Breaking Federal News


JIMMO STANDARD NOT BEING IMPLEMENTED

posted Jun 19, 2014, 7:16 AM by Frank Baskin   [ updated May 15, 2015, 5:51 AM ]

There is some evidence that the Medicare established eligibility standards for skilled care are not being followed. These were effective as of January, 2014. Beneficaries......FOR MORE CLICK TITLE... no longer had to improve but only had to maintain their level of care to be on or to stay on skilled care in a nursing home or in the community. Individuals may appeal.
Please read below for more information and how to appeal


Skilled Maintenance Services Are Covered by Medicare.
The Center for Medicare Advocacy is pleased to announce that the Medicare Policy Manuals have been revised.
The revisions, pursuant to the Jimmo vs. Sebelius Settlement, clarify that improvement is not required to obtain Medicare coverage.  The revisions were published by the Centers for Medicare & Medicaid Services (CMS) on Friday December 6, 2013. They pertain to care in Inpatient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF), Home Health care (HH), and Outpatient Therapies (OPT). 
The CMS Transmittal for the Medicare Manual revisions, with a link to the revisions themselves, is posted on the CMS website at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R179BP.pdf.  The CMS MLN Matters article is also available on the CMS site under “Downloads” at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8458.pdf
As CMS states in the Transmittal announcing the Jimmo Manual revisions: 
No “Improvement Standard” is to be applied in determining Medicare coverage for maintenance claims that require skilled care. Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition). The Medicare statute and regulations have never supported the imposition of an “Improvement Standard” rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient’s condition. Thus, such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves. The manual revisions now being issued will serve to reflect and articulate this basic principle more clearly. [Emphasis in original.]
Per the Jimmo Settlement, CMS will now implement an Education Campaign to ensure that Medicare determinations for SNF, Home Health, and Outpatient Therapy turn on the need for skilled care – not on the ability of an individual to improve. For IRF patients, the Manual revisions and CMS Education Campaign clarify that coverage should never be denied because a patient cannot be expected to achieve complete independence in self-care or to return to his/her prior level of functioning.
Background
The Jimmo settlement was approved on January 24, 2013 after a fairness hearing, marking a critical step forward for thousands of beneficiaries nationwide. (See the Order Granting Final Approval).  The lawsuit was brought on behalf of a nationwide class of Medicare beneficiaries by six individual beneficiaries and seven national organizations representing people with chronic conditions, to challenge the use of the illegal Improvement Standard.
The proposed Jimmo settlement agreement[2] was originally filed in federal District Court on October 16, 2012. The plaintiffs joined with the named defendant, Secretary of Health and Human Services Kathleen Sebelius, in asking the federal judge to approve the settlement of the case. With only one written comment received, and no class members appearing at the fairness hearing to question the settlement, Chief Judge Christina Reiss granted the motion to approve the Settlement Agreement on the record, while retaining jurisdiction to enforce the agreement in the future, as requested by the parties.
With the settlement now officially approved, the Centers for Medicare & Medicaid Services (CMS) is tasked with revising its Medicare Benefit Policy Manual and numerous other policies, guidelines and instructions to ensure that Medicare coverage is available for skilled maintenance services in the home health, nursing home and outpatient settings.  CMS must also develop and implement a nationwide education campaign for all who make Medicare determinations to ensure that beneficiaries with chronic conditions are not denied coverage for critical services because their underlying conditions will not improve. 
It is important to note that the Settlement Agreement standards for Medicare coverage of skilled maintenance services apply now – while CMS works on policy revisions and its education campaign. The Center is hearing from beneficiaries who are still being denied Medicare coverage based on an Improvement Standard, but coverage should be available now for people who need skilled maintenance care and meet any other qualifying Medicare criteria. This is the law of the land – agreed to by the federal government and approved by the federal judge.  We encourage people to appeal should they be denied Medicare for skilled maintenance nursing or therapy because they are not improving.
Patients should discuss with their health care providers the Medicare maintenance standard and whether it is applicable to them.  Health care providers should apply the maintenance standard and provide medically necessary nursing services or therapy services, or both, to patients who need them to maintain their function, or prevent or slow their decline.  Under the maintenance standard articulated in the settlement, the important issue is whether the skilled services of a health care professional are needed, not whether the Medicare beneficiary will "improve."
CMS has issued a Fact Sheet outlining the Jimmo v. Sebelius. settlement.  Use this fact sheet now as evidence that skilled maintenance services are coverable for skilled nursing facility care, outpatient therapy, and home health care.  The Center for Medicare Advocacy has Self-help Packets to help pursue Medicare coverage, including for skilled maintenance nursing and therapy.
For answers to many common questions about the Settlement, see our Frequently Asked Questions.
What Can Beneficiaries Do If They Were Denied Care Under the Improvement Standard?
The Jimmo settlement also establishes a process of "re-review" for Medicare beneficiaries who received a denial of skilled nursing facility care, home health care, or out-patient therapy services (physical therapy, occupational therapy, or speech therapy) that became final and non-appealable after January 18, 2011 because of the Improvement Standard.  You can access a request for re-review form here.  CMS discusses and links to the form here.
For people needing assistance with appeals, the Center for Medicare Advocacy has self-help materials available. This information can help individuals understand proper coverage rules and learn how to contest Medicare denials for outpatient, home health, or skilled nursing facility care.
Why the Jimmo Case Matters:


