residents’ Advocates August 17, 2023

CMS Increases nursing home reimbursement, while dismissing public comments on therapy and accountability.

Two Cases Involving Centers Health Care, a New York State Nursing Home Chain August 3, 2023

By their own admissions, four nursing facilities did not spend millions on resident care, as defined by a later state budget law.

Paycheck Protection Program: A Massive Windfall for Nursing Facilities? August 3, 2023

Nursing facilities must be held fully accountable for all funding they receive.

AHCA Should Support Nurse Staffing Ratios to Improve Care for Residents July 27, 2023

AHCA needs to support the President’s reform agenda enthusiastically and to work collaboratively to ensure that nursing facilities are good places to live and work in.

National Nursing Home Trade Associations Escalate Attacks on Nurse Staffing Ratios for Nursing Facilities July 20, 2023

Nursing home trade groups need to stop opposing nurse staffing ratios, proposing impossible conditions, and scaring residents and staff about the wrong issues.

Sufficient Nursing Facility Staffing Saves Lives, Insufficient Staffing Harms and Kills July 20, 2023

Recent analyses find what all studies of staffing have consistently found for decades – higher staffing levels mean better care for residents and lower staffing levels mean resident harm and death.

CMS Posts Nursing Home Ownership Information on Care Compare and CMS Data Website July 13, 2023

A step toward increased clarity in nursing home ownership and spending.

Join! July 13 Virtual Rally for Nurse Staffing Standards in Nursing Facilities July 6, 2023

vVrtual rally on July 13, at 2:00 pm ET, to call for strong federal nurse staffing standards

CMS to Review Five Medicare Claims from Each Skilled Nursing Facility July 6, 2023

Doubling of Improper payment rate findings leads to review.

Supreme Court Victory for Court Access and Nursing Home Residents June 29, 2023

Opinion recognizes the purpose of nursing home law to protect the “health, safety, and dignity” of nursing home residents.

Home for the Holidays | Leaving the Nursing Home During a Medicare-Covered Stay June 29, 2023

You CAN leave the nursing home for holidays with your family.

Understaffing at State Survey Agencies Places Nursing Home Residents at Risk June 22, 2023

Funding for state survey agencies has remained stagnant for a decade despite multiple proposals for an increase.

A Message to Nursing Home Trade Associations: Stop Scaring Residents and Staff About Nursing Home Staffing, Spend Public Reimbursement on Resident Care June 15, 2023

Provider group using scare tactics to demand more money, yet no promise of better care.

Bipartisan Group of Senators and Representatives Support CMS’s Proposed Rule on Nursing Home Ownership Transparency and Urges CMS to Strengthen Rule in Seven Specific Ways June 1, 2023

Senators Charles E. Grassley, Elizabeth Warren and Robert P. Casey, Jr., and Representatives Katie Porter and Lloyd Doggett expressed support.

Submit Comments on Part A Medicare Reimbursement For Skilled Nursing Facilities – Due June 5 June 1, 2023

Proposal includes a 35% reduction in penalties for poor care, and ignores the recent drastic drop in therapy care. Comment now.

Updated Factsheet: Medicare Skilled Nursing Facility Coverage Does Not Require Improvement June 1, 2023

Factsheet outlines Medicare beneficiary rights to Medicare coverage in a skilled nursing facility.

Elder Justice “No Harm” Newsletter | Volume 5, Issue 2 Now Available May 25, 2023

Read and see if YOU think these deficiencies caused “no harm.”

Health Affairs: International Nurses Won’t Solve U.S. Nurse Staffing Crisis May 18, 2023

Nursing home trade associations see increased immigration as key to solving their nurse staffing problems. It wont.

Study: Fewer Nurses in Nursing Homes Associated with More Resident Deaths May 11, 2023

nursing shortages equated to a 10.5% increase in resident deaths, from both COVID-19 and non-COVID-19 causes, during the coronavirus pandemic.

CMS Says Nursing Home Visitation “is Allowed for All residents at All Times” May 11, 2023

New order aligns with end of COVID health emergency.

Medicare Payments for Skilled Nursing Facility Care during the COVID-19 Pandemic May 4, 2023

Waiver resulted in a 26% increase in the SNF episodes without a preceding hospitalization.

Federal District Court Affirms: Medicaid Survey Teams Investigating Nursing Home Complaints Need Not Include a Registered Nurse May 4, 2023

Rule permits nursing home complaint surveys to be conducted without a registered nurse (RN) on the survey team.

CMS Proposes Updates to Medicare Part A Reimbursement for Skilled Nursing Facilities April 17, 2023

Along with greater-than expected reimbursement, several other changes should concern advocates and families.

Inspector General Audit: Care Compare Did Not Accurately Report Deficiencies at Two-Thirds of Nursing Facilities April 17, 2023

Findings mirror those from 19 years ago.

Investigation Finds Some California Nursing Facilities Experienced “Substantial Increase” in Profits April 17, 2023

Despite decline in occupancy, profits increased from 2019 to 2020.

Is the Nursing Home Industry Irrevocably Changed? April 13, 2023

The nursing home industry, as we know it today, is diminished and may be disappearing.

Federal District Court Denies Nursing Home Chain’s Motion to Dismiss Federal Government’s “Worthless Services” Case April 13, 2023

Federal Suit alleges homes provided "worthless services."

New Article: Private Equity and Nursing Homes April 13, 2023

New article explores the many negative effects of private equity ownership on nursing home quality.

Medicaid and Nursing Homes: Don’t Believe Owners and Operators That All Medicaid Rates Are Too Low April 6, 2023

Recent analyses undermine industry myths about Medicaid reimbursement.

Elder Justice “No Harm” Newsletter | Volume 5, Issue 1 Now Available March 30, 2023

Do YOU think these deficiencies caused “no harm”?

Report: Limited Federal Oversight of Cost Reports, Inflated Prices Paid in Nursing Home “Related Party Transactions” March 30, 2023

CMS should audit cost reports, require consolidated cost reports, implement a minimum nurse staffing standard, and enact a profit cap.

GAO Issues Report on Improving Infection Prevention And Control Practices In Nursing Facilities March 23, 2023

Actions that HHS could “continue, enhance, or discontinue to improve infection prevention and control practices in nursing homes.”

Nursing Homes Operate Managed Care Programs for Their Residents – A Conflict of Interest March 23, 2023

Although nursing home owners and operators complain about Medicare Advantage (MA) plans because they pay less than traditional Medicare, they increasingly see a financial opportunity in operating their OWN MA plans.

US House Effort To Support Nurse Staffing Ratios For Nursing Facilities March 16, 2023

113 Members of Congress urge the Centers for Medicare & Medicaid Services (CMS) to enact robust nurse staffing ratios for nursing facilities.

Emergency Preparedness for Long-Term Care Facilities March 9, 2023

Senate Report: Improve nursing home preparedness.

President Biden: Count Only Nursing Staff in Nurse Staffing Ratios March 2, 2023

This should be a simple concept - only nurses are nurses.

Report: Nursing Home Closures in Iowa Exemplify General Pattern February 23, 2023

Nursing home closures are not unusual, and Medicaid rates are only one of many factors, NOT the cause.

CMS Proposes Rules On Ownership Disclosure for Nursing Facilities February 16, 2023

CMS trying again to make nursing home ownership more visible.

GAO: Make Nursing Home Ownership Information “More Transparent for Consumers” February 9, 2023

Meeting one out of six criteria is not enough information for people to make informed choices about their care.

Report | Too Much Secrecy in The Nursing Home Enforcement System February 2, 2023

The nursing home enforcement system needs to be made far more transparent and effective.

Connecticut Coalition of Resident Council Presidents Urge Lawmakers to Prioritize Nursing Home Staffing Challenges February 2, 2023

Letter to state lawmakers details harm from inadequate staffing.

Nursing Home Residents Need Nurses, Wherever They Live February 2, 2023

Geography has nothing to do with the care that residents actually need.

HHS Office of Inspector General: Nursing Home COVID-19 Underscores Need for Better Staffing and Improved Surveys January 26, 2023

Current minimum staffing requirements may not be sufficient to keep residents safe from infection.

CMS Improves Public Reporting of Nursing Home Information January 19, 2023

Agency makes two big changes to nursing home quality rating system and Care Compare website.

Conviction of Florida Nursing Home Operator Affirmed January 12, 2023

Trump commuted his sentence, but penalties still stand.

Elder Justice “No Harm” Newsletter | Volume 4, Issue 6 Now Available January 12, 2023

What do nursing homes claim are "no harm" care deficiencies? You'd shocked.

Vaccinated Staff Equals Fewer Nursing Home Deaths – Require Boosters January 5, 2023

Study: a 10% increase in staff vaccination rates would have resulted in more than 20,000 fewer resident deaths.

Require Full Disclosure & Accountability for Nursing Home Reimbursement January 5, 2023

Before nursing homes get more public money, require transparency and accountability for the billions they already receive.

Nursing Homes: Addressing the Worst Operator Behaviors under Existing Law December 22, 2022

More can and should be done at the federal level, but states may be able to address some of the worst of owners’ excesses.

HHS Inspector General: Too Many Nursing Home Residents Still Inappropriately Receive Psychotropic Medications December 8, 2022

Bottom line - fewer nurses equals more drugged patients.

Nursing Home Reform: Where Are We Now? Where Do We Need to Go? December 1, 2022

Center attorney Toby Edelman calls for better nurse staffing levels, strengthened enforcement, and improved transparency and accountability for nursing home ownership and reimbursement.

Report | Trained Workers in Nursing Homes, a Requirement Since 1990, Threatened December 1, 2022

Nursing home trade associations have been relentless in efforts to weaken the law so facilities can train their own aides with few, if any, limitations.

Long-Stay Nursing Facility Placements for Younger People Are Increasing October 27, 2022

Researchers make multiple recommendations to direct and transition younger people with disabilities from nursing homes.

Supreme Court to Hear Nursing Home Case with Broad Implications for Litigation to Enforce Federal Laws October 27, 2022

Troubling implications for whether beneficiaries of federal programs can continue to litigate to enforce federal laws.

Elder Justice “No Harm” Newsletter | Vol. 4, Issue 5 Now Available October 19, 2022

What do nursing homes claim are "no harm" care deficiencies? You'd shocked.

CMS Must Strengthen Oversight of Infection Prevention and Control in Nursing Home October 13, 2022

GAO finds nursing homes deficient in 7 out of 8 measures of infection control.

CMS and Consumer Financial Protection Bureau Address Illegal Debt Collection Practices of Nursing Facilities September 14, 2022

Agencies focus on nursing homes after reports of them harassing families and friends for resident debt.

Private Equity and Nursing Facilities: A Bad Combination for Residents September 8, 2022

Nursing homes owned by private equity firms hide their ownership while providing worse care.

Consumer Financial Protection Bureau Wants to Hear about Nursing Home Debt Collection September 1, 2022

Investigating whether nursing homes are suing families and friends of residents to collect residents’ nursing home debts.

CMS Authorizes New Waivers of Nurse Aide Training Requirements for Nursing Facilities September 1, 2022

Facilities and states can request waivers as long as the public health emergency remains in effect, undermining training standards.

CMS Hosts Public Call on Nursing Home Staffing on August 29 August 25, 2022

Call to help inform proposed rule on staffing expected in 2023. Register now.

CMS Encourages Health Care Providers to Prepare for the End of the COVID-19 Public Health Emergency August 25, 2022

August 18 memo hints at end of PHE. Secretary will give 60 days notice when official,.

New from the Center: Form to Contest Multiple Medicare Denials Issued by Medicare Advantage Plans August 25, 2022

MA plan issuing repeated, frequent non-coverage notices despite the need for care? File a Grievance with this new form.

Report: Nursing Home MA Issues Survey August 18, 2022

CT Nursing homes report having consistent issues with Medicare Advantage plan denials and delays.

Nursing Home Trade Group Asks for New Waiver of Nurse Aide Training Requirements August 18, 2022

The waiver that allowed only 8 hours online training to work in a nursing home is no longer in effect. The Center for Medicare Advocacy urges CMS not to reinstate it.

Nursing Home Roundup August 11, 2022

CMS increases payment rates despite fraud; Real estate Investment trusts are bad for SNFs and patients; Illegal lawsuits against patients families.

Nurse Staffing Study Confirms Nursing Home Resident Deaths Increased When Nurse Staffing Levels Declined During Pandemic July 28, 2022

Staffing shortages during severe outbreaks correlated with resident deaths from causes other than COVID-19 - insufficient nurse staffing levels mean poorer resident outcomes.

CMS Announces Changes to Staffing Measure in Five-Star Rating System; Staffing Ratings Decline for One-Third of Nursing Facilities July 28, 2022

CMS Adds new staffing measures, and nursing home star ratings drop immediately.

Improving Nursing Home Staffing Levels Can And Must Be Done July 21, 2022

Nursing home trade group admits most facilities don't meet minimum staffing level for proper standard of care.

Special Report | Nursing Home Closures: Causes and Solutions July 14, 2022

Report shows closures may not be financial issues, but due to low quality care, rebalancing, and more.

New York State’s For-Profit Nursing Facilities’ Related-Party Transactions Hide High Profits July 14, 2022

NY For-profit nursing homes deliberately "disguise the true profitability of their business."

CMS Acts to Implement Revised Nursing Home Standards of Care July 7, 2022

After delays due to the pandemic, the CMS has issued guidance to implement standards of care for nursing homes.

Nursing Home Staffing at All-Time Low; Which Solutions Will Help? June 23, 2022

Bills supported by the nursing home industry would be an enormous step backwards. The Center for Medicare Advocacy supports the President’s comprehensive nursing home reform agenda.

Kaiser Family Foundation: Medicare Spending for Skilled Nursing Facilities Increased During Pandemic, While Fewer Residents Were Covered June 9, 2022

Medicare spending for care in skilled nursing facilities by the traditional Medicare program increased during the pandemic, though spending for most other services declined, AND the number of Medicare beneficiaries in SNFs declined.

Comments On Mandatory Staffing Ratios for Nursing Homes Due to CMS by June 10 May 26, 2022

CMS seeks comments on mandatory staffing levels for nursing homes. mandating staffing levels in nursing homes is one of the most important ways to improve staffing and make residents’ lives better.

Fewer Residents Died from COVID in Unionized Nursing Homes May 12, 2022

Study finds 10.8% lower COVID-19 mortality rate among residents in unionized facilities.

Nursing Home Staffing and Immigration April 28, 2022

Nursing home industry has supported increasing immigration as a solution to staffing shortages for many years.

Study Finds Relationship Between Religiously Affiliated Nursing Homes and Standard of Care Complaints and Violations April 21, 2022

Religious affiliation often fosters a “cognitive and emotional link between the organization and its members.”

Notice of Proposed Rulemaking for Medicare Part A Payments to Skilled Nursing Facilities Published – CMS Requests Information About Nurse Staffing April 21, 2022

We encourage residents and their families and advocates to provide CMS with specific and detailed information about staffing.

CMS Begins Process of Setting Mandatory Nurse Staffing Standards for Nursing Facilities April 14, 2022

CMS is beginning the process of establishing nurse staffing standards for facilities, as promised by President Biden in his State of the Union address.

Federal Government Must Enact and Enforce Nurse Staffing Standards for Nursing Facilities April 14, 2022

Provider complaints about staffing levels are premature.  The administration is studying staffing levels, and making immediate efforts to strengthen staffing.

National Academy of Sciences’ Nursing Home Report Continues the Drumbeat for Reform April 7, 2022

Report addresses concerns that advocates for residents have been raising for years – inadequate staffing levels, failure to enforce standards of care, lack of requirements and accountability for how public reimbursement is spent, and more.

Instability In Staffing Levels at Nursing Homes Affects Quality of Care for Residents March 24, 2022

Nursing home staffing levels often decline on weekends. In November 2018, the Centers for Medicare & Medicaid Services (CMS) identified facilities with low staffing on weekends and directed states to conduct surveys in a portion of these facilities on weekends. in ...

What Does AHCA Object to In The Biden Nursing Home Reform Agenda? Being Held Accountable for Care. March 23, 2022

Nursing Home trade association should support the President’s nursing home reform agenda.

