- Commonwealth Fund Issues Series of Articles Addressing Medicare’s Fiscal Solvency – Introductory Statement by Marilyn Moon
- It’s Time to Repeal the 3-Day Inpatient Hospital Requirement for Medicare Skilled Nursing Facility Coverage
- Center for Medicare Advocacy and Medicare Rights Center Urge Biden Administration to Take Immediate Action on Key Issues Facing Medicare Beneficiaries
- Medicare Case Study: Returning to Work After Disability Benefits End
- U.S. Government Changes Position in Supreme Court Affordable Care Act Case
- Register Now – 2021 National Voices of Medicare Summit & Sen. Jay Rockefeller Lecture
Statement by Marilyn Moon
Recently, I was fortunate to be invited to participate in a blog series on Medicare Solvency sponsored by the Commonwealth Fund. A number of experts participated offering a broad range of recommendations for how to ensure the solvency of the Part A trust fund into the future. The issue of ensuring that Medicare is on strong financial footing and that its funding reflects our society’s commitment to the long term health of this vital program should be of interest to all Americans. Most of us will depend upon Medicare at a vulnerable time in our lives.
While I do not agree with all the proposals included, the series offers a wide range of opinions and information that should contribute to the debate. The general theme that comes through to me is that this is a program that offers a valuable benefit to seniors and persons with disabilities. It is not overly generous and most writers agree that reductions in spending should be focused on areas of overpayment or inefficiency in the delivery of care rather than in reducing actual services. And most of the authors also recognize the need for increased financing for the program. This is significant, I believe, since in this period of reluctance to raise anyone’s taxes, the need for more revenue is often the elephant in the room—never spoken of but still looming over everything. It is also notable that there are many differing proposals in this area, ranging from small technical adjustments to going big by raising income or payroll taxes. A balanced debate is needed to determine how we ensure Medicare’s future and I believe that this series is a great place to start.
Marilyn Moon is a Visiting Scholar with the Center for Medicare Advocacy.
Summary of Commonwealth Series Articles
Last month (January 2021), the Commonwealth Fund published a series of articles entitled Options for Extending Medicare’s Trust Fund: The Commonwealth Fund Solvency Series.
Recognizing that the Medicare Part A Trust Fund is projected to become insolvent in 2024, the introduction to the series notes that “[w]ithout changes to expected spending or trust fund revenue, the trust fund will not have sufficient funds to cover the entire cost of beneficiaries’ health care.” Noting that the Trust Fund “is primarily funded through payroll taxes paid by employers and employees, with some additional income from interest as well as premiums paid by voluntary enrollees not automatically entitled to Medicare Part A”, the authors ask “[w]ill the trust fund solvency be adequately extended by reducing the projected growth in expenditures, raising revenues, changes to the services covered by Medicare Part A, or a combination of these options?”
The Commonwealth Fund invited Medicare thought leaders with a range of perspectives, including Marilyn Moon, to “outline how they would extend the life of the trust fund.” The articles include a breadth of policy proposals offered by these experts, some of which the Center for Medicare Advocacy agrees with, others we oppose.
Overall, the Center agrees with Dr. Moon that there should be a robust discussion concerning raising additional revenue, and that cost reductions should not lead to a reduction in services for beneficiaries.
With respect to raising additional revenue, we agree with exploring some of the proposals outlined by Dr. Moon and others, such as an “excess profits tax” during the pandemic, and/or a modest payroll tax increase. We also agree with Dr. Bruce Vladeck who promotes expanding the revenue base by taxing all personal income, including returns on capital that are currently not subject to payroll taxes.
With respect to cost-savings, we support proposals such as negotiating drug prices and reining in Medicare Advantage overpayments, including by reforming the quality bonus program and risk-coding adjustments.
We disagree with some of the other proposals, such as transforming Medicare into a premium support program, expanding the role of Medicare Advantage, raising the eligibility age for Medicare, and prohibiting supplemental coverage from offering first-dollar coverage. These suggestions would not attain savings while retaining the intent of Medicare to provide equitable health care for all beneficiaries.
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.
When Medicare was enacted in 1965, it limited coverage in a skilled nursing facility (SNF) under Part A to beneficiaries who had been inpatients in an acute care hospital for at least three consecutive days before their discharge to a SNF.[1] The benefit, called extended care, was viewed, literally, as a limited extension of a hospital stay. Since the average length of stay in an acute care hospital for a patient age 65 or older in 1965 was more than 13 days,[2] most hospitalized Medicare beneficiaries had no difficulty satisfying the three-day inpatient requirement. Times have changed.