image

Why the Jimmo v. Sebelius Case Matters: Improvement S...
The Center for Medicare Advocacy, Inc., established in 1986, is a national nonprofit, nonpartisan organization that provides education, advocacy and legal assistanc...

Preview by Yahoo

 














NEW MEDICARE STANDARD FOR SKILLED CARE

posted Dec 20, 2013, 6:27 AM by Frank Baskin   [ updated Dec 20, 2013, 6:31 AM ]

Medicare has established a new standard for community and nursing home skilled care. Maintaining current level of care or preventing deterioration are now standards along.....PLEASE CLICK TITLE FOR MORE....with Improvement as a criteria. It is all effective as of 1/6/2014.See below for more information.

Medicare Policy to Ensure Coverage for Skilled Maintenance Care

The Centers for Medicare & Medicaid Services (CMS) published revisions to the Medicare Benefit Policy manual on December 6th to clarify that skilled care and skilled therapy can be covered for conditions that will not improve.  The revisions will become effective January 7, 2014 (marked in red in the following link http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R175BP.pdf).  These revisions are a direct result of the January 24, 2013 settlement of the Jimmo v. Sebelius case.

The revisions clarify Medicare’s longstanding policy that when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration.  The need to show improvement has been challenged for decades, and the Medicare revisions are a huge victory for people with Alzheimer’s disease, multiple sclerosis, Parkinson’s disease and other chronic conditions. 


Here’s what you can do:

CMS is starting an Education Campaign to ensure that Medicare determinations are based on the need for skilled care – not on the ability of an individual to improve. 


The Center for Medicare Advocacy (CMA) below provides additional details.


Improvement Standard Update: CMS Revises Medicare Policy to Ensure Coverage for Skilled Maintenance Care

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 Jimmo case ended a longstanding practice denying Medicare coverage to people who  had “plateaued,” or were “chronic,” or “stable,” or “not likely to improve.” 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 December 6, 2013. They pertain to care in Inpatient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF) [nursing home category], Home Health care (HH), and Outpatient Therapies (OPT). 

As CMS states in the Transmittal announcing the Jimmo Manual revisions: 

No “Improvement Standard” is to be applied in determining Medicare coverage for maintenance claims that require skilled care. Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition). The Medicare statute and regulations have never supported the imposition of an “Improvement Standard” rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient’s condition. Thus, such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves. The manual revisions now being issued will serve to reflect and articulate this basic principle more clearly. [Emphasis in original.]

Per the Jimmo Settlement, CMS will now implement an Education Campaign to ensure that Medicare determinations for SNF, Home Health, and Outpatient Therapy turn on the need for skilled care – not on the ability of an individual to improve. For IRF patients, the Manual revisions and CMS Education Campaign clarify that coverage should never be denied because a patient cannot be expected to achieve complete independence in self-care or to return to his/her prior level of functioning. 