Connecticut Legislation Takes Aim at Nursing Home Temporary Staffing Agencies March 10, 2022

As nursing homes around the nation struggle to find staff, agencies that provide temporary staffing have taken advantage.

Case Against Nursing Facility Alleging Negligence and Wrongful Death From COVID-19 Affirmed to Belong in State Court March 3, 2022

Facility tried to claim federal jurisdiction, was rebuffed.

Biden Administration Issues Bold and Comprehensive Nursing Home Reform Agenda March 3, 2022

The proposed reforms can help achieve the promise of the 1987 Nursing Home Reform Law.

Nursing Homes Lose Almost All Formal Appeals of Deficiencies and Civil Money Penalties February 24, 2022

Almost always, ALJs sustain deficiencies and CMPs in their entirety.

What Happened to Harm and Jeopardy Deficiencies Cited – and Penalties Imposed – at Nursing Facilities? February 24, 2022

More transparency about the nursing home oversight system is plainly needed.

CMS Tells Public to File Complaints About Quality of Care with CMS Locations February 17, 2022

CMS has never before told people to go to their offices to file complaints when state action is inadequate. Hopefully this new recommendation will signal a renewed interest in Enforcement.

Issue Brief | States Are Weakening Training Standards for Nursing Facility Aides February 15, 2022

It is in the interests of both nurse aides and nursing facility residents that aides receive all required training. But the nursing facility lobby has argued for “grandfathering” of temporary nurse aides into permanent certification, and the federal government unfortunately has moved in that direction.

Second State Report Recommends Barring Medicaid Payments to Chronically Poor-Performing Nursing Facilities February 10, 2022

Facilities that fail or refuse to provide acceptable levels of care to residents should be barred from receiving public funding. 

What’s Happening in the Nursing Home Industry? February 10, 2022

Payments siphoned for profits while care quality declines.

It’s Time: Repeal the 3-Day Inpatient Hospital Requirement for Medicare Skilled Nursing Facility Coverage February 10, 2022

The outdated requirement of a 3 Day stay hasn't changed since 1965, when average stays were 13 days.

Hospitalized COVID-19 Patients with Disabilities Linked to Longer Stays & Greater Risk of Readmission February 3, 2022

Disability-related needs must be addressed to support patients in the hospital and after discharge.

New York Nursing Homes Suing the State Received Federal Provider Relief Funds February 3, 2022

Where did 13 nursing homes spend 20 million dollars in "relief" funds?

Former Owner of Skyline Faces Numerous Criminal and Civil Lawsuits January 27, 2022

Nursing home chain took over 100 facilities, then collapsed, abandoning residents.

Report | How Do Nursing Homes Spend the Reimbursement They Receive for Care? January 26, 2022

States have begun to question how nursing homes spend the reimbursement they already receive, as well as the many additional billions of dollars they received, and continue to receive, during the coronavirus pandemic.

New Study: Men Report Worse Quality of Life Nursing Homes January 20, 2022

Age, race/ethnicity, and marital status are some key factors in predisposing quality-of-life differences between men and women.

HHS Office of Inspector General Reports Inadequate CMS Oversight and Enforcement of States’ Nursing Home Surveys January 20, 2022

More than half of states “repeatedly failed to meet requirements for conducting nursing home surveys."

CT Governor Issues Executive Order Requiring Nursing Home Visitors Have Vaccine and Booster or Proof of Negative COVID Test – CT Long Term Care Ombudsman Expresses Support and Offers Assistance if Needed January 20, 2022

Order requires visitors and support persons to show proof of full vaccination with booster, or negative test, before entering a nursing home.

CMS Again Revises Visitation Guidance in Nursing Facilities January 13, 2022

Changing guidance on visitation reinforces the need for enactment of the Essential Caregivers Act of 2021, H.R. 3733.

CMS to Post Nursing Home Staff Turnover and Weekend Staffing Level Information on Care Compare January 13, 2022

Beginning in July 2022, CMS will use the staff turnover and weekend staffing information in its Nursing Home Five Star Quality Rating System.

CMS Revises November Visitation Guidance after Nursing Home Industry Calls on CMS to Allow Facilities to “Limit, Restrict, or Prohibit Visitors” December 23, 2021

Vaccination is the way to protect residents and staff.  Giving nursing facilities the authority to bar families is not the answer. 

Vaccination of Nursing Home Staff Correlated with Fewer Cases and Deaths among Residents December 16, 2021

Higher vaccination rates would have meant thousands fewer cases and hundreds fewer deaths.

CMS Will Now Post All Civil Money Penalties Imposed Against Nursing Facilities December 16, 2021

CMS has stated it will now publicly post all civil money penalties imposed against nursing facilities, whether or not the fines have been paid.

Build Back Better Act: House and Senate Nursing Home Provisions Compared December 16, 2021

A side-by-side comparison of the House version of the Build Back Better Act’s nursing home provisions, compared with the Senate’s current version.

Courts Order Preliminary Injunctions Against Vaccination Mandate for Medicare and Medicaid Providers and Suppliers December 9, 2021

Biden Administration suspends enforcement of provider vaccination mandate “so long as court-ordered injunctions remain in effect."

Special Report | Why Do Nursing Home Operators Who Provide Poor Quality Care Control Increasing Numbers of Facilities? December 6, 2021

Many poor quality providers are expanding the numbers of facilities that they own or operate. Why is this disturbing trend apparently increasing? Unfortunately, there is no easy or simple answer to the question. In fact, there are likely multiple inter-related explanations.View and download the full report at: https://medicareadvocacy.org/wp-content/uploads/2021/12/Special-Report-SNF-Ownership-11-2021.pdf

Pass Build Back Better — Seize the Moment to Protect Nursing Home Residents December 2, 2021

It’s time to do what is right to help protect older Americans and people with disabilities who live in our nation’s nursing homes. That means passing all five nursing home provisions in the Build Back Better Act.

Updated Factsheet | CMS Nursing Home Visitation Guidance December 2, 2021

The information in this Factsheet will be useful to help navigate resident visitation rights.

Elder Justice Vol. 3 Issue 10 Now Available December 2, 2021

Elder Justice - Did these nursing home violations really cause "no harm?"

CMS Revises Visitation Rules for Nursing Facilities November 18, 2021

Facilities can no longer limit the frequency, length or number of visitors, or require advance scheduling. 

Connecticut Begins Penalizing Long-Term Care Facilities Failing to Comply with Governor’s Vaccine Mandate November 4, 2021

226 facilities (35%) failed to report to DPH by the deadline, while 122 facilities (18.9%) failed to report altogether.

Affirmed: Negligence and Wrongful Death Cases Against Nursing Homes During COVID-19 Pandemic Belong in State Court November 4, 2021

Plaintiffs alleged facilities failed to take appropriate measures to protect them from COVID-19.

8th Circuit Court of Appeals Upholds Trump Administration’s Regulation Permitting Pre-Dispute Arbitration Agreements in Nursing Home Admissions Contracts October 21, 2021

Trump-era regulations allow nursing facilities to use binding arbitration agreements in nursing home admissions contracts, with certain resident protections.

Study | Black Nursing Home Residents Disproportionately (and Incorrectly) Diagnosed with Schizophrenia October 21, 2021

Study concludes that Black nursing home residents with Alzheimer’s disease and related dementias (ADRD) were more likely to be diagnosed with schizophrenia.

CMA Report | Privatization of County-Owned Nursing Facilities is Not Good for Residents, Staff, or States October 21, 2021

Privatization of seven county-owned nursing facilities in Pennsylvania, or even the attempted privatization of those facilities, led to reductions in staffing, shortages of medical and resident care supplies, and reduced quality of care.

Report: COVID-related Death Rates in Nursing Homes Spike Due to Delta Surge October 7, 2021

US nursing homes experienced a 400% increase in COVID-19 related deaths between July and August.

Government Releases $25.2 Billion in Provider Covid-19 Relief September 23, 2021

Federal funds should be directed to the care of residents, not to facility and corporate profits.

CMS Now Reports Resident and Staff COVID-19 Vaccination Rates on Care Compare September 23, 2021

Advocates for residents had asked CMS to make vaccination information more readily available.

Private Equity Companies Continue Buying Nursing Facilities September 15, 2021

Nursing facility purchases by private equity firms reflect what appears to be an accelerating consolidation of ownership in the nursing home industry.

Special Report | Who Provides Care for Nursing Home Residents? An Update on Temporary Nurse Aides September 15, 2021

CMS’s April 2021 guidance on Temporary Nurse Aides violates federal law and is poor public policy.

Study: Long-Term Care Facilities in Socially Isolated Neighborhoods Are Associated with 30-Day Mortality Risk September 2, 2021

Social isolation is a product of both circumstances within the walls of the facilities and the geographic location of the facilities.

CMS Delays Adjusting Medicare Rates for Skilled Nursing Facilities to Reflect Changes in Therapy September 2, 2021

Under PDPM physical and occupational therapy in nursing homes declined 30%.

Nursing Home Residents Have Private Right of Action to Enforce the Nursing Home Reform Law Against Publicly-Owned Facilities August 26, 2021

New court decision says residents in publicly-owned facilities have private right of action to enforce rights identified in the 1987 Nursing Home Reform Law.

Report Documents Private Equity’s Role in Ownership of Nursing Facilities August 19, 2021

New Report describes even more concerns about private equity’s investment in nursing homes. 

Senators Introduce Nursing Home Legislation to Improve Quality of Care August 12, 2021

Bill includes multiple provisions to improve the quality of care for residents and the oversight system.

GAO Issues New Report on Nurse Staffing in Nursing Facilities August 12, 2021

GAO report analyzes relationship between nurse staffing levels and critical incidents in nursing homes.

American Bar Association Adopts Resolution on Nursing Home Size and Density August 12, 2021

American Bar Association (ABA) adopts resolution calling for smaller nursing home facilities with single occupancy rooms.

Study Links Long-Term Care Staff Vaccination Rates with Disparities August 5, 2021

Disparities in vaccination rates among staff in long-term care facilities likely mirror social disparities that are found in the surrounding communities.

CMA Special Report | What Can and Must Be Done about the Staffing Shortage in Nursing Homes August 5, 2021

Methods to strengthen staffing are well-known. The question is whether we have the will to make necessary changes.

Per Day Civil Money Penalties are Back for Nursing Facilities July 29, 2021

CMS has allowed the reinstatement of per day civil money penalties for deficiencies that reflect past noncompliance.

Immunity for Long-Term Care Facilities During the Coronavirus Pandemic July 22, 2021

38 states have either issued executive orders or passed legislation giving long-term care facilities immunity.

Special Report | Nursing Home Industry is Heavily Taxpayer-Subsidized July 9, 2021

The nursing home industry receives more taxpayer money than any other industry in the United States.

Elder Justice Newletter, Vol. 3 Issue 8 Now Available July 8, 2021

In the Elder Justice Newsletter, we highlight citations, that have been identified as not causing any resident harm.

Bill To Recognize Essential Caregivers Introduced in Congress July 1, 2021

Proposed legislation says unequivocally that the government cannot ever again totally ban families.

Advocates for Nursing Home Residents Propose Framework for Legislative and Administrative Changes to Benefit Residents June 24, 2021

Advocates propose multiple post-COVID changes to ownership, payment, and more to benefit residents.

Racial/Ethnic Minorities and Dually Eligible Beneficiaries More Likely to Get COVID-19 in Nursing Homes, According to Office of Inspector General June 24, 2021

About half of all Black, Hispanic, and Asian Medicare beneficiaries in nursing homes had or likely had COVID-19 in 2020.

Nursing Home Health Equity: More Evidence Showing COVID-19’s Racial Disparities June 10, 2021

Reports say race and ethnicity of people living in a nursing home were predictors of whether it was hit with COVID-19.

Elder Justice Newletter, Vol. 3 Issue 7 Now Available June 10, 2021

highlighting citations, including deficiencies related to abuse, neglect, and substandard care, that have been identified as not causing any resident harm.

United States Settles False Claims Act Case with SavaSeniorCare June 10, 2021

Provider billed billing Medicare for unnecessary rehabilitation services and provided worthless services to residents.

Report: Nursing Homes Had Highest Death Rate of All Senior Housing From COVID – Although 39% Had None June 10, 2021

“Health status and frailty levels of residents living in senior housing” are a primary driver of the differences in the COVID mortality rates.

Nursing Homes Fined for Infection Control Should Not Receive COVID-19 “Performance Based” Relief Funds May 27, 2021

Facilities cited by CMS with infection prevention and control deficiencies should not be eligible for “performance-based incentive payments.”

CMS Interim Final Rule Addresses Covid-19 Vaccinations for Nursing Home Residents and Staff May 20, 2021

Rule goes into effect May 21, 2021; comments are due by July 12, 2021.

Arizona Governor Vetoes Bill Reauthorizing Nursing Home Administrator Licensing Board After The Arizona Republic Reports That Board Granted A License To A Convicted Felon May 13, 2021

While this may be an exceptionally troublesome case, the Center for Medicare Advocacy has expressed ongoing concerns about state licensure requirements and federal certification requirements for owners and managers of nursing facilities.

HHS Inspector General Finds CMS Data Understates Antipsychotic Drug Use in Nursing Homes May 13, 2021

A serious and longstanding quality of care problem in nursing homes is the inappropriate use of antipsychotic drugs with residents who have dementia.

CMS Confirms Steep Decline in Therapy at Nursing Facilities May 6, 2021

As soon as the new PDPM reimbursement system was implemented, therapy minutes dropped from 91 minutes per resident per day to 62 minutes, a decline of more than 30%.

Policies and “Regulatory Failure” Endangered Nursing Home Residents April 29, 2021

Professor Nina A. Kohn challenges the nursing home industry’s narrative that nursing facilities are victims of COVID-19.

Elder Justice Newsletter – Vol 3, Issue 6 Now Available April 29, 2021

The Elder Justice Newsletter highlights SNF citations that have been identified as not causing any resident harm - despite causing great harm.

Personal Care Attendants: Troubling New Class of Worker in Florida Long-Term Care Facilities April 22, 2021

Lowering the bar on training and qualifications are troubling and potentially dangerous to the vulnerable residents who live in these facilities.

Oscar Nominated Documentary Goes Undercover in Chilean Nursing Home April 22, 2021

Film illustrates how even a simple phone call to a loved one can make a meaningful difference.

Nurse Aide Training Bill Could Diminish Quality of Care for Nursing Home Residents April 22, 2021

Now, more than ever, nurse aides need more training – not less – to equip them with the skills they need.

New Study: High Nursing Home Staff Turnover Impacts Quality of Care April 15, 2021

High staff turnover can hurt the quality of care residents receive resulting in diminished health outcomes.

Last Week Tonight with John Oliver Tackles the Long-Term Care Crisis April 15, 2021

For a great, quick, long-term care primer, check out this clip from "Last Week Tonight with John Oliver."

Experts Spotlight Systemic Racism in U.S. Nursing Homes and Call for Action April 8, 2021

Evidence suggests some racial and ethnic minority groups were disproportionately affected by COVID-19, and remain at increased risk.

Covid-19 and Nursing Home Residents: Increased Loneliness and Isolation April 8, 2021

Study shows increase in depression, weight loss, incontinence, and loss of cognitive function during pandemic.

Center for Medicare Advocacy submits Statement for the Record for Senate Finance Committee March 17 Hearing on Nursing Homes and COVID-19 March 25, 2021

Statement for the record asks Congress to address longstanding problems in nursing facilities.

Nursing Home Trade Associations’ Legislative Agenda for 2021: More Familiar Than Bold March 25, 2021

Familiar agenda seeks more public funding and less public oversight.

Center Report: Billions of Dollars to Nursing Homes in Covid-19 Relief March 25, 2021

New report identifies primary sources of financial aid and concerns that have been raised about COVID funding for poor performing facilities.

Senate Finance Committee Hearing on Covid-19 and Nursing Homes March 18, 2021

More transparency and accountability about facility spending practices are essential.

Special Report | Nursing Facilities Have Received Billions of Dollars in Direct Financial and Non-Financial Support During Coronavirus Pandemic March 17, 2021

Concerns have been raised about nursing facilities that have received extensive COVID financial assistance, though they were sanctioned for fraud or poor care.