Congress should repeal the three-day inpatient requirement for multiple reasons.
1. Medical care has changed in the past 55 years
Many medical procedures, including surgeries, that required hospital stays for multiple days or weeks in 1965 now require limited hospital stays or may even be done on an outpatient basis. Following these procedures, patients may nevertheless need the skilled nursing or skilled rehabilitation services that a SNF provides. As the Centers for Medicare & Medicaid Services (CMS) acknowledged in 2014, in proposed rules for Accountable Care Organizations (ACOs),
Because of changes in medical care over the half century since enactment of the original Medicare legislation, it may now be medically appropriate for some patients to receive skilled nursing care and or rehabilitation services provided by SNFs without a prior inpatient hospitalization, or with an inpatient hospital length of stay of less than 3 days. It may be medically appropriate for patients to go to SNFs earlier, due to changes in medical care, given that hospital lengths of stay are shorter than they were decades ago, and the types of patients that were staying 3 days in an inpatient hospital in 1965 are no longer staying 3 days in an inpatient hospital now. Because of this, over time, we have repeatedly expressed interest in testing alternatives to the SNF 3-day rule.[3]
Repealing the three-day inpatient hospital requirement reflects the realities of modern medicine.
2. Traditional Medicare and Medicare Advantage need to be aligned
While the traditional Medicare program retains the three-day requirement, Medicare Advantage (MA) plans are permitted by law to waive the three-day requirement[4] and most do. At present, approximately 39 percent of Medicare beneficiaries receive their health care through MA plans,[5] either because MA is the only option offered by their former employers or unions as retiree health[6] or because they choose MA.
In addition, beneficiaries in traditional Medicare who are “aligned” to ACOs may also benefit from ACOs’ waiver of the three-day inpatient hospital requirement. In 2018, more than 20 percent of Medicare beneficiaries received their health care through ACOs.[7]
Nearly 60 percent of all Medicare beneficiaries receive coverage through programs that generally waive the three-day requirement. All Medicare beneficiaries should receive comparable care and services, regardless of how they participate in Medicare.
3. Observation status in hospitals deprives beneficiaries of Medicare SNF benefits and necessary care
Over the last 20 years, acute care hospitals have increasingly described patients as receiving care in observation stays. Observation is an outpatient status, which does not qualify patients for Part A SNF coverage, even though the care and services that observation patients receive may be indistinguishable from the care and services received by inpatients and even when observation patients have been hospitalized for three days or more. The HHS Office of Inspector General has identified the unfair and uneven impact of observation status on beneficiaries across the country and, in December 2016, called for ensuring that all Medicare beneficiaries have the same access to post-hospital care in a SNF, regardless of how their hospital stays are classified.[8]
4. Neither a 2013 regulation (the two-midnight rule) nor a 2015 law (the NOTICE Act) has reduced the problem of observation status
Administrative and legislative actions have not reduced the problems with observation status. In October 2013, CMS promulgated the “two-midnight rule,”[9] establishing time-based criteria to clarify when physicians should either admit patients as inpatients or classify patients as outpatients. CMS also intended to reduce the numbers of long outpatient stays and short inpatient admissions. The HHS Office of Inspector General reported in 2016 that the two-midnight rule had not achieved those goals and that inpatient stays decreased while outpatient stays increased in fiscal year 2014.[10]
The Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, enacted in 2015, requires hospitals to inform patients of their outpatient observation status when they are outpatients for more than 24 hours.[11] Since March 2017, hospitals have been required to use the Medicare Outpatient Observation Notice (MOON) and provide patients in observation status with an oral explanation of their status and its consequences. The MOON does not give patients hearing rights[12] and does not count the time in the hospital for purposes of SNF coverage.
Both the regulation and the law retained the three-day inpatient requirement. Neither resolved problems for beneficiaries resulting from the statutory provision.
5. Health equity requires elimination of observation stays
New research finds that the poorest Medicare beneficiaries nationwide are more likely both to have their repeated hospital stays classified as observation and not to receive SNF care as a result.[13] The study also finds that if these beneficiaries receive care in a SNF following hospitalization, they are less likely to return to an acute care hospital. The coronavirus pandemic has highlighted racial and economic disparities in health care (and elsewhere). Eliminating the three-day inpatient requirement would further health equity.