As with components of all settlement agreements, the Jimmo revisions are not perfect,” says Judith Stein, Executive Director of the Center for Medicare Advocacy. “But they do make it absolutely clear that skilled care is covered by Medicare for therapy and nursing to maintain a patient’s condition or slow decline – not just for improvement.”

Plaintiffs in Jimmo vs. Sebelius are represented by the Center for Medicare Advocacy and Vermont Legal Aid.  Jimmo is a certified national class action lawsuit brought by individual Medicare beneficiaries and national organizations. It was formally settled by the Plaintiffs and Secretary Sebelius on January 24, 2013, when federal Judge Christina Reiss approved the settlement Agreement.

The CMS Transmittal for the Medicare Manual revisions, with a link to the revisions themselves, is posted on the CMS website.  The CMS MLN Matters article is also available on the CMS site under “Downloads.”


Retweet our Tweets about the Jimmo Medicare revisions and help spread the news.

For more details on the Improvement Standard and the Jimmo case, see: http://www.medicareadvocacy.org/medicare-info/improvement-standard/.



posted Dec 5, 2013, 11:19 AM by Frank Baskin   [ updated Dec 5, 2013, 11:26 AM ]

 

Anti-Psychotic Medication Use/Misuse

posted Nov 15, 2013, 7:20 AM by Frank Baskin   [ updated Nov 15, 2013, 7:26 AM ]


Misuse of Antipsychotic Drugs in Nursing Homes: Are We Making Any Progress?

The recent settlement of criminal and civil charges against Johnson & Johnson for off label....FOR MORE CLICK TITLE... 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 antipsychotic drugs in nursing facilities recently issued a joint Statement about the settlement.[1]  This Alert discusses the Johnson & Johnson settlement and three additional developments that are troubling to advocates who describe the misuse of antipsychotic drugs as a form of elder abuse.  These developments are:

  • Recent data from the Centers for Medicare & Medicaid Services (CMS) indicating that nursing facilities have fallen far short of the goal set in July 2012 for reducing the inappropriate use of antipsychotic drugs;
  • The Inspector General's cancellation (as a result of sequestration) of a study of antipsychotic drug use in nursing homes; and
  • CMS' decision not to require that consultant pharmacists (required by the federal Nursing Home Reform Law) be independent of long-term care pharmacies and pharmaceutical manufacturers.

Background

The misuse and overuse of antipsychotic drugs in nursing homes have been recognized as serious problems for many decades.[2]   In December 2007, Lucette Lagnado brought attention to atypical antipsychotic drugs in her Wall Street Journal article "Prescription Abuse Seen In U.S. Nursing Homes; Powerful Antipsychotics Used to Subdue Elderly; Huge Medicaid Expense."[3]  Lagnado reported that the drugs, while intended for only a small portion of the population, were often used instead as a substitute for adequate nurse staffing levels.  The Office of Inspector General analyzed the use of atypical antipsychotic drugs in nursing facilities and found in 2011 that more than 90% of the atypical antipsychotic drug use violated one or more federal laws (i.e., is prescribed off-label or is otherwise illegal).[4]

Johnson & Johnson Settlement


On November 4, 2013, the U.S. Department of Justice announced that Johnson & Johnson, in a global settlement, had agreed to pay more than $2.2 billion dollars to resolve criminal and civil charges involving the misuse of antipsychotic drugs.  Johnson & Johnson was alleged to have engaged in off-label marketing of the atypical antipsychotic drug Risperdal for nursing home residents who have dementia, but no diagnosis of psychosis, and to have paid kickbacks to physicians and pharmacists to prescribe Risperdal.[5] 

A criminal information, to which a Johnson & Johnson wholly-owned subsidiary pleaded guilty, charged the company with directing its ElderCare sales force, from May 1, 1998 through November 2005, to market Risperdal for use with nursing home residents who had dementia.[6]  Marketing materials emphasized use of the drug to treat symptoms, despite the Food and Drug Administration's (FDA) approval of Risperdal solely for patients with a diagnosis of schizophrenia and the FDA's Black Box warnings for both atypical and conventional antipsychotic drugs (warning that antipsychotic drugs may cause the death of older people with dementia).