New CMS Guidance Allows Visitors in Nursing Homes March 11, 2021

CMS encourages visitors to become vaccinated , but facilities should not require visitors to be tested or vaccinated.

Congressman Neal Asks CMS to Reinstate Nursing Home Surveys and Enforcement March 4, 2021

Longstanding resident protections were waived during the COVID-19 pandemic.

Nursing Home Advocates and Members of Congress Call for Reinstatement of Nurse Aide Training Rules March 4, 2021

Rules requiring that nurse aides be trained and competent before providing care must be reinstated.

New Report Documents Causes and Cures for COVID-19 Crisis in Long-Term Care Facilities February 18, 2021

New report explores nursing home responses to the coronavirus crisis and examines how residents’ deaths were not “inevitable”, as some have claimed.

It’s Time to Repeal the 3-Day Inpatient Hospital Requirement for Medicare Skilled Nursing Facility Coverage February 11, 2021

Times have changed. Congress should repeal the three-day inpatient requirement for multiple reasons.

Staffing is Key to Determining Whether Covid-19 Affects Nursing Home Residents February 4, 2021

NY Attorney General finds that the majority of resident deaths occurred in facilities with low nurse staffing levels.

Expanded Medicare Skilled Nursing Facility Coverage During the Covid-19 Pandemic January 28, 2021

CMS has waived two limitations on Medicare Part A skilled nursing facility (SNF) coverage during the coronavirus pandemic.

Elder Justice Newsletter – Vol 3, Issue 4 Now Available January 21, 2021

Four “no-harm” SODs from February 2020 show residents deprived of their rights to 1) Following an advance directive; 2) Proper oxygen therapy; 3) Gender pronoun preferences; and 4) Appropriate blood pressure medication.

Consumer Advocacy Organizations Sue CMS Over 2017 Guidance on Civil Money Penalties Imposed Against Nursing Facilities January 21, 2021

Suit challenges unilateral penalty change made by CMS in 2017 that weakened beneficiary protections in nursing homes.

HHS Inspector General Issues Report on Focused Infection Control Surveys in Nursing Facilities December 31, 2020

From March 23 to May 30, 2020, states cited only 68 deficiencies at nursing facilities.

“Observation Status” May Disproportionately Burden Medicare Beneficiaries in the Most Vulnerable Neighborhoods December 17, 2020

Medicare’s observation status policies have a disproportionate impact on those who can least afford it.

Senators Casey and Wyden Release Third Report on Nursing Homes and COVID-19 December 17, 2020

In "The Cost of Inaction: 19 Deaths an Hour and Rising," Senators Bob Casey and Ron Wyden describe the worsening coronavirus crisis in nursing homes.

Toby S. Edelman on This is Getting Old: Moving Towards an Age-Friendly World December 15, 2020

Perspectives on what policymakers can learn from COVID-19's devastating impacts on nursing facilities.

Elder Justice Newsletter – Vol 3, Issue 3 Now Available December 10, 2020

Nursing home stories from homes in New York, Alaska, New Hampshire and Texas.

CMS Replaces all Eight Care-Specific Websites with Single Website: Care Compare December 10, 2020

New site looks different, and some information previously available on Nursing Home Compare may be difficult to find.

Nursing Home Residents and COVID-19: Staffing and Quality of Care Matter December 3, 2020

When it comes to COVID in nursing homes, it's not about geography it's about staffing.

Center for Medicare Advocacy Senior Policy Attorney, Toby Edelman and Health and Aging Policy Fellow, Cinnamon St. John Featured On This Is Getting Old Podcast November 19, 2020

A discussion of what is happening in the nation’s nursing homes, and strategies to help.

HHS Continues Giving Provider Relief Funds to Nursing Facilities November 12, 2020

Department of Health and Human Services offers “performance payments” to nursing facilities under Provider Relief Fund.

Infection Control Surveys In Nursing Facilities: As Deaths Soar, CMS Reports Few Deficiencies, Primarily “No Harm” November 12, 2020

As COVID-19 cases increase in nursing facilities nationwide and residents and staff die, CMS continues to report that surveys cite few deficiencies and classify most of them as “no-harm.”

Nursing Facilities and COVID: Staffing Matters November 5, 2020

While geographic location of a nursing facility has relevance, factors within the control of the nursing facility matter more.

Members of Congress Write CMS Urging Restoration of Nurse Aide Training Requirements for Nursing Facilities November 5, 2020

Congressman Lloyd Doggett and colleagues asked Seema Verma, Administrator of CMS, to reinstate nurse aide training requirements that have been suspended since March 2020.

Infection Control Surveys At Nursing Facilities October 29, 2020

Infection control deficiencies are rarely cited and, even if cited, they are not cited as immediate jeopardy and are not enforced. Proper enforcement could prevent unnecessary deaths.

Provider Relief Funds: Care for Patients or Boosting Provider Revenues? October 29, 2020

HHS says providers can use Provider Relief Funds (PRF) to revenues lost during the pandemic “without limitation” despite quality of care.

Long-Term Care Policy: Trump vs. Biden October 22, 2020

A comparison of the presidential campaigns’ long-term care policies based on the Democratic Party’s 2020 platform and position paper and relevant policies implemented or proposed by the Trump Administration.

Paying Direct Care Workers a Living Wage October 15, 2020

Raising direct care workers’ wages could pay for itself, just by improving care for residents.

COVID-Only Nursing Facilities: What Happened To A Good Idea? October 15, 2020

The policy of establishing COVID-only facilities can work, but only if facilities or units are required to meet specific standards for designation and if these standards are appropriately enforced.

Special Report: CMS Releases Fifth Cumulative List of Focused Infection Control Surveys October 8, 2020

Like previous reports, the fifth report shows that few facilities are cited with deficiencies and that most deficiencies are called “no harm.”

AHRQ Launches National Nursing Home COVID Action Network Training Program October 8, 2020

AHRQ launches free training and mentorship to nursing homes to increase evidence-based infection prevention and safety practices.

Nursing Facilities and Covid-19 – It’s not Inevitable October 8, 2020

While location may influence COVID-19 infection rates in nursing facilities, it is far from the deciding factor.

Study Finds Lower Mortality Rates in Unionized New York State Nursing Facilities September 17, 2020

New York state facilities with employee unions had lower moratality rates, COVID infection rate, and better access to protective equipment.

CMS Long-Term Care Commission Issues Report September 17, 2020

The report understandably focuses on the immediate issue of COVID-19, but it does not tackle the longer term changes to the nursing home system that are needed to try to prevent the tremendous suffering the pandemic has caused and could cause again in the future.

Testing Nursing Home Residents for COVID-19 September 10, 2020

Testing of staff is essential to preventing the introduction or spread of COVID-19 in nursing facilities.

What’s New in Infection Control Surveys for Nursing Facilities? September 3, 2020

Accurate citing of deficiencies is a key component of the oversight system for nursing facilities.

Center for Medicare Advocacy Toolkit: How to Obtain an Additional 100 Days of Medicare Coverage in a Skilled Nursing Facility During the COVID Public Health Emergency September 3, 2020

A compilation of self-help materials regarding the nursing home 100-Day Waiver.

CMS Restarts Survey and Enforcement Activities at Nursing Facilities August 27, 2020

Extended desk reviews and limitations on Civil Monetary Penalties mean that serious care concerns that were cited by surveyors during the pandemic may be largely overlooked and not sanctioned.

Congress Gives COVID Relief Money to Nursing Facilities, Regardless of Fraud Lawsuits, Poor Quality of Care August 27, 2020

The federal government has given money to nursing facilities during the COVID-19 pandemic without regard to their violations of federal law and federal care standards.

Responding to CMS Announcement on Nursing Home Enforcement – Infection Control Deficiencies in Nursing Facilities: QCOR Data August 20, 2020

Public databases report far fewer immediate jeopardy infection control deficiencies than CMS’s internal database.

Nursing Homes Nationwide Report Shortages of Nursing Staff August 20, 2020

Nursing homes in every state have a shortage of those valuable nurse resources.

Nursing Facilities Owned By Private Equity Firms Have Higher Rates of Covid Infections than Other Facilities August 13, 2020

Recent studies document that nursing facilities owned by private equity firms have higher rates of COVID-19 infections and deaths than facilities with other ownership.

Studies Find Higher Nurse Staffing Levels in Nursing Facilities Are Correlated With Better Containment Of Covid-19 August 13, 2020

Containing COVID-19 and reducing the number of COVID-19 deaths are related to increased nurse staffing levels.

Inspector General Finds More Than Half of All Nursing Facilities Failed to Meet Professional Nurse Staffing Standards in 2018 August 13, 2020

New public policies must ensure that all facilities have sufficient numbers of professional nurses as well as certified nurse assistants.

Infection Control Surveys and Deficiencies In Nursing Facilities August 11, 2020

The limited number of infection control deficiencies identified in CMS databases is not believable.

CMS Will Not Track Minimally Trained Aides at Nursing Facilities August 6, 2020

Accurate information about workers in nursing homes is essential to understanding who is providing care to residents in facilities during the pandemic.

Coalition Opposes Immunity for Nursing Facilities August 6, 2020

The Coalition for the Protection of Residents of Long-Term Care Facilities opposes efforts at the federal and state levels to grant nursing homes blanket immunity from liability during the COVID-19 pandemic.

Who’s Providing Care to Nursing Home Residents? July 29, 2020

Since nurse aides provide most of the direct care to residents, the qualifications of nurse aides and other staff members providing care to residents are critically important.

Center for Medicare Advocacy Submits Recommendations to the Nursing Home Commission July 23, 2020

The Center for Medicare Advocacy (Center) calls for a national solution to the national coronavirus crisis.

COVID Does Not Have to Lead to Deaths in Nursing Homes July 23, 2020

With nearly 4 million confirmed cases of COVID-19 in the United States, the nation braces as the disease surges in the Sun Belt, where Arizona, Florida, and Texas are now considered the epicenters of the illness. A recent article in The Atlantic contends that despite the fact that one in five nursing homes around the ...

American Health Care Association’s CEO Issues Message to Members: “We Won’t Back Down” July 16, 2020

Nursing Home Association blames community, lack of support for COVID spread, but other researchers find relation to staffing and quality rating levels.

Groups File Petition Demanding that HHS and its Agencies “Mitigate the COVID-19 Crisis in America’s Nursing Homes” July 16, 2020

ACLU, SEIU, and disability organizations, petitioned the Department of Health and Human Services to take immediate action to correct the Federal Government’s mishandling of the coronavirus pandemic.

Additional Infection Control Surveys at Nursing Facilities Show Same Results: Few Deficiencies, Most Called “No Harm” July 9, 2020

only a very small fraction of facilities received a deficiency for infection prevention and control, and 96% of those were classified as “no harm” or “substantial compliance.”

Center for Medicare Advocacy Comments on Coronavirus Reporting Requirements for Nursing Facilities July 9, 2020

CMS Interim Rule authorizes national reporting only during the COVID-19 pandemic. We believe that more attention to infections at the national level is critical.

Special Report – Nursing Homes Cited With Immediate Jeopardy Deficiencies During Pandemic: Poor Health Inspection Results, Low Staffing Levels July 2, 2020

Facilities cited with immediate jeopardy deficiencies generally have poor survey histories and low nurse staffing levels, are more likely to be operated on a for-profit basis, and had civil money penalties imposed in the prior three years.

CMS Liberalizes Visitation to Nursing Homes. . . A Little July 2, 2020

States have already begun liberalizing visitation rules. This will be a welcome change for many residents and families

Center for Medicare Advocacy Senior Policy Attorney Testifies Before Congressional Committee re: Nursing Facilities and the COVID-19 Crisis June 25, 2020

Center for Medicare Advocacy Senior Policy Attorney Toby Edelman provided invited testimony before the House Ways & Means Health Subcommittee hearing “Examining the COVID-19 Nursing Home Crisis.”

Special Report – Nursing Homes Cited with Infection Control Deficiencies During the Pandemic: Poor Results In Health Inspections, Low Staffing Levels June 17, 2020

We analyzed the information on Nursing Home Compare for the 160 facilities that were cited with infection control deficiencies during the pandemic. By various measures, these facilities provide poor quality care.

House Briefing on Covid and Nursing Homes Highlights Longstanding Problems in Staffing and Infection Control; Committee Launches Investigation of CMS and Five Nursing Home Chains June 17, 2020

A June 11 briefing by the Select Committee on COVID identified nursing homes’ longstanding problems in staffing levels and infection control, as well as the failure of the federal government to take a strong leadership position in confronting the coronavirus pandemic.

COVID-19’s Impact on Beneficiary Rights – A Case Study Examining Medicare Coverage Exceeding 100 Days in a Skilled Nursing Facility June 11, 2020

A Case Study Examining Medicare Coverage Exceeding 100 Days in a Skilled Nursing Facility.

Infection Control Surveys at Nursing Facilities: CMS Data Not Plausible June 11, 2020

The Center for Medicare Advocacy analyzed recently reported nursing home infection prevention deficiencies and has issued a full report.

How Many Nursing Home Residents Have Died of Covid-19? June 4, 2020

Instead of rolling back nursing home regulations, CMS needs to impose meaningful and appropriate sanctions when facilities fail to meet standards for infection prevention and control.

CMS Rule: Nursing Facilities Must Report Covid-19 Data to CDC, Residents, Families and Representatives May 28, 2020

In interim final rules that went into effect May 8, 2020, the Centers for Medicare & Medicaid Services (CMS) requires nursing facilities, at least on a weekly basis, to report electronically to the Centers for Disease Control and Prevention (CDC) information about COVID-19. The required reporting includes suspected and confirmed cases among residents and staff; ...

GAO on Infection Control Deficiencies in Nursing Facilities Before Covid-19 Pandemic: “Widespread,” “Persistent,” “Ignored” May 21, 2020

The GAO plans “to examine CMS guidance and oversight of infection prevention and control in a future GAO report."

State Attorneys General Open Criminal Investigations of Nursing Facilities in Light of the Pandemic; For Regulatory Agencies, Business As Usual May 21, 2020

State Attorneys General have opened criminal investigations into nursing facilities. But for regulatory agencies it appears to be business as usual.

New CMA Report – Nursing Home Industry Seeks Immunity During COVID Crisis; States Are Obliging May 14, 2020

  In response to coronavirus pandemic, the nursing home industry is seeking broad immunity from COVID-related harm. Through executive orders and state legislation, Governors and states are rapidly granting immunity to various health care providers, including nursing facilities. The Nursing Home Industry’s Interest in Preventing Litigation is Longstanding.  When the federal standards of care for nursing facilities ...

Case Study: Medicare Advantage and Repeated Coverage Denials Amid the COVID Crisis May 14, 2020

  Mr. A, is a retired professor from a state university. He was auto-enrolled in his state’s retiree Medicare Advantage (MA) plan. The plan prospectus states that it covers an unlimited number of days in a skilled nursing facility (SNF). An active 73-year old, Mr. A went to his primary care doctor because he was experiencing some ...

CMA Special Report – Infection Control Surveys at Nursing Facilities: It Looks Like Business as Usual May 7, 2020

  When the Centers for Medicare & Medicaid Services (CMS) suspended the regular survey system for nursing facilities during the COVID-19 crisis, it reported that, for a three-week prioritization period (beginning March 20) and since extended until further notice, it would suspend regular survey activities and conduct only two types of surveys: (1) complaints and facility-reported ...

CMS to Require Transparency Regarding Coronavirus in Nursing Facilities April 23, 2020

In guidance released Sunday evening, April 19, 2020, the Centers for Medicare & Medicaid Services (CMS) announced that in two sets of future rulemaking, it will require nursing facilities to report information about suspected and confirmed cases of coronavirus to the Centers for Disease Control and Prevention (CDC) and to residents and their representatives. Although CMS ...

Federal District Court in Arkansas Upholds Federal Rule Authorizing Arbitration Requirements in Nursing Home Contracts April 16, 2020

In a summary judgment decision, Federal District Court Judge Timothy L. Brooks sustained  regulations promulgated by the Trump Administration that permit pre-dispute arbitration agreements, with resident protections, which replaced the Obama Administration’s prohibition of pre-dispute arbitration agreements under all circumstances. Northport Health Services of Arkansas v. United States Department of Health and Human Services, Case ...