6. Observation status is a surprise medical bill
Congress addressed surprise medical bills in the No Surprises Act, part of the Consolidated Appropriations Act, 2021.[14] The essence of surprise medical bills is that a patient receives a bill for medical care that the patient had no way of knowing about or anticipating or agreeing to in advance. Although the new federal legislation addresses surprise medical bills only in private insurance, Congressman Joseph Courtney (D-CT) has described observation status for Medicare beneficiaries as “surprise medical bills on steroids.” The consequences for patients are the same in observation status – patients have no way to protect themselves from large bills for necessary health care. Repealing the three-day inpatient requirement would eliminate surprise bills for beneficiaries needing SNF care.
Conclusion
The three-day inpatient stay requirement is an anachronism. Both medical care and the Medicare program have dramatically changed in the last 55 years. More than half of all Medicare beneficiaries receive coverage through Medicare programs that waive the three-day inpatient requirement. When hospitals classify patients as receiving observation services, an outpatient status, rather than as inpatients, they deprive patients of necessary SNF care or result in surprise costs for SNF stays. Observation status has a disparate impact on the poorest Americans. Since March 2020, CMS has waived the three-day requirement during the health emergency and coronavirus pandemic.[15] Congress needs to repeal the 1965 statutory provision that limits Medicare Part A coverage in a SNF to beneficiaries who have been hospitalized as inpatients for at least three consecutive days. It is time to simplify and modernize Medicare – and eliminate the 3-day inpatient hospital requirement!
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[1] 42 U.S.C. §1395x(i); 42 C.F.R. §409.30(a)(1).
[2] Center for Disease Control and Prevention, Patients Discharged From Short-Stay Hospitals by size and type of ownership United States-1965, p. 19, Table 10 (Dec. 1968), https://www.cdc.gov/nchs/data/series/sr_13/sr13_004acc.pdf.
[3] 79 Fed. Reg. 72760, 72818, CMS-1461-P (Dec. 8, 2014), https://www.govinfo.gov/content/pkg/FR-2014-12-08/pdf/2014-28388.pdf.
[4] 42 U.S.C. §1395d(f).
[5] Meredith Freed, Anthony Damico, and Tricia Neuman, A Dozen Facts About Medicare Advantage in 2020 (Jan. 13, 2021), https://www.kff.org/medicare/issue-brief/a-dozen-facts-about-medicare-advantage-in-2020/.
[6] Id. Nineteen percent of MA enrollees “are in group plans offered by employers and unions for their retirees.”
[7] National Association of ACOs, NAACOS Overview of the 2018 Medicare ACO Class, https://www.naacos.com/assets/docs/pdf/Overivew2018MedicareACOCohortFinal043018.pdf .
[8] Office of Inspector General, Vulnerabilities Remain Under Medicare’s 2-Midnight Hospital Policy, OEI-02-15-00020 (Dec. 2016), https://oig.hhs.gov/oei/reports/oei-02-15-00020.pdf.
[9] 78 Fed. Reg. 50506 (Aug. 19, 2013).
[10] Office of Inspector General, Vulnerabilities Remain Under Medicare’s 2-Midnight Hospital Policy, OEI-02-15-00020 (Dec. 2016), https://oig.hhs.gov/oei/reports/oei-02-15-00020.pdf.
[11] Pub. L. 114-42, signed Aug. 6, 2015. The NOTICE Act adds (Y) to 42 U.S.C. §1395cc(a)(1)(Y).
[12] 42 C.F.R. §405.926(u).
[13] Ann Sheehy, W. Ryan Powell, Farah Kaiksow…”Thirty-Day Re-observation, Chronic Re-observation, and Neighborhood Disadvantage” (Dec. 1, 2020), https://www.mayoclinicproceedings.org/article/S0025-6196(20)30858-2/pdf; “‘Observation Status’ May Disproportionately Burden Medicare Beneficiaries in the Most Vulnerable Neighborhoods” (CMA Alert) (Dec. 17, 2020), https://medicareadvocacy.org/observation-status-may-disproportionately-burden-medicare-beneficiaries-in-the-most-vulnerable-neighborhoods/.
[14] Public Law 116-260, pp. 1629-1700 (Dec. 21, 2020), https://rules.house.gov/sites/democrats.rules.house.gov/files/BILLS-116HR133SA-RCP-116-68.pdf.