A related civil complaint charged the company with providing false and misleading information about Risperdal and paying kickbacks to physicians to prescribe the drug.  The civil settlement also resolved allegations made in a separate 2010 lawsuit that Johnson & Johnson paid kickbacks to Omnicare, the largest pharmacy company in the country serving nursing homes, "under the guise of market share rebate payments, data-purchase agreements, 'grants' and 'educational funding'" and that Omnicare treated its consultant pharmacists as part of its sales force to promote off-label use of Risperdal.

On November 4, 2013, The New York Times reported that Risperdal was among Johnson & Johnson's top-selling drugs, accounting for $3.1 billion in sales (and 5% of the company's revenues) in 2004.[7]  In the past five years, the Times reported, other drug companies have settled similar cases with the Federal Government for marketing antipsychotic drugs for nursing home residents – Eli Lilly (Zyprexa) and AstraZeneca (Seroquel).[8]

The Wall Street Journal reported that in 2011, Medicare Part D (Medicare's prescription drug program) spent $7.68 billion on antipsychotic drugs (not all for nursing home residents and not including Medicare Part A spending for residents), an increase from $4.5 billion in 2007.[9]


Partnership to Improve Dementia Care Goal Not Met

In March 2012, the Centers for Medicare & Medicaid Services initiated a campaign (with nursing facilities, ombudsman programs, Quality Improvement Organizations, and others) to reduce the misuse of antipsychotic drugs in nursing homes.  As part of its Partnership to Improve Dementia Care in Nursing Homes, CMS set a goal of reducing antipsychotic drug use for long-stay residents by 15% by the end of calendar year 2012.[10]  The 15% reduction meant that the rate of antipsychotic drug use would be reduced from 23.9% in July 2012 to 20.2% by the end of 2012.[11] 

When the goal was not reached in 2012, CMS continued the goal for calendar year 2013.  As reported by The Wall Street Journal, the decline from 23.9% to 21.7% (as of March 31, 2013) represented only a 9% decrease in the use of antipsychotic drugs.[12]  More recently, CMS reported in October 2013 that, as of June 30, 2013, the antipsychotic drug rate for long-stay residents was 21.14%, still far above the initial goal that CMS set for December 2012.  The 21.14% rate means that more than one-in-five residents nationwide – more than 300,000 people – continue to be given antipsychotic drugs. 

Inspector General's Cancellation of Audit

In its Fiscal Year 2013 Work Plan, the Office of the Inspector General (OIG), Department of Health and Human Services, described a proposed study of nursing homes' use of antipsychotic drugs – specifically, "nursing homes' administration of atypical antipsychotic drugs, including the percentage of residents receiving these drugs and the types of drugs most commonly received" and a description of "the characteristics associated with nursing homes that frequently administer atypical antipsychotic drugs."[13]However, in July 2013, the Center for Public Integrity reported that, as a result of sequestration and the loss of 20% of its workforce, OIG cancelled the antipsychotic drug project, among others.[14]

CMS' Decision Not to Require the Independence of Consultant Pharmacists

The federal Nursing Home Reform Law requires facilities to employ or obtain the services of a consultant pharmacist to review each resident's entire drug regimen monthly and to make recommendations to the attending physician.[15]  The Reform Law also requires the attending physician to respond to the consultant pharmacist's recommendations.[16] 

Describing the role of consultant pharmacists, CMS reports that physicians adopt the recommendations of consultant pharmacists in 74% of cases, and that long-term care pharmacies often provide consultant pharmacist services as part of their contracts with facilities, often at cost and below fair market value.[17]  Accordingly, CMS indicated in the Federal Register in October 2011 that it was considering requiring that consultant pharmacists be independent of long-term care pharmacies and pharmaceutical manufacturers.[18]

Although CMS reported receiving overwhelming evidence from commenters that conflict-of-interest problems are pervasive and serious, and concluded that changes were necessary to assure the independence of consultant pharmacists, CMS did not act on its proposed recommendation.[19]  Instead, it stated that requiring independent consultant pharmacists would not solve the entire problem of the misuse of antipsychotic drugs and would be "significantly disruptive for much of the LTC industry."[20]  CMS declined to publish rules requiring the independence of consultant pharmacists and called on the long-term care industry, voluntarily, to adopt changes, but warned, "[s]hould marked improvement in inappropriate utilization not occur, we will use future notice and comment rulemaking to propose requirements to address these concerns."[21]

Conclusion

Inappropriate use of antipsychotic drugs by nursing facilities remains a significant problem.  While this misuse is slowly declining, CMS must do more to protect the more than 300,000 residents who are given these drugs.  The failure to act more aggressively risks the life and health of nursing facility residents and adds to the spiraling cost of nursing home care.