CDC’s Report on Coronavirus in a Seattle Nursing Facility: What it Tells Us About Staffing Problems Nationwide; What We Must Do to Address Lessons Learned April 9, 2020

The Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Weekly Report for March 18, 2020 describes, as of March 9, coronavirus and the Life Care Center at Kirkland (Washington State): “Introduction of COVID-19 into a long-term residential care facility in Washington resulted in cases among 81 residents, 34 staff members, and 14 visitors; ...

Medicare Skilled Nursing Facility Coverage, Discharges, and Transfers During the COVID Crisis April 9, 2020

Skilled nursing facilities (SNFs/nursing homes) often tell residents and families that they are discharging the resident because Medicare will no longer pay for the resident’s stay.  In a previous Alert (Jan. 2016), the Center for Medicare Advocacy explained that Medicare coverage for care and discharge from SNFs are two distinct issues, each with its own ...

Hospitals Should Discharge Patients with Coronavirus Only to Qualified Nursing Homes April 2, 2020

As the coronavirus pandemic continues, nursing facilities are being asked, or told, to admit or readmit residents who had or may have COVID-19. Hospitals need beds for acutely ill residents and need to discharge patients that they determine can be safely discharged to other settings.  How do we keep as many people as safe as ...

New Guidance On Nursing Home Health Inspections Severely Limits Oversight and Enforcement for a Three-Week Period March 26, 2020

On March 20, 2020, the Centers for Medicare & Medicaid Services (CMS) issued new guidance directing state survey agencies to conduct health inspections only if they relate to complaints and facility-reported incidents (FRIs) triaged at the immediate jeopardy level. These facilities will simultaneously have a streamlined infection control review. Additionally, the guidance indicates that federal ...

CMS Temporarily Waives Medicare Access Barriers for Skilled Nursing Facility Care March 26, 2020

On March 13, 2020, President Trump proclaimed the COVID-19 pandemic a national emergency. As a result, the U.S. Department of Health and Human Services (HHS) now has the authority under Section 1135 of the Social Security Act to waive or modify certain requirements of public health programs, including Medicare. The Centers for Medicare & Medicaid ...

Restrictions on Family Caregivers Raise Concerns about Unmet Care Needs In Nursing Homes March 19, 2020

On March 13, 2020, the Centers for Medicare & Medicaid Services (CMS) issued guidance to nursing homes on COVID-19 (coronavirus). CMS is directing nursing homes to restrict all visitors and non-essential health care workers from entering facilities, except in end-of-life and other compassionate care situations. While COVID-19 presents significant danger to vulnerable nursing home residents, ...

The Coronavirus and Nursing Home Residents March 19, 2020

A Statement from the Center for Medicare Advocacy and the Long Term Care Community Coalition March 19, 2020—At least twenty-six residents at Life Care Centers at Kirkland have died of the coronavirus and many more residents and staff at the Washington State nursing facility are showing signs of the illness. Why have these medically fragile residents ...

Elder Justice Newsletter – Vol. 2, No. 7 Available Now March 19, 2020

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 ...

LTCCC Facts & Tips on Infection Control and Coronavirus March 5, 2020

Our colleagues at the Long term Care Community Coalition have prepared a Fact Sheet for nursing home residents justifiably concerned with the spread of Coronavirus. The Fact Sheet lays out key concerns for resident safety, tips for residents, families and the public, and some key differences for residents in nursing homes vs. those in assisted ...

Issue Brief: Medicare Payment vs. Coverage for Home Health & Skilled Nursing Facility Care March 3, 2020

New Issue Brief: Medicare Payment vs. Coverage for Home Health & Skilled Nursing Facility Care The Centers for Medicare & Medicaid Services (CMS) — the federal agency responsible for administering the Medicare program — has begun implementing new Medicare payment models for both home health and skilled nursing facility care. These payment models create a different ...

Lawmakers Must Be Cautious about Recommendations from a New Industry Report on Nursing Home Closures February 28, 2020

Joint Statement from the Long Term Care Community Coalition and the Center for Medicare Advocacy Feb. 28, 2020 – LeadingAge, a trade association for non-profit nursing homes, has released a report on nursing home closures and trends between June 2015 and June 2019. The report finds that more than 550 nursing homes—approximately four percent of all ...

Massachusetts Task Force Calls for Closure of Low-Performing, Low Occupancy Nursing Facilities February 20, 2020

The nursing home industry instinctively responds to the closures of nursing facilities by claiming that Medicaid rates are too low and must be increased. A legislatively-mandated Massachusetts task force on nursing facilities has a different response. Describing declining occupancy in nursing facilities, multiple facilities having both chronically low quality and low occupancy, and the dramatic ...

Changes Coming to CMS Websites for Consumers February 13, 2020

A recent blogpost by Administrator Seema Verma of the Centers for Medicare & Medicaid Services (CMS) announces CMS’s plan to “combine and standardize” the eight Compare websites into a Medicare Compare website. At the same time, an unidentified spokeswoman wrote to McKnight’s Long-Term Care News, an on-line trade publication, that “‘CMS is interested in evaluating ...

Study Finds Nursing Home Compare Data about Patient Falls with Major Injuries Underreported and “Highly Inaccurate” January 30, 2020

In the first “national-level assessment of how nursing homes self-report major injury fall rates, which are used by CMS for quality measurement and public reporting,” researchers “found substantial underreporting on the specific Minimum Data Set (MDS) item (J1900C) used by NHC .”  Prachi Sanghav, Shengyuan Pan, Daryl Caudry, “Assessment of nursing home reporting ...

Medicare SNF Payment Model Creates Changes in Care and Admissions – What about Facility Assessments? January 30, 2020

The new Medicare reimbursement system for skilled nursing facilities (SNFs) – the Patient-Driven Payment Model (PDPM) – fundamentally changes the financial incentives for facilities. With PDPM, Medicare now pays lower rates for residents needing therapy and higher rates for residents needing complex nursing care. Responding to these financial incentives, SNFs laid off therapists across the ...

Accountable Care Organizations and Observation Status January 30, 2020

One of the ongoing problems that Medicare beneficiaries face is so-called “outpatient” hospital observation status. When a hospital classifies a patient as an outpatient, rather than as an inpatient, the result is that the patient is ineligible for Medicare Part A coverage of the post-hospital stay in a skilled nursing facility (SNF) (because the Medicare ...

Nursing Facilities and Medicare Advantage: If You Can’t Beat ’Em, Join ’Em . . . But What About the Medicare Beneficiaries? January 9, 2020

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 ...

Skilled Nursing Facilities Lay off Therapists, Change Therapy Services – What Can Residents & Therapists Do? December 20, 2019

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). 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 ...

Patients Need Therapy – Medicare Payment Systems Create Barriers December 12, 2019

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 ...

Fairness in Nursing Home Arbitration Act Provides Important Protections December 12, 2019

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 ...

Center for Medicare Advocacy Submits Statement to Ways & Means Hearing on “Caring for Aging Americans” December 12, 2019

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. The ...

Quality Care for Nursing Home Residents Act of 2019 December 5, 2019

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 22, ...

Issue Alert – Medicare Benefit Periods Under PDPM November 21, 2019

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 ...

Poorly Performing Skilled Nursing Facilities: What Happens to Them? November 7, 2019

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, ...

Medicare’s New Skilled Nursing Facility Payment System Alters Access to Care November 7, 2019

Medicare’s new reimbursement system for skilled nursing facilities (SNFs), called Patient-Driven Payment Model (PDPM), are already being seen. The former reimbursement system, Resource Utilization Groups (RUGs), ...

Potential Impacts of New Medicare Payment Models On Skilled Nursing Facility and Home Health Care October 31, 2019

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 ...

Nursing Home Compare’s Abuse Icon is Now Live October 24, 2019

On October 23, 2019, the Centers for Medicare & Medicaid Services (CMS) began use of a new “abuse icon” on Nursing Home Compare. Consumers using the website will now be alerted when a nursing home has been cited for an abuse violation in the past year or over each of the past two years, depending ...

Joint Issue Alert on Medicare Payment and Skilled Therapy Services in Nursing Homes October 17, 2019

On October 1, 2019, the Centers for Medicare & Medicaid Services (CMS) implemented a new payment system for Medicare-covered nursing home stays—the “Patient Driven Payment Model” (PDPM). PDPM creates new financial incentives for nursing homes and new challenges for nursing home residents. One of the biggest challenges for residents under PDPM is access to skilled ...

Drug Company Sued Over Kickbacks for Off-Label Marketing of Psychotropic Drug for Nursing Home Residents to Pay Over $115 Million October 17, 2019

Background When the Centers for Medicare & Medicaid Services (CMS) launched a national campaign to reduce the off-label prescribing of antipsychotic drugs for nursing home residents in 2012, Avanir Pharmaceuticals directed its sales force to talk to nursing facilities about using Nuedexta as a substitute for antipsychotic drugs. The Food and Drug Administration had approved Nuedexta ...

Free Webinar about the New Medicare Payment System For SNFs October 10, 2019

The Long Term Care Community Coalition is hosting a webinar on Medicare’s new payment system for skilled nursing facilities, Patient-Driven Payment Model (PDPM) on Tuesday, October 15, 2019, at 1:00 p.m.  The Center for Medicare Advocacy’s Senior Policy Attorney Toby S. Edelman will discuss how the new system works and what it means for residents.For ...

Nursing Home Residents and Therapy Under The New Medicare Payment System October 10, 2019

The Centers for Medicare & Medicaid Services (CMS) implemented a new Medicare Part A reimbursement system for skilled nursing facilities (SNFs), called Patient-Driven Payment Model (PDPM), on October 1, 2019. Therapists immediately began reporting that nursing homes and therapy companies were laying them off and demanding that they change their therapy practices, shifting residents from ...

Important Update to Nursing Home Compare Will Enable Public to Identify Facilities with a History of Abuse October 10, 2019

Joint alert from the Center for Medicare Advocacy and the Long Term Care Community Coalition.New IconOn October 7, 2019, the Centers for Medicare & Medicaid Services (CMS) announced changes to Nursing Home Compare that make it easier for residents and families to identify facilities with a history of resident abuse, neglect, or exploitation. Starting on ...

The Patient Driven Payment Model is Here October 3, 2019

The Patient Driven Payment Model is Here What Does It Mean For Residents? On October 1, 2019, the Centers for Medicare & Medicaid Services (CMS) began implementing a new payment system for Medicare-covered nursing home care. The payment system is called the “Patient Driven Payment Model” (PDPM). PDPM creates a new set of financial incentives for nursing ...

California Attorney General Calls on CMS to Withdraw Proposed Revisions to Nursing Home Requirements of Participation September 26, 2019

In his September 16, 2019 comments on the Administration’s proposed revisions to the nursing facility Requirements of Participation, California State Attorney General Xavier Becerra writes that the proposed rule violates the 1987 federal Nursing Home Reform Law, the Social Security Act, the Affordable Care Act, and the Administrative Procedures Act. Beccera describes the proposed changes ...

House of Representatives Passes Bill Prohibiting Pre-Dispute Arbitration Agreements September 26, 2019

On September 20, 2019, the U.S. House of Representatives passed the Forced Arbitration Injustice Repeal (FAIR) Act. The FAIR Act prohibits pre-dispute arbitration agreements in consumer, employment, antitrust, and civil rights cases. The Act also prohibits any agreements or practices that interfere with an individual’s right to participate in joint, class, or collective action. Representative ...

Center for Medicare Advocacy Submits Comments Opposing the Administration’s Proposed Roll Back of Nursing Home Standards September 19, 2019

On September 15, 2019, the Center for Medicare Advocacy (the Center) and the Long Term Care Community Coalition (LTCCC) submitted comments opposing the Trump Administration’s proposed rule to revise the nursing home Requirements of Participation. The proposed rule is the latest example of the Administration’s efforts to deregulate the nursing home industry. Among the changes, ...

Rule Allowing Pre-Dispute Arbitration Agreements in Nursing Homes Takes Effect September 19, 2019

As of September 16, 2019, nursing homes nationwide can begin asking residents (or their representatives) to sign a pre-dispute arbitration agreement. The Trump Administration reversed a previous prohibition on such agreements in a July 2019 final rule. Although there is ongoing legal action to overturn the Administration’s rule, implementation has not been delayed for the ...

Nursing Home Deregulation Continues, Despite Substantial Risk to Residents September 5, 2019

September 2019 Background Under the Trump Administration, the Centers for Medicare & Medicaid Services (CMS) has been advancing efforts to deregulate the nursing home industry by rolling back the rights and protections of nursing home residents. These efforts include reducing accountability for substandard care, such as by shifting the default financial penalty for the most serious health ...

Stop Drugging Nursing Home Residents Without their Written Consent August 29, 2019

Background. Nursing homes administer antipsychotic drugs to approximately 20 percent of residents nationwide. Sadly, and too often, nursing homes use these drugs as a way of chemically restraining residents exhibiting the behavioral symptoms of dementia, despite the Food and Drug Administration’s (FDA) “black box” warning against using antipsychotic drugs on elderly patients with dementia. The ...

Annual Surveys at Nursing Facilities Are Essential To Protect Residents August 8, 2019

For decades, the nursing home industry has proposed relaxing the requirement for annual surveys at nursing facilities.  Industry representatives argue that surveyors should excuse “good” facilities from annual surveys and focus their attention on poorly-performing facilities. The argument’s superficial appeal fails with scrutiny. First, how would we identify “good” facilities? As the Government Accountability Office (GAO) ...

Federal Reports Find Incidents of Nursing Home Resident Abuse Are on the Rise but also Underreported August 1, 2019

                      Joint statement from the Center for Medicare Advocacy and the Long Term Care Community Coalition. On July 23, 2019, the U.S. Government Accountability Office (GAO) published a report on nursing home resident abuse, Improved Oversight Needed to Better Protect Residents from Abuse. The GAO found ...

CMS’s Proposed Changes to Nursing Home Requirements of Participation, Survey and Enforcement: Nothing Good for Residents August 1, 2019

Although the revised Requirements of Participation published in October 2016  CMS contends that its proposals are intended to “promote efficiency and ...

Senate Finance Committee Holds Hearing on Nursing Home Issues July 25, 2019

On July 23, 2019, the Senate Finance Committee held its second nursing home hearing this year, “Promoting Elder Justice: A Call for Reform,”  The Center for Medicare Advocacy is pleased that the July 23 hearing included a national advocate ...

Center Statement on Nursing Home Reform for Senate Finance Committee July 25, 2019

PROMOTING ELDER JUSTICE: A CALL FOR REFORM HEARING BEFORE THE U.S. SENATE COMMITTEE ON FINANCE July 23, 2019 Statement of Toby S. Edelman Senior Policy Attorney Center for Medicare Advocacy 1025 Connecticut Avenue, N.W., Suite 709 Washington, DC  20036 I am a Senior Policy Attorney in the Washington, D.C. office of the Center for Medicare Advocacy, a national not-for-profit legal organization that focuses ...

CMS Releases Special Focus Facility Candidate List But Transparency Issues Remain July 25, 2019

                      Background. Every month, the Centers for Medicare & Medicaid Services (CMS) identifies nursing homes with an extremely poor record of resident care for inclusion in the Special Focus Facility (SFF) program for enhanced oversight. Due to limited resources, CMS currently caps the SFF program to ...

CMS finalizes Rollback of Pre-Dispute Arbitration Protections July 18, 2019

                      In 2016, the Obama Administration promulgated regulations prohibiting pre-dispute arbitration agreements between nursing homes residents (or their representative) and facilities. On July 18, 2019, the Trump Administration published a Final Rule rolling back certain features of the 2016 resident protection. Most notably, the Final Rule ...

Nursing Home “Quality Measures” Do Not Reflect Quality of Nursing Home Care July 3, 2019

The federal website for information about nursing homes, Nursing Home Compare, reports information for each Medicare-certified and Medicaid-certified nursing facility in three categories – health inspections, staffing, and quality measures – as well as an overall score that combines the three domains. The health inspections domain reflects the findings of standard (annual) and complaint surveys ...

Latest Issue – Elder Justice Newsletter June 27, 2019

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 ...