[15] CMS, “COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers,” p. 15 (updated Dec. 1, 2020), https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf.
In a letter sent on February 9, 2021 to the U.S. Department of Health and Human Services (HHS) Acting Secretary Norris Cochran, the Center for Medicare Advocacy and the Medicare Rights Center urged the Biden Administration to take swift action to strengthen Medicare, Medicaid, and the Affordable Care Act.
While both organizations have issued lengthy policy recommendations to the new Administration (see the Center for Medicare Advocacy’s Transition Memo here), the letter outlines matters requiring immediate attention, including the issues raised below (links to previous writings by the Center are included where relevant).
In order to ensure that all Medicare-eligible individuals can access their earned Medicare benefits during the COVID-19 pandemic, we urged HHS to:
- Reinstate and strengthen COVID-19 Medicare Enrollment Flexibilities, similar to those provided to Affordable Care Act plans in an Executive Order issued on January 28;
- Define “Hospital Inpatient” to counteract the harm caused by hospital “outpatient observation status” (see here); and
- Implement Telehealth Flexibilities concerning Speech Generation Devices (SGDs), to prevent people who need such devices from having to access in-person care (see here).
With respect to Medicare outreach and enrollment, we urged HHS to launch implementation of the Beneficiary Enrollment Notification and Simplification (BENES) Act and guarantee objectivity in consumer tools that in recent years have inappropriately steered people towards enrollment in Medicare Advantage (MA) plans (see here).
In order to stop harmful and often last-minute policies issued by the Trump Administration, our organizations called on HHS to include the following actions as part of their regulatory review process:
- Immediately pause the New “Geo” Demonstration Model and the Medicaid Managed Care Organization (MCO)-based Direct Contracting Entity Model, both of which are being rushed despite important unanswered questions and issues (see here);
- Revise the Medicare Part D Model that weakens the protected drug classes guarantee—an important consumer protection;
- Suspend expansion of the Medicare Home Health Value-Based Purchasing Model (HHVBP), which limits access to home care for those with longer term and chronic conditions (see here);
- Rescind provisions of the final 2021 Medicare Part C & D rule, which, among other things, further complicates the Part D benefit by adding another specialty drug tier, and weakens the distinction between educational and marketing events (see here); and
- Rescind the SUNSET Rule, which puts an arbitrary expiration date on almost all regulations issued by HHS (see here).
With respect to policies outside of Medicare, the organizations urged HHS to ensure access to Healthcare.gov, revoke changes to Medicaid Maintenance of Effort (MOE) requirements, and restore Medicaid safeguards.
The complete letter is available here and accompanying press release is available here.
Medicare Case Study: Returning to Work After Disability Benefits End
Ms. A. had been eligible for Medicare due to her disability. On January 1, 2020, she returned to work. Because her new work income was greater than “substantial gainful activity”[1] (SGA) her monthly Social Security (SSA) Disability Insurance cash benefits (DI benefits) were ending.
Throughout 2020, Ms. A. received conflicting information about her disability health insurance (D-HI) Medicare eligibility from SSA/Medicare and her employer, causing Ms. A to file a request with SSA (Form CMS-1763) to terminate her Medicare coverage in favor of her employer coverage. Ms. A’s employer has less than 100 employees.
Question: What are Ms. A’s appropriate options for health insurance, either through Medicare or her Employer’s Group Health Plan (EGHP), and can the appropriate health insurance be re-instated retroactively for 2020 coverage?
Brief Answer: The answer depends on whether Ms. A. was terminated from DI and D-HI Medicare Part A benefits based on medical recovery, or if she remained entitled to D-HI Medicare Part A benefits based on a disabling condition that still meets SSA rules. Losing eligibility for DI benefits due to SGA does not negate beneficiary entitlement to extended Medicare benefits for 8.5 years (which includes a nine-month trial work period and an additional 93 months of eligibility).[2] The only way to sever Medicare entitlement is either by ceasing the disability with medical recovery (termination) or, if the disabling condition continues (entitlement continues), returning all previous benefits conferred since the disability application.[3]
Having Medicare Part A entitlement continue after Social Security Disability Insurance benefits end due to Substantial Gainful Activity causes a particular problem for a disabled beneficiary working for an employer with less than 100 employees, thus making Medicare the primary payer according to coordination of benefit rules.[4] The beneficiary should also keep Medicare Part B benefits in place because: 1) the EGHP will only be a secondary payer; 2) if the beneficiary stops Medicare Part B, she would likely have to wait to regain coverage through the Medicare general enrollment period (creating a potential gap in insurance coverage); and 3) the beneficiary may incur Part B penalties.[5]
[Note: In this case study, if Ms. A’s employer had 100 or more employees, then the EGHP would be primary and Medicare would be secondary.[6] Ms. A. could keep premium-free Medicare Part A, and stop paying for Part B without penalty, or use Part B as secondary to the EGHP.]
