- Guest Author – The Myth of the Medicare Improvement Standard
- Report Calls for Congress to Add Oral Health and Other Key Coverage to Medicare and Medicaid
- HHS Inspector General Issues Report on Focused Infection Control Surveys in Nursing Facilities
- Wishing You A Happy, Healthy New Year
The Issue Brief linked below is posted and reprinted with permission of the author, Catherine G. Hopper, Esq.
The Center for Medicare Advocacy is grateful to Ms. Hopper not only for permission to reprint, but for her diligence in understanding and sharing the myth of the need to improve in order to receive Medicare coverage for necessary care.
The “Improvement Standard,” litigated by the Center for Medicare Advocacy in Jimmo v. Sebelius, remains one of our top priorities for the new administration. For details, see the Center’s recent Transition Memorandum for Biden Administration Department of Health & Human Services (HHS)
Ms. Hopper summarizes the issue elegantly in the introduction to her brief, stating
The Medicare rules themselves never prevented Medicare recipients from receiving coverage for necessary nursing or therapy services when they ceased to improve, but the need for an “improvement standard” became an ingrained myth among the morass of companies who are responsible for reviewing Medicare claims.
- Read the full brief at https://medicareadvocacy.org/wp-content/uploads/2020/12/Myth-of-the-Medicare-Improvement-Standard-C.-Hopper.pdf
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A recent Center on Budget and Policy Priorities (CBPP) report Medicaid and Medicare Enrollees Need Dental, Vision, and Hearing Benefits highlights the need for dental, vision, and hearing benefits in the two programs, and calls on Congress to fill these gaps in coverage.
As the Center for Medicare Advocacy has detailed in previous CMA Alerts and advocacy, Medicare does not currently provide comprehensive coverage for oral health, or for vision or hearing. The CBPP report cites this gap in Medicare coverage, while also highlighting the limited benefit in Medicaid. “States are not required to offer dental, vision, or hearing services to adult Medicaid enrollees. . . . the scope of the benefits varies widely between states, and states often cut these benefits when facing budget shortfalls.”
Serious health consequences can arise from untreated dental, vision and hearing needs in both populations. Lack of coverage can lead to delays in necessary treatment, often resulting in more expensive treatment at a later time, decreased quality of life, additional emergency department visits, complications for other chronic conditions and harm to overall health.
In calling for Congressional action, the Report also cited disparities in care, with statistics demonstrating that low-income adults and people of color were more likely to have poor access to care and increased unmet needs, such as untreated cavities. “Among adults aged 65 and older, 37 percent of those in poverty had complete tooth loss, compared to just 16 percent of those with incomes at or above 200 percent of the poverty line.”
The Report emphasized that only expanding coverage in Medicare would be insufficient to meet the vast need for such services among vulnerable adults. “Fixing gaps in coverage only in Medicare without making the corresponding changes in Medicaid would exclude many people with significant unmet needs. Providing access to a full range of preventive services and treatment for non-elderly adults with Medicaid coverage could prevent more serious conditions later in life as well as the need for more invasive, costly procedures.”
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The HHS Office of Inspector General (OIG) reports that between March 23 and May 30, 2020, states using the Centers for Medicare & Medicaid Services’s (CMS’s) focused infection control survey protocol cited only 68 deficiencies at nursing facilities (only 3% of surveys resulted in a deficiency) while they increased their efforts to support and assist facilities during the pandemic. Between March 23 and May 30, 2020, 1% of onsite surveys resulted in an infection control deficiency; in the comparable period in 2019, 10 percent of surveys led to an infection control deficiency. CMS attributes the small number of infection control deficiencies to the limited scope of the surveys, facilities’ use of a CMS self-assessment tool, and facility vigilance about infection control issues. States explain that surveyors spent less time onsite, less than two days; one state told OIG that surveyors were onsite for two hours.
State challenges in conducting on-site surveys included difficulties acquiring and fitting personal protective equipment and shortages of surveyors. States prioritized more of the complaints they received as immediate jeopardy, but they received half as many complaints as in the same period in 2019. OIG attributes the reduced number of complaints to the ban on visitors. States expressed concern about the backlog of surveys and high-priority complaint investigations. In 2019, high-priority complaints (frequently related to care, residents’ rights, and neglect) resulted in 21,120 deficiencies.
OIG recognizes that while it may have been appropriate to limit surveys to infection control at the beginning of the pandemic, that limitation, combined with the ban on visitors, raises questions about how well the oversight system is identifying problems. Among its three recommendations, OIG recommends that CMS consider whether to expand the focused survey “to include assessments of additional quality of care requirements.” CMS did not concur with OIG’s recommendations.
OIG describes its additional work, now underway, on the impact of COVID-19 on nursing homes. These reports will describe the characteristics of facilities with the largest numbers of COVID-19 cases and deaths and will assess facilities’ reporting of CMS-required information during the pandemic.
 Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23-May 30, 2020, OEI-01-20-00430 (Dec. 2020),https://oig.hhs.gov/oei/reports/OEI-01-20-00430.pdf
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As we turn the corner on 2020, we are energized every day by the resilience and determination of the people who contact the Center for Medicare Advocacy for help and those that support our work.
Thank you for being part of our community.
We wish you an uplifting new year.
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