Special Report – “Graduates” From the Special Focus Facility Program Provide Poor Care June 20, 2019

The Centers for Medicare & Medicaid Services (CMS) identifies about 88 nursing facilities – generally one to two facilities per state – that are among the most poorly performing facilities in the country. These nursing facilities, which CMS calls Special Focus Facilities (SFFs), have “more problems” than other facilities, “more serious problems” than other facilities, ...

Center for Medicare Advocacy Submits Joint Comments on Proposed Revisions to the Definition Of Group Therapy In Skilled Nursing Facilities June 20, 2019

On April 25, 2019, the Centers for Medicare & Medicaid Services (CMS) published a notice of proposed rulemaking that would revise the definition of group physical, speech and occupational therapy to allow six residents, rather than four, to participate in a group therapy session. If finalized, the rule would place even more nursing home residents ...

The New York Times Reports On HUD-Backed Nursing Homes June 13, 2019

Nursing home financial arrangements are important issues of public policy. Failures by state and federal governments to ensure nursing home financial accountability and integrity have an increasingly devastating impact on nursing home residents and their families across the country. According to a recent report by The New York Times, the U.S. Department of Housing and Urban ...

Senators Release Secret List of Poor Quality Nursing Homes June 6, 2019

At present, only 88 nursing facilities nationwide (0.6% of the nation’s total number of facilities) are identified as Special Focus Facilities (SFFs). The Centers for Medicare & Medicaid Services (CMS) describes SFFs as having “more problems” than other facilities, “more serious problems” than other facilities, and “ pattern of serious problems that has persisted over ...

Nursing Home Study Finds Discharges Linked to Medicare Copayments June 6, 2019

   Background. Medicare beneficiaries are entitled to a maximum of 100 days of skilled nursing facility (SNF) care in a benefit period when they meet specific coverage criteria. However, Medicare Part A only covers the full cost of a beneficiary’s skilled care during the first 20 days of a nursing home stay. Starting on day ...

Nursing Homes, Medicaid Rates, and Campaign Contributions May 30, 2019

As part of its investigative series on nursing home care in Florida, Naples Daily News (part of the USA Today Network) reports that the new Medicaid reimbursement system for Florida’s nursing homes, scheduled for full implementation in 2023, will increase reimbursement for some of the state’s most poorly performing facilities by millions of dollars while simultaneously reducing reimbursement for ...

Nursing Home Compare Inaccurately Reports Civil Money Penalties Imposed Against Nursing Facilities May 30, 2019

Public information about enforcement actions imposed and upheld against nursing facilities is inaccurate and limited, or missing.The Center for Medicare Advocacy (the Center) analyzed whether the federal website Nursing Home Compare to determine if it accurately reports civil money penalties (CMPs) that were imposed against nursing facilities and upheld by Administrative Law Judges (ALJs).  The Center identified 18 decisions by ALJs ...

Webinar: Where Does the Money Go? Insights and Consumer Perspectives on Nursing Home Profits and Losses May 23, 2019

On May 21, 2019, the Long Term Care Community Coalition (LTCCC) hosted a webinar on nursing home profits and losses. Dara Valanejad, a Policy Attorney with both the Center for Medicare Advocacy and LTCCC, participated in the webinar. Mr. Valanejad presented findings from the Medicare Payment Advisory Commission’s March 2019 report to Congress, discussed how poor quality of care may ...

Protecting Nursing Home Residents from Reckless Operators May 16, 2019

Last year, New Jersey-based Skyline Healthcare abandoned more than 100 nursing facilities nationwide, forcing multiple states to seek receiverships in court in order to protect residents and make sure they received food, medications, and care. States had allowed Skyline to take over the facilities, many from the nursing home chain Golden Living, even as Skyline’s ...

Improve Physician Staffing in Nursing Homes May 16, 2019

With more and more patients quickly discharged from acute care hospitals to skilled nursing facilities (SNFs), SNF residents are more clinically complex than ever. Despite the fact that residents have greater health care needs, federal standards for professional staffing at SNFs have not changed in more than 30 years. The consequences are dire. The Inspector ...

Sign-On Opportunity: Advocating for Individualized Therapy in Nursing Homes May 16, 2019

On April 25, 2019, the Centers for Medicare & Medicaid Services (CMS) published a notice of proposed rulemaking that would revise the definition of group physical, speech and occupational therapy to allow six residents, rather than four, to participate in a group therapy session. If finalized, the rule would place even more nursing home residents ...

CMS Proposed Rule to Redefine Group Therapy in Skilled Nursing Facilities: Concern for Resident Care April 25, 2019

On April 25, 2019, the Centers for Medicare & Medicaid Services (CMS) published a notice of proposed rulemaking (NPRM) on fiscal year 2020 payment and policy changes for Medicare-certified skilled nursing facilities. Most notably, the proposed rule projects an $887 million increase in aggregate payments to SNFs and revises the definition of group therapy to ...

How to Prevent Re-Hospitalization Of Nursing Home Residents: More Physicians and Nurses In Nursing Homes April 18, 2019

Reducing the re-hospitalization of nursing home residents is a constant and important public policy goal. At present, the goal is largely met by imposing financial sanctions against hospitals when residents are re-hospitalized. A better way of reducing re-hospitalizations of nursing home residents would be ensuring that residents get the care ...

Joint Statement: Federal Report Finds That CMS Failed to Properly Oversee State’s Nursing Home Investigations April 18, 2019

                      GAO Findings. Federal law requires state survey agencies to investigate allegations of resident abuse and neglect stemming from complaints and facility-reported incidents. About three-quarters of all abuse violations nationwide stem from these investigations. Unfortunately, a recently published management report by the U.S. Government Accountability Office ...

Latest Issue – Elder Justice Newsletter April 18, 2019

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 ...

Nursing Home Requirements of Participation: Will the Administration Overturn 2016 Rules for Infection Control? April 11, 2019

The Trump Administration solicited ideas for cutting nursing home standards of care In October 2016, the Obama Administration revised these Requirements, which establish the standards of care for nursing facilities that receive public reimbursement from the ...

Observation Status Deprives Medicare Beneficiaries of their Skilled Nursing Facility Benefit. Period. April 11, 2019

The facts are in: The ever-increasing use of observation status deprives many Medicare beneficiaries of care and coverage in skilled nursing facilities (SNFs).  In 2018, research by Avalere Health confirmed that the use of SNFs by beneficiaries in the traditional Medicare program declined each year between 2009 and 2016. Avalere identified the cause as “fewer hospital ...

What’s Causing Nursing Home Closures? April 4, 2019

Many nursing homes have closed in recent months throughout the country.  The nursing home industry instinctively claims that the cause is Medicaid rates that are low, too low even to cover nursing home costs (See our joint letter, below). The New York Times’ recent article about the closure of a rural South Dakota nursing facility pointed ...

Free Webinar – Overview of Phase 3 Nursing Home Regulations: A Look Ahead April 4, 2019

On November 28, 2019 – three years after the revised federal nursing home rules were issued – “Phase 3” requirements will go into effect. These include a number of new requirements that nursing homes must implement, and in some cases, new systems that must be put in place. This presentation will examine the Compliance and ...

Nursing Home Resident Advocates, Not Invited to Testify, Submit Statement for the Record March 21, 2019

The U.S. Senate Committee on Finance held a hearing on nursing home resident abuse and neglect on March 6, 2019. The Senate Finance Committee did not invite a single consumer advocate to testify before the Committee, although a nursing home industry representative did participate in the hearing. As a result, the Center for Medicare Advocacy ...

LTCCC Publishes Report on Nursing Home Resident Abuse, Neglect, and Crime March 21, 2019

The Long Term Care Community Coalition (LTCCC), a non-profit consumer advocacy organization headquartered in New York, has published a report examining the federal requirements and key practices for addressing nursing home resident abuse, neglect, and crime. The report, Addressing Abuse, Neglect, and Suspicion of a Crime Against Nursing Home Residents, is free and available on ...

Average Nursing Home Fine Drops Significantly After Administration Rolls Back Civil Money Penalties March 21, 2019

Nursing homes can be penalized through the imposition of a civil money penalty (CMP) for either the number of days that the facility has not been in compliance with a federal requirement (per-day) or for each instance of noncompliance (per-instance). Responding to requests from the nursing home industry, the Trump Administration rolled back previous guidelines ...

Members of Congress Reintroduce Legislation to Fix Outpatient Observation Status March 14, 2019

Medicare requires a three-day inpatient hospital stay in order to qualify for care at a skilled nursing facility. Sadly, and all too often however, beneficiaries are classified as hospital outpatients on observation status. While outpatients on observation status and inpatients may receive the same care and services, for the same number of days or weeks, ...

Senate Finance Committee Holds Hollow Hearing for the Nursing Home Industry March 7, 2019

On March 6, 2019, the U.S. Senate Committee on Finance held a hearing entitled “Not Forgotten: Protecting Americans From Abuse and Neglect in Nursing Homes.” The hearing consisted of two panels of witnesses. The first panel included Patricia Blank (daughter of a nursing home neglect victim), Maya Fischer (daughter of a nursing home rape victim), ...

There’s Nothing Special About How CMS Treats Special Focus Nursing Facilities February 14, 2019

In cooperation with states, the Centers for Medicare & Medicaid Services (CMS) regularly identifies a subset of nursing facilities, generally one to two facilities per state, that are among the most poorly performing facilities in the country. These nursing facilities, which CMS calls Special Focus Facilities (SFFs), have “more problems” than other facilities, “more serious ...

Registered Nurses Are the Key to Reducing Hospital Readmissions of Nursing Home Residents January 17, 2019

States Whose Nursing Facilities Employ Few Registered Nurses Are More Likely To Be Penalized for Readmissions of Their Residents to Hospitals In 2014, as part of the Protecting Access to Medicare Act, Congress created the Skilled Nursing Facility Value-Based Purchasing Program, whose financial incentives are intended to reduce rehospitaliations of nursing home residents.  In December 2018, ...

Nursing Home Residents at Risk: Advocates Submit Briefing to Congress January 17, 2019

The Center for Medicare Advocacy, the Long Term Care Community Coalition, the National Consumer Voice for Quality Long-Term Care, Justice in Aging, and California Advocates for Nursing Home Reform recently submitted a briefing to members of Congress addressing ongoing concerns regarding the health and safety of nursing home residents. The Nursing Home Reform Law requires every ...

Joint Statement on Turmoil in the Nursing Home Industry January 3, 2019

January 2019 – The nursing home industry is facing tremendous turmoil because some operators are undertaking risky financial deals in an attempt to squeeze out larger profits from their nursing homes, even when these deals could potentially harm residents. The recent collapse of several nursing home chains around the country also raises serious concerns about ...

Elder Justice “No Harm” Newsletter – Issue 10 December 13, 2018

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 to nursing home ...

State Attorneys General Successfully Take on Nursing Home Issues November 29, 2018

State Attorneys General are successfully litigating issues of key importance to nursing home residents, including insufficient nurse staffing levels and inappropriate transfers or discharges of residents. This Alert discusses two cases: the Pennsylvania Attorney General’s challenge to inadequate staffing levels by a national chain and the Maryland Attorney General’s challenge to a state chain’s transfer ...

CMS Proposes Rollback of Emergency Preparedness Requirements to Reduce “Burdens” for Nursing Home Providers November 20, 2018

On September 20, 2018, CMS issued a notice of proposed rulemaking (NPRM) to revise the emergency preparedness program requirements. Most notably, the proposed rule would allow nursing homes to review their emergency preparedness programs and to train staff to carry out those plans every two years rather than annually. The HHS Office of the Inspector ...

Center for Medicare Advocacy Comments on Proposed Nursing Home Legislation and Rule November 8, 2018

Legislation to Reduce Rehospitalizations Fails to Answer Questions About Resident Protections The Reducing Unnecessary Senior Hospitalizations (RUSH) Act of 2018 (H.R. 6502) would allow certain medical groups to provide telehealth and on-site first responder services to nursing home residents in an attempt to reduce rehospitalizations. Although the goal of reducing unnecessary and inappropriate rehospitalizations is ...

HHS Publishes Final Rules Providing Annual Inflation-Related Increases for Civil Money Penalties in Its Programs. Better Late than Never? November 1, 2018

On October 11, 2018, the Department of Health and Human Services published final rules updating civil money penalty (CMP) amounts for civil penalties assessed on or after October 11, 2018 for violations of various HHS programs occurring on or after November 2, 2015.  83 Fed. Reg. 51369 (Oct. 11, 2018) (“Annual Civil Monetary Penalties Inflation ...

Checklist for Medicare Nursing Home “Improvement Standard” Denials October 25, 2018

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy has produced a new Checklist to help Medicare beneficiaries and their families respond to unfair Medicare denials for skilled nursing facility care based on an erroneous “Improvement Standard.” The Checklist outlines the coverage criteria for SNF care and emphasizes language from the Jimmo Settlement ...

Who Owns Nursing Facilities and Why? October 4, 2018

In September 2007, The New York Times published a lengthy investigative article about private equity’s purchase of nursing facilities – “At Many Nursing Homes, More Profits, Less Nursing.”  The Times reported that private equity firms purchased facilities and divided ownership into multiple companies, insulating themselves from private litigation and meaningful regulatory enforcement.  Meanwhile, the firms ...

Transfer and Discharge Deficiencies Cited Since 2017: Surveyors Focus On paperwork, Not Residents’ Rights September 20, 2018

The involuntary transfer and discharge of nursing home residents is the top complaint received by nursing home ombudsman programs nationwide.  In December 2017, the Centers for Medicare & Medicaid Services (CMS) announced an initiative “to examine and mitigate facility-initiated discharges that violate federal regulations.”  While recognizing the seriousness of involuntary transfer and discharge for residents ...

House Committee Holds Hearing on Nursing Home Quality Issues September 13, 2018

For the first time in many years, Congress held a hearing on nursing home quality of care on September 6, 2018.  The hearing of the Subcommittee on Oversight and Investigations of the House Energy and Commerce Committee, entitled “Examining Federal Efforts to Ensure Quality of Care and Resident Safety in Nursing Homes,” featured three witnesses: ...

Final Rules for New Medicare Reimbursement System for Skilled Nursing Facilities: Goodbye Therapy August 23, 2018

Effective October 1, 2019, CMS will replace the prospective payment system for skilled nursing facilities, Resource Utilization Group (RUG-IV), with a new prospective payment system called the Patient-Driven Payment Model (PDPM). The new system, which is budget-neutral, bases payment on resident ...

Special Focus Nursing Facilities that “Have Not Improved:” Poor Care for Residents, Overall Ratings Artificially Boosted by 5-Star Ratings in Self-Reported Quality Measures August 15, 2018

The Centers for Medicare & Medicaid Services (CMS) identifies some of the most poorly performing nursing facilities in the country as Special Focus Facilities (SFFs).  In this Second Report on SFFs, the Center for Medicare Advocacy looks at one of four categories of SFFs – those that “have not improved” – and how they game ...

Nursing Facilities’ “Quality Measures” Do Not Reflect Actual Quality of Care Provided to Residents August 9, 2018

The Center for Medicare Advocacy wanted to determine whether nursing facilities that had one-star in their health survey ratings on Nursing Home Compare were able to boost their overall ratings from one star to two stars through the designation of five stars in the self-reported quality measure domain.  The finding – that many facilities in ...

Center for Medicare Advocacy Co-Authors Case Study Journal Article on Nurse Staffing Litigation in Arkansas August 2, 2018

Charlene Harrington, professor emerita at the University of California San Francisco, and Center for Medicare Advocacy Senior Policy Attorney Toby S. Edelman have written an analysis of the class action lawsuit against twelve Golden Living nursing facilities in Arkansas for insufficient nurse staffing. The case was settled for $72 million in 2017.  In “Failure to ...

Special Report – Special Focus Facilities: Poor Care for Residents, Limited Consequences for Providers July 30, 2018

The Center for Medicare Advocacy issues this Special Report to shine a light on nursing homes throughout the country that have been identified as providing the poorest quality care to residents – while facing limited, if any, enforcement action as a consequence. Known as Special Focus Facilities, (SFFs), these facilities are identified by the Centers ...