Unfortunately, Medicare coordination of benefit rules are inflexible to individual circumstances, complicated to navigate, and could have severe unintended consequences to a beneficiary if not followed properly.
Legal Analysis
1. What Should Ms. A.’s Health Insurance Have Been in 2020?
For Medicare purposes, when a disabled beneficiary starts earning SGA, it must first be determined if a) the disability ceased due to the beneficiary’s medical recovery, or b) the beneficiary is working with the disabling condition, but as she is making SGA, the beneficiary can no longer receive monthly DI benefits.
- Loss of DI benefits – Based on Medical Recovery[7], With No Trial Work Period (TWP)[8] Medicare coverage based on a disability will end if such disability ends.[9] When Ms. A. began employment on January 1, 2020, if she had achieved “medical recovery” (meaning she no longer had a disabling condition per SSA rules), her Medicare should also have terminated the later of 1) the month in which her entitlement to DI benefits ended, or 2) the month after the month in which the benefit termination notice was sent to Ms. A.[10] Under these circumstances, once DI benefits and Medicare coverage terminated, she likely should have enrolled in her work EGHP.
- Loss of DI benefits – Not Based on Medical Recovery, Based Only on SGA
If SSA determined Ms. A still had a medical disability when she started working (even though DI benefits would end because she was making SGA level earnings), her entitlement to Medicare coverage would continue.[11] Because she would be entitled to Medicare based on her disability, and her employer had less than 100 employees,[12] Medicare coverage would be primary and the EGHP would be secondary.[13] If Medicare coverage is primary, Ms. A. should continue to have Medicare Part B to cover medical insurance as the primary payer (and to avoid subsequent Part B penalties[14] and a potential gap in insurance coverage if she stopped Part B and had to re-enroll in Part B during the Medicare general enrollment period.) The EGHP may be secondary insurance.- If Ms. A. attempts to discontinue Medicare[15] and only have EGHP coverage, as the EGHP is in the secondary payer position (given Ms. A’s ongoing entitlement for Medicare), the EGHP will not be primary payer. Ms. A should have Medicare primary and employer GHP secondary.
- If Ms. A. attempts to terminate Medicare while she is still “entitled” to Medicare (as long as the disabling condition meets SSA rules, she would be entitled to Medicare for 9 months of TWP and 93 additional months – total of 8.5 years), she may be required to return all benefits previously received through Social Security and Medicare.[16] The only way to avoid entitlement to Medicare Part A is to forego the source of the entitlement and repay all benefits received, including health insurance payments made.[17] If Ms. A. achieves medical recovery at any time during the 8.5 year period, and therefore no longer meets Social Security disabling condition rules, her entitlement to Medicare will terminate.[18]
2. What Should Ms. A. Do Now To Obtain Appropriate Health Insurance Coverage Retroactive for 2020?
Based on the misinformation Ms. A. received from Social Security/Medicare and her employer, about what correct course of action she should have taken, Ms. A. should be entitled to Equitable Relief for the appropriate health coverage to be re-instated retroactively.
- If Ms A. began employment on January 1, 2020 having achieved “medical improvement”, her Medicare should have terminated when her Social Security cash benefits terminated. When Medicare ceased, her EGHP likely should have become her primary insurance. Therefore, Ms. A should request relief from her EGHP to enroll as of the time Medicare terminated. [Note: This recommendation is to the employer, but it is outside the scope of Medicare analysis.]
