Center for Medicare Advocacy

Advancing Access to Medicare and Healthcare

CMA Alert – More Bad Home Health Rules; More Health Care Sabotage; And Some Good News – Re-Review of Some HH Denials Now Available

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  1. Center Comments on Harmful Proposed Home Health Rule
  2. Health Care Sabotage Continues: New Pre-Existing Conditions Legislation Not What It Seems; GAO Critical of HHS ACA Enrollment Actions
  3. Re-Review of Some Home Health Denials Now Available

Center Comments on Harmful Proposed Home Health Rule

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 clinically complex and ill beneficiaries have adequate access to home health care.” (See pages 32380-32381). However, the rule provides significant incentives for home health agencies to serve post-acute care patients for brief periods of time. In turn, the proposed Medicare payment model will further diminish access to care, particularly for people with complex, longer-term and chronic conditions – people who are already often unable to access the care they need. Simply put, the Patient Driven Groupings Model (PDGM) is not guided by the needs of patients. It will exacerbate an existing crisis in access to home health care for people most in need.

The deadline to submit Comments to CMS is 5:00 pm EDT on Friday, August 31. Comments can be filed at http://www.regulations.gov. The Center encourages additional comments to CMS and invites use of our comments to amplify urgent concerns that the proposals would further limit access to Medicare-covered home health care for vulnerable people who qualify under the law.

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

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 bill protects people with pre-existing health conditions by prohibiting discrimination based on health status. This protection would purportedly be guaranteed even if the Affordable Care Act (ACA) repeal lawsuit led by Texas is successful (oral arguments for the Texas lawsuit are set to begin on September 10th).

This bill’s guaranteed issue and protection for people with pre-existing conditions only sounds good until the details are considered. Under the proposed legislation, it is true that people with pre-existing conditions may be able to buy a plan. However, insurers would not be obligated to actually cover treatment costs associated with their health condition. Obtaining and paying for insurance wouldn’t actually mean receiving coverage. A health policy advisor for Senator Brian Schatz tweeted “Let’s say you have cancer. Under this bill, you can buy health insurance, but that plan doesn’t have to cover your cancer treatment.”[1]

Many other Affordable Care Act coverage and consumer protections are also not included. Larry Levitt, an executive at the Kaiser Family Foundation tweeted that "So-called 'pre-existing condition exclusions' were common in individual market insurance policies before the ACA, and are also typical in current short-term policies. The new Republican bill would allow them, making guaranteed access to insurance something of a mirage.”[2] Senator Susan Collins is quoted as saying "I do support the objective of it, but the problem is it doesn’t deal with essential benefits like maternity care and treatment of substance abuse and some of the other consumer protections of the [Affordable Care Act] that I think are important.”[3]

It is clear that this bill won’t ensure that people who need coverage the most will be able to get it.  

GAO Report Critical of HHS ACA Open Enrollment Actions

Also last week, the Government Accountability Office (GAO), issued a report highlighting the unfortunate way HHS handled ACA open enrollment. GAO found that HHS did not develop enrollment goals for 2018, the funding process used for Navigators was based on unreliable data, and that refusal to pay cost-sharing reductions drove up premiums in silver plans. The report also highlighted that some stakeholders interviewed by GAO agreed that consumer confusion created by the Administration’s lack of support likely detracted from enrollment.

As we approach the upcoming open enrollment period, it is time for the Administration and Congress to provide real assistance to consumers who need quality coverage. It is past time to end attempts to weaken the ACA, and limit true access to health coverage, through legislation, executive action or the courts.     

[1] https://www.newsobserver.com/news/politics-government/article217278340.html
[2] https://www.healthcaredive.com/news/critics-say-gop-pre-existing-conditions-bill-flawed/531083/
[3] https://www.washingtonexaminer.com/policy/healthcare/susan-collins-opposes-gop-pre-existing-conditions-bill-because-it-doesnt-go-far-enough

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Re-Review of Some Home Health Denials Now Available

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 such denials for people who had previously been found to be homebound in an earlier appeal. The agency will review the claims under the proper legal standard that was in effect at the time, which gave “great weight” to a previous determination that the person was homebound. In other words, if a beneficiary had previously been found to be homebound in an appeal, and then was denied in a subsequent appeal for not being homebound, the second claim may be eligible for re-review and is more likely to be approved. If there have been no changes that affect the beneficiary’s ability to leave the home, and all other criteria for home health services are met, the second claim will ordinarily be paid.

Eligible class members must identify themselves and their eligible claims to the Medicare agency (CMS) by completing and submitting the “Ryan Re-Review Form,” along with any supporting documentation, no later than August 1, 2019.

The form provides information to assist in determining whether the beneficiary’s claims qualify for re-review under the settlement (for example, the home health services have to have been received on or before August 2, 2015, and denied on or after January 1, 2010). The re-review form and other important information about the settlement are published on CMS’s website here. Please contact Vermont Legal Aid or the Center for Medicare Advocacy with questions about the settlement.