Nursing Home “In-House” Managed Care Plans May Harm Residents July 19, 2018

An emerging issue of concern for advocates is nursing facilities’ increased marketing of “in-house” managed care plans – specifically, Institutional Special Needs Plans, or I-SNPs – to their residents.  These Medicare Advantage plans are limited to beneficiaries who require, or are expected to need, institutional long-term care for 90 days or more. A recent article in ...

Did CMS’s Partnership to Improve Dementia Care Reduce the Inappropriate Prescribing of Antipsychotic Drugs for Nursing Home Residents as Much as CMS Claims? Two Recent Studies Say No June 28, 2018

The Centers for Medicare & Medicaid Services (CMS) has ended its campaign to reduce the inappropriate use of antipsychotic drugs for long-stay residents in nursing facilities (formally called the National Partnership to Improve Dementia Care in Nursing Homes) for facilities that reduced their antipsychotic drug usage by 34% by the end of 2016 (from 23.9% ...

Center for Medicare Advocacy Discusses Nursing Home Resident Protections with CMS Administrator Seema Verma June 28, 2018

Seema Verma, the Administrator of the Centers for Medicare & Medicaid Services (CMS), invited the Center for Medicare Advocacy and other advocacy organizations to meet with her on June 25, 2018. The Administrator asked our organizations to provide one to two recommendations for the Requirements of Participation that would reduce burdens on nursing facilities. However, ...

CMS Reverses Obama Policy on Nursing Home Quality Enforcement June 21, 2018

The Centers for Medicare & Medicaid Services (CMS) issued a Survey and Certification Letter on October 27, 2017, which outlined proposed changes to Chapter 7 of the State Operations Manual (SOM), and invited public comment. As the Center for Medicare Advocacy noted in a previous alert, the proposed changes sought to reverse surveyor guidance issued ...

Nursing Home Residents at Risk June 14, 2018

Since January 2017 the health and safety of nursing home residents has become increasingly imperiled. Nursing home lobbyists have urged the Centers for Medicare & Medicaid Services (CMS) to eliminate or delay regulations and dramatically reduce enforcement of violations. Unfortunately, CMS has shown a disturbing willingness to follow these lobbyists’ recommendations. For example, under regulations finalized ...

Read the Center’s Comments on Proposed Reimbursement for Skilled Nursing Facilities June 14, 2018

On May 8, 2018, the Centers for Medicare & Medicaid Services (CMS) proposed a new Medicare Part A reimbursement system for skilled nursing facilities, called Patient-Driven Payment Model (PDPM).  The Center for Medicare Advocacy issued an Alert on the proposed rules (“CMS Tries Again: Another New Skilled Nursing Facility Medicare Reimbursement System Proposed – If ...

Center for Medicare Advocacy Emphasizes Need to Protect Nursing Home Residents at Congressional Briefing June 7, 2018

On June 4, 2018, the House of Representatives Democratic Caucus Seniors Task Force held a briefing on “Protecting Seniors by Improving – Not Eroding – Nursing Home Quality Standards.” The Center for Medicare Advocacy, led by Senior Policy Attorney Toby Edelman, presented on the enforcement of the nursing home standards, as well as the current ...

Buying and Selling Nursing Homes: Who’s Looking Out for the Residents? May 23, 2018

In recent months, the buying and selling of nursing facilities and the transfers of licenses to new managers have raised questions about who the new owners/managers/lessees are and whether there are sufficient state and federal laws, regulations, and practices in place, meaningfully implemented and enforced, to protect residents. The issue came vividly into public consciousness when ...

CMS Tries Again: Another New Skilled Nursing Facility Medicare Reimbursement System Proposed – If Implemented, Would Gut Therapy May 17, 2018

Proposed changes to nursing facility payment under consideration by CMS would reduce financial incentives to provide therapy, and would do so with such force – providing higher reimbursement to skilled nursing facilities (SNFs) that provide residents fewer types of therapy over a shorter period of time, or no therapy at all – that it would ...

Corporate Integrity Agreements and Nursing Homes May 10, 2018

In their April 2, 2018 letter to CMS Administrator Seema, Republican leaders of the House Energy and Commerce Committee express serious concern about “recent media reports describing horrific instances of abuse, neglect, and patient harm allegedly occurring at SNFs and NFs across the country.”  They focus particular attention on Dr. Jack Michel, an owner of ...

Nursing Home Roundup April 12, 2018

Nurse Staffing in Nursing Homes: CMS Transition to Payroll-Based Journal Staffing Data on Nursing Home Compare Will Provide Better Information for the Public Beginning in April 2018, the Centers for Medicare & Medicaid Services (CMS) will begin using Payroll-Based Journal (PBJ) staffing data to determine each facility’s staff rating on Nursing Home Compare. All facilities must ...

Fact Sheet – Skilled Nursing Facility Coverage and Jimmo v. Sebelius April 5, 2018

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy provides the following Fact Sheet to help Medicare nursing home beneficiaries and their families respond to unfair Medicare denials based on an erroneous “Improvement Standard.” The Fact Sheet emphasizes language from the Jimmo Settlement Agreement, wherein the Centers for Medicare & Medicaid ...

Elder Justice Newsletter – March 2018 April 5, 2018

Elder Justice: What "No Harm" Really Means for Residents is a monthly 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 to residents. This ...

Elder Justice Alert: New York Times Publishes Article on Drug Use Among Older Adults March 29, 2018

Revelations have shed light on an opioid crises in the United States that remained largely hidden until recently. These drugs have affected the lives of children and adults nationwide. Unfortunately, the inappropriate use of medication – legally or illegally – is not limited to opioids in its multigenerational reach. As the New York Times reports ...

Latest Nursing Home Rights Issue Alert February 22, 2018

The Long Term Care Community Coalition (LTCCC), in partnership with the Center for Medicare Advocacy, publishes monthly Issue Alerts on the rights of nursing home residents. These Issue Alerts focus on specific standards of care that nursing homes must follow as a requirement of participating in Medicare and Medicaid. The goal of this project is ...

Elder Justice Alert: Human Rights Watch Publishes In-Depth Report on Antipsychotic Drug Use in U.S. Nursing Homes February 7, 2018

On February 5, 2018, Human Rights Watch published an in-depth report on antipsychotic drug use in U.S. nursing homes. The Report, entitled “‘They Want Docile’: How Nursing Homes in the United States Overmedicate People with Dementia,” finds that over 179,000 nursing home residents are given off-label antipsychotic drugs every week. The Report notes that most ...

Lawsuit Challenging Chronic SNF Understaffing Settled for $72 Million January 24, 2018

A lawsuit by former residents at 12 Arkansas nursing facilities owned by Golden Living alleged that the facilities were chronically understaffed between December 2006 and July 2009, in violation of the facilities’ admission agreement, the Arkansas Long-Term Care Residents’ Rights Act, and the Arkansas Deceptive Trade Practices Act.  The case was settled in 2017 for ...

CMS to Propose Revising the Nursing Home Requirements of Participation January 24, 2018

In October 2017, CMS announced its new “Patients over Paperwork” initiative. Specifically, the purported intent of the initiative is to put patients first by reducing the so-called “burdens” on the health care industry. ...

Medicare Advantage Enrollees Have Fewer SNF Options than Traditional Medicare Beneficiaries January 24, 2018

“Medicare Advantage Enrollees More Likely to Enter Lower-Quality Nursing Homes Compared to Fee-For-Service Enrollees,” a report recently published by Health Affairs, examines the quality of skilled nursing facilities (SNFs) used by Medicare Advantage (MA) enrollees and traditional Medicare beneficiaries. As the title indicates, the authors of the report found that traditional Medicare beneficiaries “tended to ...

CMA Alert -Spotlight on SNF Enforcement December 27, 2017

Are Nursing Home Residents at Risk? New York Times and Los Angeles Times Report on SNF Deregulation Special Issue Alert: Enforcement in KansasAre Nursing Home Residents at Risk? The New York Times and Los Angeles Times Report on SNF DeregulationDon't Miss It! 5th Annual National Voices of Medicare Summit & Sen. Jay Rockefeller LectureThis year's Summit will focus ...

CMS Halts Enforcement, as Requested by the Nursing Home Industry December 6, 2017

In October of 2016, the Obama Administration issued a Final Rule regarding the Requirements of Participation (RoP) for nursing homes. The Final Rule was issued, in part, because the regulations had “not been comprehensively reviewed and updated since 1991.” Under the Final Rule, the revisions to the RoP were to be implemented over three phases: ...

Elder Justice Newsletter: What “No Harm” Really Means for Residents November 30, 2017

The majority of nursing home violations are identified as causing “no harm” to residents, despite any harm the resident may have actually experienced. Sadly, the failure to recognize resident harm when it occurs too often means that nursing homes are not properly held accountable for resident abuse, neglect, and other forms of harm. In order ...

Alert – Tax Cut Harm Just Got Worse; This Week in Sabotage; CMS Pushing MA Plans; SNF Deregulation November 15, 2017

Tax Cut Bill Just Got Worse. Health Care at Risk. This Week in Sabotage CMS Steering to Medicare Advantage Administration And Nursing Home Industry: Lockstep in Deregulating Nursing Facilities & Reducing Resident ProtectionsTax Cut Bill Just Got Worse.  Health Care at Risk.Free Webinar Series Next Webinar: Hospital Observation Status Update January 24, 2018 3:00 p.m. ET  Presenters: Center for Medicare Advocacy Litigation Director, attorney ...

CMA Alert, October 18, 2017 – Nursing Home Rights Roundup; ACA Stabilization; More October 18, 2017

This Week in ACA Sabotage Bipartisan Agreement on ACA Stabilization Package Nursing Home Rights RoundupCMS Signals End of Campaign to Reduce Unnecessary Use of Antipsychotic Drugs In Nursing Homes; Claim of Success is Grossly Overstated OIG Report about Nursing Home Complaints Leaves Questions Unanswered Congressional Letter Asks for Revision and Delay of Nursing Home Requirements of ParticipationThis Week In ...

Center Submits Statement On SNF Requirements for Senate Aging Committee Hearing on “Disaster Preparedness and Response: the Special Needs of Older Americans” September 20, 2017

The U.S. Senate Special Committee on Aging held a hearing on "Disaster Preparedness and Response: The Special Needs of Older Americans" today. The hearing came on the heels of Hurricanes Harvey and Irma, which resulted in the deaths of at least nine nursing home residents in Florida. Chairman Collins began the hearing by acknowledging the ...

CMA Alert – OIG Warns of Abuse in SNFs; Ted Kennedy, Jr. Joins CMA Advisory Board; “Jimmo” Corrective Action Plan August 30, 2017

HHS OIG Warns of Potential Elder Abuse in Skilled Nursing Facilities Connecticut State Senator Ted Kennedy, Jr. Joins Center for Medicare Advocacy Advisory Board Jimmo Corrective Action Plan CompletedHHS OIG Warns of Potential Elder Abuse in Skilled Nursing Facilities Last week, the HHS Office of Inspector General (OIG) issued an Early Alert, warning of the Centers for Medicare ...

CMA Alert – SNF Update: Comments on Reimbursement; Civil Money Penalties Weakened August 9, 2017

Center for Medicare Advocacy Submits Comments on CMS’s Proposed Redesign of Medicare Reimbursement for Skilled Nursing Facilities  As Sought By Nursing Home Industry, CMS Changes Guidance to Reduce Civil Money Penalties for Nursing Facility DeficienciesCenter for Medicare Advocacy Submits Comments on CMS’s Proposed Redesign of Medicare Reimbursement for Skilled Nursing Facilities  In an Advance Notice of Proposed ...

CMS Extends Comment Period for New Medicare Skilled Nursing Reimbursement System Until August 25, 2017 June 14, 2017

On May 4, 2017, the Centers for Medicare & Medicaid Services (CMS) published an Advance Notice of Proposed Rulemaking setting out options that CMS is considering to replace the Medicare reimbursement system for skilled nursing facilities (SNFs).  The Center for Medicare Advocacy’s Alert described the proposal at length and the ways it would change financial ...

Reversing Obama Rules, Trump Administration Proposes Allowing Nursing Homes to Require Pre-Dispute Arbitration Clauses as a Condition of Admission June 14, 2017

In 2016, the Obama Administration promulgated final regulations that revised and updated the Requirements of Participation, the federal standards of care that nursing facilities must meet in order to be eligible to receive Medicare or Medicaid reimbursement.  The Obama rules explicitly prohibit facilities from entering into pre-dispute mandatory arbitration agreement with a resident or resident ...

CMS Considers New Medicare Reimbursement System for Skilled Nursing Facilities: If Implemented, Would Gut Therapy May 17, 2017

Proposed changes to nursing facility payment under consideration by CMS would reduce financial incentives to provide therapy, and would do so with such force – providing higher reimbursement to skilled nursing facilities (SNFs) that provide fewer types of therapy to residents over a shorter period of time or no therapy at all – that it ...

Issue Brief: Nursing Home Residents in Jeopardy if Medicaid Becomes a Block Grant February 1, 2017

If Medicaid becomes a block grant program, nearly one million nursing home residents who rely on Medicaid could immediately lose coverage for their nursing home care.  In addition, all of the federal standards that govern nursing home care today could be in jeopardy.  The United States does not have a comprehensive program to pay for long-term ...

Nursing Home “Advancing Excellence” Quality Program Ends after a Decade November 16, 2016

Advancing Excellence in America’s Nursing Homes, a voluntary program promoted as an effort to improve quality of care in nursing homes, has ended after a decade.  Unfortunately, the Centers for Medicare & Medicaid Services (CMS) will continue the website (“New name, new logo, same GREAT website!”), which it has funded since 2006, in a new ...

Observation Status Impedes Access to End-of-Life Skilled Nursing Facility Care November 3, 2016

Mr. P. has been hospitalized after having a heart attack. He also has terminal cancer for which he wants to continue treatment. If Mr. P. is admitted as an inpatient for a total of three days while in the hospital, he can qualify for Medicare Part A coverage of subsequent Skilled Nursing Facility (SNF) stay ...

CMS Rescinds Erroneous Medicare Nursing Home Policy October 26, 2016

The Center for Medicare Advocacy is grateful to CMS for responding to concerns we and others raised regarding changes to the skilled nursing facility (SNF) coverage standards in the Medicare Benefit Policy Manual. The policy changes, issued this September, misstated and limited nursing home (SNF) coverage and care available under Medicare. For example, the revisions ...

Don’t be Fooled by the Federal Nursing Home Five-Star Quality Rating System October 5, 2016

In 2014, The New York Times reported that nursing facilities were gaming the Five-Star Quality Rating System on Nursing Home Compare and that “even nursing homes with a history of poor care rate highly in the areas that rely on self-reported data."  The Times reported that nearly two-thirds of 50 facilities on CMS's watch list ...

New Nursing Home Requirements of Participation: A Missed Opportunity October 5, 2016

Public coverage of the new nursing home Requirements of Participation (RoPs)  While advocates for residents applaud this ...

CMS Increases Mandatory Enforcement to Protect Nursing Home Residents August 17, 2016

Under the federal Nursing Home Reform Law, the Centers for Medicare & Medicaid Services (CMS) has authority and the “responsibility”  For the first time in more than ...

A Model to Waive the Three-Day Inpatient Hospital Stay Requirement for Care in a Skilled Nursing Facility July 20, 2016

In order for Medicare Part A to pay for a patient’s stay in a skilled nursing facility (SNF), the patient must first have spent at least three consecutive days as an inpatient in an acute care hospital.  For many Medicare beneficiaries, Part A SNF coverage is denied because the hospital classifies the stay as Outpatient ...

Center Comments on Proposed Rules for Medicare Skilled Nursing Facilities June 22, 2016

The Center for Medicare Advocacy’s comments on the Medicare prospective payment system for skilled nursing facilities (SNFs), submitted June 20, 2016, support the recommendation of the Medicare Payment Advisory Commission (MedPAC) not to increase reimbursement to SNFs for FY 2017.  MedPAC reports that SNFs have enjoyed Medicare margins exceeding 10% for 15 consecutive years. With respect ...