- If Ms. A. began employment and she still has her disabling condition that meets SSA rules, Ms. A. should be entitled to Equitable Relief from Medicare and continuous Medicare coverage should be re-instated, despite her request during 2020 to terminate Medicare. Ms. A. is entitled to equitable relief because she was provided misinformation, about her insurance choices and the attendant consequences, by Social Security and/or Medicare and/or her employer and/or her EGHP.[19] This equitable relief should ensure that Medicare continuously remains the primary payer and the EGHP could be the secondary payer.[20]
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[1] In 2020, a non-blind person who is earning more $1,260 a month ($1,310 in 2021) (net of impairment-related work expenses) is ordinarily considered to be engaging in SGA. https://www.ssa.gov/oact/COLA/sga.html.
[2] 42 United States Code (U.S.C.) Section 426(b); https://medicareadvocacy.org/medicare-info/medicare-coverage-for-people-with-disabilities/.
[3] POMS HI 00820.025A.4 Termination of Disability https://secure.ssa.gov/poms.nsf/lnx/0600820025; POMS HI 00801.002 (B) Waiver of Entitlement By Monthly Beneficiary – Individuals entitled to monthly benefits which confer eligibility for HI may not waive HI entitlement. The only way to avoid HI entitlement is through withdrawal of the monthly benefit application. Withdrawal requires repayment of all RSDI and HI benefit payments made. https://secure.ssa.gov/apps10/poms.nsf/lnx/0600801002; POMS GN 00206.020(D) Hospital Insurance and Withdrawal https://secure.ssa.gov/poms.nsf/lnx/0200206020.
[4] https://www.medicare.gov/Pubs/pdf/02179-Medicare-Coordination-Benefits-Payer.pdf, page 18.
[5] https://www.medicare.gov/your-medicare-costs/part-b-costs/part-b-late-enrollment-penalty.
[6] Id.
[7] Social Security – The Red Book – Returning to Work (ssa.gov) If we find that your disability ceased due to medical improvement, our decision is effective in the month shown by the evidence, or the month we give you written notice, if later. In either case, we pay SSDI benefits for the cessation month and the following two months. We call these three months the “grace period”.
[8] POMS HI 00820.025A.4 Termination of Disability https://secure.ssa.gov/poms.nsf/lnx/0600820025.
[9] Social Security Program Operating Manual System (POMS) HI 00820.100 Cessation of Disability https://secure.ssa.gov/apps10/poms.nsf/lnx/0600820100.
[10] POMS HI 00820.025A.3 Termination of Disability https://secure.ssa.gov/poms.nsf/lnx/0600820025 If DI benefits end because of SGA, but after a TWP is completed.
[11] 20 Code of Federal Regulations 404.640 Withdrawal of Application https://www.ssa.gov/OP_Home/cfr20/404/404-0640.htm; POMS HI 00801.002 Waiver of HI Entitlement by Monthly Beneficiary https://secure.ssa.gov/apps10/poms.nsf/lnx/0600801002; POMS HI 00801.034 Withdrawal Considerations https://secure.ssa.gov/apps10/poms.nsf/lnx/0600801034; POMS GN 00206.020 Hospital Insurance and Withdrawal https://secure.ssa.gov/apps10/poms.nsf/lnx/0200206020#d3.
[12] If Ms. A’s employer has 100 or more employees, or her employer belongs to a multi-employer group with 100 or more employees, the EGHP would be primary and Ms. A. would only have to carry mandatory Medicare Part A. https://www.medicare.gov/Pubs/pdf/02179-Medicare-Coordination-Benefits-Payer.pdf, page 18.
[13] Medicare Publication Your Guide to Who Pays First https://www.medicare.gov/Pubs/pdf/02179-Medicare-Coordination-Benefits-Payer.pdf, page 18.
[14] Id.
[15] Withdrawing from Medicare can be achieved by filing form CMS1763. CMS 1763 Request for Termination of premium Hospital and/or supplementary Medical insurance. SSA has procedures to ensure beneficiaries understand the potential dire consequences of withdrawing from Medicare entitlement.
[16] Participation in Medicare Part A is statutorily mandated for those who are disabled or over age 65 and receiving Social Security benefits. 42 United States Code Section 426(b)(C); Bowen v. Michigan Academy of Family Physicians, 476 US 667, 674-675 (describing Medicare Part A as “ Mandatory Institutional Health Benefits”); (see also Hall v. Sebelius Civil Action No. 08-1715 (RMC) https://ecf.dcd.uscourts.gov/cgi-bin/show_public_doc?2008cv1715-54); As long as a disabling condition still meets SSA rules, a beneficiary is entitled to keep Medicare coverage for at least 8 ½ years after the beneficiary returns to work (102 months). (The 8 years includes the nine-month trial work period.) https://www.ssa.gov/disabilityresearch/wi/extended.htm.