Elder Abuse in Nursing Facilities: The Over-Administration of Antipsychotic Drugs to Nursing Home Residents June 15, 2016

The Administration on Aging defines a subcategory of elder abuse – “physical abuse” – as “inflicting physical pain or injury on a senior, e.g. slapping, bruising, or restraining by physical or chemical means.” Administering antipsychotic drugs to more than a quarter of a million nursing home residents meets the definition of elder abuse and, left unanswered, ...

Improving Quality of Care for Nursing Home Residents by Improving Wages, Benefits, Training and Working Conditions for Nurse Aides April 13, 2016

The single factor most critical to high quality of care and quality of life for nursing home residents is the staff who provide residents with care.  Most direct care in nursing facilities is provided by nurse aides, primarily women of color, who are poorly paid and often poorly treated.  In a sobering new report, Raise ...

International Study: Privatization of Long-Term Care Facilities Does Not Lead to Greater Transparency or More Care March 23, 2016

A comparison of the long-term care industry in California, Ontario (Canada), England, and Norway evaluates the extent to which ownership of nursing facilities has shifted from the public sector to private for-profit and not-for-profit companies, and how this shift affects the transparency of information and accountability for public reimbursement. While privatization has been a recent ...

“Discharge” from a Skilled Nursing Facility: What Does it Mean and What Rights Does a Resident Have? January 13, 2016

Skilled nursing facilities (SNFs) often tell Medicare beneficiaries and their families that they intend to “discharge” a Medicare beneficiary because Medicare will not pay for the beneficiary’s stay under either Part A (traditional Medicare) or Part C (Medicare Advantage).  Such a statement unfortunately misleads many beneficiaries into incorrectly believing, not only that Medicare has decided ...

Budget Act of 2015 Increases Penalties for Programs under the Social Security Act, Including Nursing Facilities November 18, 2015

For the first time in 20 years, there will be an increase in the amounts of federal fines that nursing facilities may be required to pay for violating the Nursing Home Reform Law.  A little-noticed provision of the Bipartisan Budget Act of 2015, Pub.L. 114-74 (signed by President Obama on November 2, 2015), amends the ...

Discharge Planning: Tips for Evaluating a Hospital’s Skilled Nursing Facility Placement Choices November 17, 2015

Medicare beneficiaries often need care in a Medicare- participating skilled nursing facility (SNF) after an inpatient hospitalization.  For these patients, hospitals are responsible for identifying skilled nursing facilities within the geographic region that can meet the patient’s medical needs.  Until such a placement is found, the beneficiary will not be responsible for her hospital stay.  ...

CMS Proposed Rules for Nursing Facility Requirements of Participation: Center for Medicare Advocacy Submits Comments October 23, 2015

On July 16, 2015, the Centers for Medicare & Medicaid Services (CMS) published proposed rules to revise the Requirements of Participation (RoPs) for nursing facilities that participate in Medicare or Medicaid, or both.  Since most nursing facilities participate in both programs, the federal regulations set the standards of care for facilities.  The current RoPs, which ...

CMS Reopens Public Comment Period for Proposed Revisions to the Nursing Home Requirements of Participation September 17, 2015

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 or Medicaid programs, or both.  At the request of many ...

Proposed Requirements of Participation for Nursing Facilities Do Not Strengthen Standards for Residents July 16, 2015

On July 13, 2015, the Centers for Medicare & Medicaid Services (CMS) posted proposed regulations to revise the Requirements of Participation for nursing homes (called Skilled Nursing Facilities under Medicare and Nursing Facilities under Medicaid).  The proposed rules were published in the Federal Register on July 16, with a 60-day comment period.  The public announcement stressed ...

Center for Medicare Advocacy Submits Comments to Senate Finance Committee and CMS Regarding Important Health Care Proposals June 25, 2015

1. Comments to Senate Finance Committee Chronic Care Workgroup On June 22, 2015, the Center for Medicare Advocacy submitted comments to the Senate Finance Committee Chronic Care Workgroup in response to the Committee’s May 22, 2015 request for comments on reforming care for individuals with chronic conditions. The Committee identified three overarching goals to guide the development ...

Advancing Excellence: Very Few Nursing Homes are “Full Active Participants” and Nearly Half of Them Provide Poor Care June 18, 2015

In September 2006, the nursing home industry announced a voluntary quality improvement campaign – Advancing Excellence in America’s Nursing Homes.  The Center for Medicare Advocacy (Center) was skeptical about the campaign ...

National Public Radio Program Features CMS’s New Quality Rating System for Nursing Homes March 18, 2015

On March 11, 2015, the Diane Rehm program on National Public Radio hosted a discussion of the revisions to the Centers for Medicare & Medicaid Services’s (CMS’s) Five Star Quality Rating System for nursing homes. Patrick Conway, CMS Chief Medical Officer and Deputy Administrator for Innovation and Quality began the show by describing the changes.  ...

Antipsychotic Drugs and Nursing Home Residents: What Do the Different Numbers Mean? March 12, 2015

Last week’s Alert discussed the Centers for Medicare & Medicaid Services’ (CMS’s) National Partnership to Improve Dementia Care and the Government Accountability Office’s (GAO) recent report on antipsychotic drugs.  The CMS Partnership and the GAO reported different numbers of nursing home residents receiving antipsychotic drugs.  Some of the differences appear to reflect the different databases ...

Has CMS’s Partnership with the Nursing Home Industry Really Reduced the Inappropriate Use of Antipsychotic Drugs by Nursing Home Residents as Much as CMS Claims? No. March 5, 2015

In September 2014, the Centers for Medicare & Medicaid Services (CMS) reported that the National Partnership to Improve Dementia Care had reduced the use of antipsychotic drugs with nursing home residents by 15.1%, “exceeding” the Partnership’s 15% drug reduction goal for long-stay residents.  That claim of success was overstated.  When CMS originally announced the initial ...

Changes to Nursing Home Compare and the Five Star Quality Rating System February 26, 2015

Two-Thirds of Nursing Facilities Nationwide Will See Decline In their Quality Measures; One-Third of Facilities Will See Decline in Their Overall Score As promised in October 2014, the Centers for Medicare & Medicaid Services (CMS) has made significant changes to Nursing Home Compare, effective February 20, 2015.  The changes recalibrate the Quality Measures (QMs), add antipsychotic drug ...

CMS Tool for Assessing Civil Money Penalties Imposed Against Nursing Facilities Continues to Ensure that Penalties Will Remain Low January 29, 2015

Civil Money Penalties for nursing facilities have historically been too low to provide meaningful incentive for most facilities to comply with federal standards of care implemented to ensure patient safety and well-being.  The new Civil Money Penalty Analytic Tool from the Centers for Medicare & Medicaid Services (CMS) does not solve this problem. Background Every state has ...

Twelfth Largest U.S. Nursing Home Company Sued for Inadequate Staffing January 15, 2015

Inadequate nurse staffing is the most significant predictor of poor care in nursing facilities.  Despite the fact that understaffing is a pervasive and nationwide problem,  One reason for the lack of deficiencies and enforcement actions is that the federal standard for nurse staffing is vague.  Aside from ...

No Site Neutral Payments for Inpatient Rehabilitation Facilities and Skilled Nursing Facilities December 11, 2014

The Medicare Payment Advisory Commission (MedPAC), the nonpartisan government agency that advises Congress on Medicare policy, indicated at its November 7, 2014 public meeting that, at its next public meeting in December, it would recommend (1) phasing-in site-neutral payments for inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) for 17 conditions, which it has ...

Changes to Nursing Home Compare: Some Good, Some Bad November 20, 2014

The Centers for Medicare & Medicaid Services (CMS) announced plans to expand its focused surveys on resident assessments and nurse staffing for nursing facilities nationwide (but not in all facilities), beginning in early fiscal year 2015.  Expanded surveys should lead to more accurate reporting of quality measures and staffing data on the federal website Nursing ...

Administration Plans Major Improvements to Nursing Home Compare October 16, 2014

The federal nursing home website, Nursing Home Compare, is about to undergo major changes that should significantly improve the accuracy of information about nursing homes that is provided to the public.  The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act of 2014), signed by President Obama on October 6, 2014, supports one of ...

Nursing Facilities Owned by Private Equity Firms: Fewer Nurses, More Deficiencies August 20, 2014

A recent study in the Journal of Health Care Finance finds that Florida nursing facilities owned by private equity firms have fewer registered nurses and more deficiencies than chain-owned for-profit facilities and that the longer the facilities are owned by private equity firms, the fewer registered nurses they employ and the more deficiencies they have.  ...

Inpatient Rehabilitation Facilities and Skilled Nursing facilities: Vive La Difference! July 31, 2014

A study assessing the outcomes of patients who were treated in inpatient rehabilitation facilities (IRFs) with clinically and demographically similar patients who received their post-acute rehabilitation in skilled nursing facilities (SNFs) finds that IRFs provide better care to their patients over a number of outcome measures – IRF patients live longer, spend more days at ...

Quality Assessment and Performance Improvement (QAPI) In Nursing Homes: Diverting CMS Attention from Enforcement June 12, 2014

June 12, 2014 Quality Assessment and Performance Improvement (QAPI) In Nursing Homes: Diverting CMS Attention from Enforcement In the past few years, the Centers for Medicare & Medicaid Services (CMS) has focused considerable attention on Quality Assessment and Performance Improvement (QAPI) in nursing homes.  This focus, we fear, is diverting the agency's resources from enforcing the Nursing ...

Harm from Medicare’s Hospital Observation Status Debated In Congressional Hearing – Center for Medicare Advocacy Presents Beneficiary Perspective May 21, 2014

May 21, 2014 The May 20, 2014 hearing on "Current Hospital Issues in the Medicare Program," held by the Health Subcommittee of the House Committee on Ways and Means, was the first Congressional hearing to consider the impact of observation status on hospitalized Medicare patients.  At the hearing, the Center for Medicare Advocacy's Senior Policy Attorney, ...

Senior Policy Attorney Toby S. Edelman Testifies about Observation Status before Congress May 15, 2014

Center for Medicare Advocacy Senior Policy Attorney Toby S. Edelman will testify before the House Ways and Means Health Subcommittee on Tuesday, May 20, 2014 at 9:30 AM regarding current hospital issues in the Medicare program, specifically the ongoing problem of observation status. The hearing, announced on May 13th, is the first Congressional hearing to consider ...

Federal Nursing Home Enforcement System is Not Punitive: Setting the Record Straight Again May 8, 2014

The Department of Health and Human Services' Inspector General recently reported that nearly one third-of nursing home residents suffered an adverse event or other harm during a stay in a Medicare-participating nursing home in August 2011, and that most of the adverse events or other harm were preventable and the result of problems in staffing. ...

The Myth of Improved Quality in Nursing Home Care: Setting the Record Straight Again April 17, 2014

April 17, 2014 A recent report by the Department of Health and Human Services' Inspector General found that one third-of nursing home residents in a Medicare-nursing home stay suffered an adverse event or other harm in August 2011 and that most of the events were preventable and caused by problems in staffing.  Yet the nursing home ...

OIG Report: Care in Skilled Nursing Facilities Harmed Nearly One-Third of Medicare Residents in August 2011 March 19, 2014

In its first analysis of adverse events in skilled nursing facilities (SNFs), the Department of Health and Human Services' Office of Inspector General (OIG) reports that care is poor and dangerous for many residents.  OIG reports that nearly one in three Medicare beneficiaries who went to SNFs for 35 days or fewer in August 2011 ...

Staffing Deficiencies in Nursing Facilities: Rarely Cited, Seldom Sanctioned March 7, 2014

Although most nursing facilities nationwide do not have sufficient staff to provide necessary care to their residents, an analysis by the Center for Medicare Advocacy (Center) finds that the federal enforcement system cites very few facilities with staffing deficiencies and often does not impose any financial penalties, even when it finds that facilities do not ...

CMA Report: Inappropriate Use of Antipsychotic Drugs in Nursing Homes, Part Three – Recommendations to Improve the Citing of Deficiencies January 23, 2014

As required by the 1987 federal Nursing Home Reform Law, CMS has developed, tested, and periodically revised a survey protocol that state surveyors, who are generally employed by the state health departments, must use to determine nursing facilities' compliance with federal standards of care.  The survey protocol, which is composed of two Appendices to the ...

CMA Report: Examining Inappropriate Use of Antipsychotic Drugs in Nursing Facilities December 12, 2013

The misuse of antipsychotic drugs by nursing homes has been the subject of Congressional hearings and Government reports for many decades.  With funding from the Commonwealth Fund of New York and in cooperation ...

Misuse of Antipsychotic Drugs in Nursing Homes: Are We Making Any Progress? November 14, 2013

The recent settlement of criminal and civil charges against Johnson & Johnson for off-label marketing of Risperdal for nursing home residents once again brings the issue of antipsychotic drugs and nursing homes to public attention.  A group of residents' advocates working to reduce the inappropriate use of antipsychotic drugs in nursing facilities recently issued a ...

$2.2 Billion Johnson & Johnson Settlement Sends New Warning: Antipsychotic Drugs Should Not Be Used to Treat Dementia November 14, 2013

November 14, 2013 For Immediate Release Statement of California Advocates for Nursing Home Reform, Center for Medicare Advocacy, Legal Aid Justice Center, Long Term Care Community Coalition, The National Consumer Voice for Quality Long-Term Care Washington, DC – The Department of Justice's $2.2 billion settlement with Johnson & Johnson over allegations that it illegally promoted Risperdal to treat ...

Debunking Nursing Home Myths about Quality of Care and Enforcement of Federal Care Standards September 12, 2013

As policymakers in Washington, DC and beyond continue a national discussion about the state of long-term care in the United States, a critical component of the discussion is the quality of care provided in nursing homes across the country. The nursing home industry argues that nursing home quality is improving, pointing to higher ratings on the Centers ...

HHS Announces First Guidance Implementing Supreme Court’s Decision on the Defense of Marriage Act August 30, 2013

From CMA Press Release, Thursday, August 29, 2013 …he Department of Health and Human Services (HHS) issued a memo clarifying that all beneficiaries in private Medicare plans have access to equal coverage when it comes to care in a nursing home where their spouse lives. This is the first guidance issued by HHS in response to ...

CMS Addresses Observation Status Again… And Again, No Help for Beneficiaries May 16, 2013

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 ...

Medicare Paid $5.1 Billion to SNFs that Did Not Provide Care-Planning and Discharge-Planning (February 2013 OIG Report) April 18, 2013

In its most recent report on nursing home payments and quality, February 2013, the Office of Inspector General (OIG), Department of Health and Human Services (HHS) reports that many skilled nursing facilities (SNFs) failed to provide adequate care planning and discharge planning to residents and provided "egregious" care to some residents, yet were paid by ...

Nursing Home Enforcement by United States Attorneys: What Happened to the Regulatory System? February 7, 2013

Two recent cases – one in Georgia and the other in Pennsylvania – enforce nursing home quality of care standards through actions by United States Attorneys.   In neither case had the regulatory agencies cited deficiencies for the significant care problems at the three facilities in question.   In addition, two of the three facilities have high ...

The Worst-Performing Nursing Facilities Are Seldom Sanctioned; Self-Reporting is Not an Accurate Quality Measurement January 24, 2013

According to an analysis by the Center for Medicare Advocacy (the Center) few sanctions are imposed for the poor care provided by nursing facilities identified by the Federal Government as among those providing the poorest quality of care and quality of life to residents – Special Focus Facilities (SFFs).  The Center's analysis documents an enforcement ...

Déjà Vu All Over Again: CMS Decides (Again) Not to Decide About Observation Status November 20, 2012

On July 30, 2012, as part of proposed rulemaking on the outpatient prospective payment system, the Centers for Medicare & Medicaid Services (CMS) asked for public comment on potential policy options related to "observation status." What is Observation Status? Observation status refers to the classification of a patient in an acute care hospital as an outpatient, even ...

How the Ryan Budget (and Republican Platform) Would Hurt Current Nursing Home Residents August 30, 2012

In March 2012, the House of Representatives passed the House Budget Committee Fiscal Year 2013 Budget Resolution, The Path to Prosperity: A Blueprint for American Renewal – called here, the Ryan Budget.   In August 2012, the Republican Party adopted the Ryan Budget's principles for Medicare and Medicaid in its Platform for 2012, We Believe in ...

CMS Invites Public Comment on Observation Status August 9, 2012

August 9, 2012 Note to Alert readers: This Posted version contains additional information beyond that in the emailed version.As part of a notice of proposed rulemaking published in the Federal Register on July 30, 2012, the Centers for Medicare & Medicaid Services (CMS) is asking for public comments on potential policy changes related to observation status.  ...

Compare Hospitals or Nursing Homes Using Medicare’s Online Tools July 20, 2012

Two websites that help Americans make informed choices about hospitals and nursing homes have been redesigned and will make more information available to the public, CMS announced on July 19, 2012.The two sites – Hospital Compare and Nursing Home Compare – have been enhanced to make navigation easier by users, and have added important new ...

More Concerns About Observation Status: Hospitals Join the Chorus July 12, 2012

Hospital case managers and the hospital industry have joined the chorus of those opposed to observation status – a designation that renders a beneficiary ineligible for Medicare-covered skilled nursing facility (SNF) care.  This Alert discusses a recent survey by the American Case Management Association and an amicus brief filed by the American Hospital Association in ...

Recognizing Elder Abuse Awareness Day: Working Together to Curb Misuse of Powerful Antipsychotic Drugs in Nursing Homes June 14, 2012

On May 31, 2012, the Centers for Medicare & Medicaid Services (CMS) announced an initiative to reduce the rampant misuse and overuse of antipsychotic drugs in nursing facilities.  The Center for Medicare Advocacy has been working to educate policy makers, advocates, and the public about the misuse of antipsychotic drugs for many years, and is ...

Brown University Confirms Observation Continues to Replace Hospital Admission Status June 7, 2012

Since 2008, the Center for Medicare Advocacy (the Center) has been reporting that an increasing number of Medicare beneficiaries are being placed in acute care hospital beds for multiple days – receiving medical and nursing care, diagnostic tests, treatments, medications, and food – but are being called “outpatients” in observation status, rather than admitted “inpatients.”  ...

Low Staffing in Nursing Homes Leads to More Deaths May 3, 2012

When research conducted a decade ago documented that mortality rates actually increased when employment rates increased, health economists sought to identify the cause.  Focusing on employed workers did not explain the increased mortality rates.  A new analysis by the Center for Retirement Research at Boston College – focused on who was actually dying when employment ...

Press Release – Fewer Antipsychotic Drugs, More Nurses Will Improve Care in Nursing Homes and Save Money April 19, 2012

April 18, 2012 Contact: Toby S. Edelman at (202) 293-5760 tedelman@medicareadvocacy.org The Center for Medicare Advocacy knows that huge savings in nursing facility costs, and advances in resident care, could be achieved if facilities eliminated the inappropriate use of antipsychotic drugs and provided sufficient staff to meet resident needs.  The Center commends the Senate Special Committee on Aging for holding ...

Toby Edelman Statement to Senate Committee Regarding Antipsychotic Drugs in Nursing Facilities April 19, 2012

The Future of Long-Term Care: Saving Money by Serving Seniors Senate Special Committee on Aging April 18, 2012 2:00 p.m. Statement for the Record Toby S. Edelman Senior Policy Attorney Center for Medicare Advocacy 1025 Connecticut Avenue, NW, Suite 709 Washington, DC  20036 The Center for Medicare Advocacy suggests that huge savings in the cost of care in nursing facilities could be achieved if facilities ...

Non-Profit vs. For-Profit Nursing Homes: Is there a Difference in Care? March 15, 2012

One of the many decisions individuals and families face when they need long-term care is choosing a facility.  A key factor that should be considered is whether to choose a for-profit corporate facility or a non-profit facility. Federal and state policymakers also need to consider the implications of ownership information as they design and implement ...

Reducing Rehospitalizations… The Right Way March 1, 2012

For several years, reducing rehospitalizations of Medicare beneficiaries has been a key public policy goal, the intent of which is to improve quality of care for beneficiaries and reduce costs for the Medicare program.  Studies have shown that rehospitalizations are common and expensive.  In 2006, for example, nearly one-quarter of nursing home residents (23.5%) were ...

Voluntary Nursing Home Improvement Campaign Does Not Work January 11, 2012

Nursing Facilities Participating in Advancing Excellence Still Among Worst Performers Many nursing facilities that are identified by the federal government as among the facilities providing the poorest quality of care to residents in the country – the Special Focus Facilities (SFFs) – participate in the nursing home industry's voluntary quality improvement campaign, Advancing Excellence in America's ...

Special Focus Facility Study: Nursing Facilities’ Self-Regulation Cannot Replace Independent Surveys December 22, 2011

Each month, the Centers for Medicare & Medicaid Services (CMS) identifies nursing facilities that are among the facilities providing the poorest care to their residents, as determined by federal deficiencies cited in the prior three years.   These facilities, called Special Focus Facilities (SFFs), receive special attention from state survey agencies – at least two surveys ...

Toby Edelman Testifies Before Senate Special Committee Regarding Antipsychotics In Nursing Homes December 1, 2011

UNITED STATES SENATE SPECIAL COMMITTEE ON AGING OVERPRESCRIBED: THE HUMAN AND TAXPAYERS' COSTS OF ANTIPSYCHOTICS IN NURSING HOMES November 30, 2011 Testimony of Toby S. Edelman Senior Policy Attorney Center for Medicare Advocacy The misuse of antipsychotic drugs as chemical restraints is one of the most common and longstanding, but preventable, practices causing serious harm to nursing home residents today.   We ...

Preserving Access to Necessary Care: Ending Hospital “Observation Status” November 3, 2011

The Center for Medicare Advocacy has heard increasingly about beneficiaries throughout the country whose entire stays in a hospital, including stays as long as 14 days, are classified by the hospital as outpatient observation.  In some instances, the beneficiaries' physicians order their admission, but the hospital retroactively reverses the decision.  As a consequence of the classification of ...

Congressman Joe Courtney and Center for Medicare Advocacy Hold Congressional Briefing on Observation Status October 24, 2011

Coalition Urges Congress to Pass Legislation Safeguarding Medicare Beneficiaries' Skilled Nursing CareFor Immediate Release October 21, 2012 Terry Berthelot 860-456-7790 Toby Edelman 202-293-5760Washington, DC. – A Congressional briefing on "observation status," sponsored by Congressman Joe Courtney (D. CT), was held yesterday afternoon to examine Medicare beneficiaries' being denied Medicare coverage for care in a skilled nursing facility (SNF) when their ...

Medicare Reimbursement For Skilled Nursing Facilities Remains High For 2012 Despite Reductions In Overpayments August 25, 2011

In final rules setting out Medicare reimbursement rates for skilled nursing facilities (SNFs) for Fiscal Year (FY) 2012 (which starts October 1, 2011), the Centers for Medicare & Medicaid Services (CMS) reduced reimbursement by $3.87 billion, or 11.1%.  The reduction was targeted, correcting the "unintended excess payments" that occurred in therapy-related reimbursement for FY 2011, ...

The Changing Demographics of Nursing Home Care: Greater Minority Access… Good News, Bad News August 18, 2011

A major public policy goal in the United States is "rebalancing" the long-term care system – reducing what was formerly, for many people, a near-total reliance on nursing facilities and increasing the use of home and community-based alternatives.  While rebalancing has begun to change the long-term care system, its benefits have not been equally shared.  ...

New Initiatives to Improve Services for Dual Eligibles July 15, 2011

The Centers for Medicare & Medicaid Services (CMS) recently announced several new initiatives focused on improving care for people who are eligible for both Medicare and Medicaid (dual eligibles). Two initiatives relate to providing fully integrated services to dual eligibles, through both capitation and fee-for-service structures.  A third initiative addresses preventing unnecessary hospitalizations of nursing home residents, ...

Real Solutions to Save Medicare Dollars in Skilled Nursing Facilities June 30, 2011

For many years, advocates for nursing home residents have argued that when residents are denied good care, the costs of trying to treat and correct avoidable conditions and bad resident outcomes are high.  Advocates refer to this phenomenon as "the high cost of poor care."  Others identify the phenomenon as "the business case for quality."  ...

CMA And Others Support Legislation to End “Observation Status” June 21, 2011

Max Richtman, Chair May 20, 2011 The Honorable John Kerry The Honorable Olympia Snowe United States Senate Washington, DC 20510 The Honorable Joe Courtney The Honorable Tom Latham United States House of Representatives Washington, DC 20515 Dear Senators Kerry and Snowe and Representatives Courtney and Latham: The Leadership Council of Aging Organizations (LCAO) – a coalition of national not-for-profit organizations representing 60 million older Americans – ...

Senators Kerry and Snowe, with Representatives Courtney and Latham, Introduce Legislation to Ensure Skilled Care for Seniors April 26, 2011

Improving Access to Medicare Coverage Act of 2011 Section by Section Summary Sen. John F. Kerry & Sen. Olympia Snowe Section 1:  Short Title—"Improving Access to Medicare Coverage Act of 2011". Section 2:  Counting a Period of Receipt of Outpatient Observation Services in a Hospital towards the 3-Day Inpatient Hospital Requirement for Coverage of Skilled Nursing Facility Services under ...

What Happens to Current Nursing Home Residents if the House Budget Resolution Becomes Law? April 21, 2011

Under the proposed budget resolution passed by Republicans in the House of Representatives, nearly a million nursing home residents could immediately lose coverage for nursing home care.  Further, all of the standards that govern nursing home care today could disappear.  A study of the costs of nursing home care, released April 21, 2011 by John Hancock ...

Reducing Antipsychotic Drug Use in Nursing Homes: Save Residents’ Lives, Save Medicare Billions of Dollars March 17, 2011

Many nursing home residents who do not have a diagnosis that supports their taking antipsychotic medications are nevertheless given antipsychotic drugs.  These drugs are both dangerous to residents and extremely expensive for the Medicare program.   Reducing the use of antipsychotic drugs in nursing facilities would both dramatically improve the quality of care and quality of ...

More Nurses in Nursing Homes Would Mean Fewer Patients Headed to Hospitals March 10, 2011

Nursing home residents are frequently hospitalized.  Residents who have recently been admitted from the hospital are frequently rehospitalized. are considered avoidable.  The 2010 National Healthcare Quality Report found that residents' hospitalization ...

Concern over Skilled Nursing Facilities’ Upcoding Medicare Reimbursement Should Not Be Allowed to Deprive Residents of Necessary Care February 10, 2011

Between 2006 and 2008, skilled nursing facilities (SNFs) increasingly billed for residents' care at higher-paying reimbursement categories (upcoding) under Medicare's prospective payment system.  Medicare uses Resource Utilization Groups (RUGs) to determine payments, and facilities upcoded even though beneficiary characteristics, on which RUGs are based, went largely unchanged over the two-year period. For-profit facilities were more ...

Judge Rejects “Eden Alternative” Defense In Nursing Home Appeal February 3, 2011

The nursing home industry has called for major changes in the federal survey process by which federal and state survey agencies determine whether facilities are complying with federal standards of care and providing residents with high quality of care and quality of life.  The industry argues that the nursing home industry has changed since Congress ...

CMS Reins in Overpayments to Skilled Nursing Facilities October 15, 2010

For many years, the Medicare Payment Advisory Commission (MedPAC) has reported that the Medicare program overpays skilled nursing facilities (SNFs) for rehabilitation services and underpays SNFs for certain residents needing specialized services and skilled nursing care. The Government Accountability Office (GAO) has similarly reported that the prospective payment system (PPS) significantly overpays SNFs for rehabilitation ...

Extended Observation Stays in Acute Care Hospitals: Criticism, Legislation and Discussion August 26, 2010

“Observation” is the term used to describe the outpatient status of a patient who is in a hospital, but not as an inpatient. Although the Medicare Manuals limit observation to 24-48 hours, many beneficiaries nationwide are experiencing extended stays in acute care hospitals under observation. A major consequence for beneficiaries of not being classified as ...

Preventable Emergency Department Visits by Nursing Home Residents August 19, 2010

One of the goals of health care reform is the reduction of unnecessary hospital readmissions of patients. The Centers for Disease Control and Prevention (CDC) reports in 2010 that, in 2004, 8% of nursing home residents nationwide – 123,600 individuals – had an emergency department (ED) visit in the prior 90 days and that 40% ...

Health Reform: The Nursing Home Provisions June 17, 2010

This is the sixth in a series of Alerts by Center for Medicare Advocacy regarding Patient Protection and Affordability Care Act of 2010 (PPACA) and the Health Care and Education Reconciliation Act of 2010 (HCERA). This Alert focuses on provisions affecting nursing homes. The two new laws are collectively referred to as the Affordable Care Act. ...

New GAO Report Demonstrates Need for Stronger Enforcement of Nursing Home Quality Standards: Health Reform Provisions Could Help May 20, 2010

The Patient Protection and Affordable Care Act of 2010 (PPACA), the health care reform legislation enacted earlier this year, provides a new opportunity to strengthen and improve federal oversight mechanisms for nursing homes. Implementation of new statutory requirements for public reporting of nursing home ownership information and for Ethics and Compliance Programs in all facilities ...

Off-Label Drug Use Is Common and Hurts Nursing Home Residents March 25, 2010

Introduction The three-year old, and still ongoing, investigation and criminal prosecution of former staff members of a California skilled nursing facility for improper use of antipsychotic drugs on residents raises issues that go far beyond the gruesome facts of the case; issues that remain current today. This Alert discusses that case, research and Federal Drug Administration (FDA) ...

Overcoming Barriers to Medicare Coverage of Skilled Nursing Facility Care March 10, 2010

On March 10, 2010 NCCCNHR, The National Consumer Voice for Quality Long-Term Care, along with the Center for Medicare Advocacy hosted a web seminar on overcoming barriers to skilled nursing care, presented by Center Senior Policy Attorney Toby S. Edelman. Recorded copies are still available! Medicare pays for more residents in nursing homes than ever before, and ...

Observation Services: What Can Beneficiaries and Advocates Do? February 18, 2010

What are Observation Services? CMS Brochure Favorable DecisionsWhat Should Beneficiaries and their Advocates Do? Continuing WorkBeing in a hospital bed in a Medicare-participating hospital is no guarantee that a Medicare beneficiary is an inpatient.  In our December 11, 2008 Alert, the Center for Medicare Advocacy described the increasingly common practice of placing Medicare beneficiaries in acute care hospital beds ...

Nursing Home Residents’ Access to Physicians and Pain Medication February 4, 2010

Whether federal law and policies are preventing nursing home residents from getting the pain medications they need has become a major concern. In May 2009, the Milwaukee Office of the Drug Enforcement Administration (DEA) received a tip that PharMerica, a provider of pharmacy services to nursing facilities, was delivering controlled substances, including Fentanyl and OxyContin, ...

Serious Deficiencies in Nursing Facilities are Understated and the Problem May Get Worse January 7, 2010

Nursing facilities that choose to participate in the Medicare or Medicaid programs, or both, must undergo an annual survey to determine their compliance with federal standards of care, which are called Requirements of Participation. Facilities that are cited with deficiencies in the survey process are subject to a range of intermediate remedies, which are intended ...

Myths About Nursing Home Tort Reforms April 18, 2003

The following is an executive summary. You can also view the full report here and the appendices here in .pdf form. The Center for Medicare Advocacy performed a study entitled Tort Reform and Nursing Homes that deflates the myths that pervade the nursing home industry’s discussion of tort litigation. It found that cases about nursing home abuses ...

Important Provisions Reinstated In Medicare Skilled Nursing Facility Regulations September 20, 1999

In July,1998 revisions were made to the federal regulations which made significant changes to the Medicare skilled nursing facility level-of-care requirements. The revisions created a lack of clarity about what constitutes skilled nursing and, therefore, about a beneficiary's ability to receive Medicare coverage for skilled nursing facility care. This confusion was resolved, one year later, ...

The Medicare Prospective Payment System (SNF) September 20, 1999

Payment System Prior to July, 1998: Retrospective and Cost-Based Until July, 1998, nursing homes used to be reimbursed for care provided to Medicare Part A-covered residents residing in Medicare-certified beds through a retrospective cost-based system. The rate received by a nursing home for a Medicare covered resident was based on three components: Routine costs: These consisted of ...

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