[17] 20 Code of Federal Regulations 404.640 Withdrawal of Application https://www.ssa.gov/OP_Home/cfr20/404/404-0640.htm; POMS HI 00801.002 Waiver of HI Entitlement by Monthly Beneficiary https://secure.ssa.gov/apps10/poms.nsf/lnx/0600801002; POMS HI 00801.034 Withdrawal Considerations https://secure.ssa.gov/apps10/poms.nsf/lnx/0600801034; POMS GN 00206.020 Hospital Insurance and Withdrawal https://secure.ssa.gov/apps10/poms.nsf/lnx/0200206020#d3.
[18] https://www.ssa.gov/disabilityresearch/wi/extended.htm.
[19] Policy behind equitable relief and proof needed POMS HI 00805.170 Conditions for Providing Equitable Relief https://secure.ssa.gov/apps10/poms.nsf/lnx/0600805170; POMS HI 00805.320 Equitable Relief for Disabled Individuals Covered Under a GHP/LGHP https://secure.ssa.gov/poms.nsf/lnx/0600805320; see also POMS HI 00805.310 Disability SEP Enrollments https://secure.ssa.gov/poms.nsf/lnx/0600805320.
[20] If Ms. A was over age 65, equitable relief would only be available if an agency of the government (e.g. Medicare, Social Security, a Medicare Contractor) provided her with the misinformation that led to an inappropriate choice of coverage. POMS HI 00805.175 HI 00805.175 Evidence of Government Error or Delay https://secure.ssa.gov/apps10/poms.nsf/lnx/0600805175
U.S. Government Changes Position in Supreme Court Affordable Care Act Case
The federal government, which, in the Trump administration, was supporting Texas and several other states that are seeking to have the entire Affordable Care Act (ACA) struck down by the Supreme Court, stated yesterday that it has changed its position. In a letter to the Court, lawyers for the government said that following the change in administration, the Department of Justice has reconsidered, and its position is that the law’s individual mandate – which now carries no penalty for failure to carry health insurance – is constitutional. The government also stated that even if the Court finds that provision of the ACA to be unconstitutional, it is “severable” from the rest of the law, meaning the entire rest of the ACA does not have to fall along with the mandate.
The federal government’s opinion is now consistent with the position of California and the other states defending the law, as well as the position of the Center for Medicare Advocacy and numerous other organizations and individuals who filed amicus briefs urging the Supreme Court to uphold the law. It is also consistent with the opinion of the American people, who have made it clear that the ACA should and must remain the law of the land. The Center has highlighted the devastating effect that striking down the ACA would have on Medicare beneficiaries and the Medicare program itself. A decision from the Supreme Court is expected by the end of June.
Register Now for the
2021 National Voices of Medicare Summit
& Sen. Jay Rockefeller Lecture
Medicare & Health Care:
Where We’ve Been, Where We Are, Where We Need to Be
Virtual Presentation, by Webinar
Thursday April 1, 2021, 1:00 PM EDT- 4:00 PM EDT
We are pleased to welcome 2021 Sen. Jay Rockefeller Lecturer,
Dr. Donald Berwick.
Dr. Berwick is one of the country’s leading advocates for high-quality health care, and one of the top thinkers in health care today. Dr. Berwick is currently President Emeritus and Senior Fellow at the Institute for Healthcare Improvement and previously Administrator of the Centers for Medicare & Medicaid Services.
We are also honored to present: Ben Belton (Director of Global Partner Engagement, AARP), Robert Espinoza (Vice President of Policy, PHI), Dr. Judith Feder (Georgetown University Professor and Center for Medicare Advocacy Board President), Chris Jennings (President, Jennings Policy Strategies), David Lipschutz (Associate Director, Center of Medicare Advocacy), Patricia Neuman (Vice President for Medicare, Kaiser Family Foundation), Senator Jay Rockefeller, and Judith Stein (Executive Director, Center for Medicare Advocacy).
Panel Discussions
Challenges and Opportunities Facing Medicare and Health Care in the New Administration and Congress
Acknowledging Health Disparities and Advancing Health Equity
To kick off the Center for Medicare Advocacy’s 35th Anniversary, and to make this program widely accessible in light of this challenging time, we are offering an early registration fee of only $35.