For more information, contact attorney Toby S. Edelman (tedelman@medicareadvocacy.org) in the Center for Medicare Advocacy's Washington, DC office at (202) 293-5760.


[1] See Statement at http://www.medicareadvocacy.org/2-2-billion-johnson-johnson-settlement-sends-new-warning-antipsychotic-drugs-should-not-be-used-to-treat-dementia/.
[2] See Center for Medicare Advocacy (the Center), "Antipsychotic Drugs," http://www.medicareadvocacy.org/medicare-info/skilled-nursing-facility-snf-services/antipsychotic-drugs/.  In addition, the Center recently completed, with Dean Lerner Consulting, a study of antipsychotic drug deficiencies in seven states, finding that 95% of antipsychotic drug deficiencies are cited as causing "no harm" to residents.  Additional findings of this study will be reported in a future Weekly Alert.
[3] http://online.wsj.com/news/articles/SB119672919018312521.
[4] OIG, Medicare Atypical antipsychotic Drug Claims for Elderly Nursing Home Residents, OEI-07-08-00150 (May 2011), http://oig.hhs.gov/oei/reports/oei-07-08-00150.pdf.
[5] U.S. Department of Justice, "Johnson & Johnson to Pay More Than $2.2 Billion to Resolve Criminal and Civil Investigations," (News Release, Nov. 4, 2013), http://www.justice.gov/opa/pr/2013/November/13-ag-1170.html.
[6] http://www.justice.gov/opa/documents/jj/janssen-info.pdf.
[7] Katie Thomas, "J.&J. to Pay $2.2 Billion in Risperdal Settlement," The New York Times (Nov. 4, 2013), http://www.nytimes.com/2013/11/05/business/johnson-johnson-to-settle-risperdal-improper-marketing-case.html?_r=0
[8] Ibid.
[9] Lucette Lagnado, "Nursing Homes’ Drug Use Falls; Effort to reduce use of antipsychotic drugs falls short of goal," The Wall Street Journal (Aug. 27, 2013), http://www.lucettelagnado.com/news/nursing-homes-drug-use-falls.
[10] CMS, Description of Antipsychotic Medication Quality Measures on Nursing Home Compare, http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/AntipsychoticMedicationQM.pdf.
[11] In announcing the goal, CMS stressed that the 15% reduction was just a beginning:  "The initial target for the national partnership was to ensure that we made rapid progress and put systems and infrastructure in place to continue to work toward lower antipsychotic medication use. It does not mean that we believe that a rate of 20.3% is acceptable. We will set 2013 goals with our partners toward the end of 2012."  Description of Antipsychotic Medication Quality Measures on Nursing Home Compare, http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/AntipsychoticMedicationQM.pdf.
[12] Lucette Lagnado, "Nursing Homes’ Drug Use Falls; Effort to reduce use of antipsychotic drugs falls short of goal," The Wall Street Journal (Aug. 27, 2013), http://www.lucettelagnado.com/news/nursing-homes-drug-use-falls.
[13] HHS Office of Inspector General, HHS OIG Work Plan FY 2013, https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf .
[14] The Center for Public Integrity, Fred Schulte, "ObamaCare oversight among health watchdog cuts; Budget squeeze, staff departures force HHS inspector general to trim investigative targets" (July 25, 2013), http://www.publicintegrity.org/2013/07/25/13048/obamacare-oversight-among-health-watchdog-cuts.   See also Fred Schulte, "Advocates for nursing home reform push back against proposed health watchdog cuts; Groups alarmed by IG’s plans to scrap audit of how drugs are prescribed for patients" (Aug. 1, 2013), http://www.publicintegrity.org/2013/08/01/13091/advocates-nursing-home-reform-push-back-against-proposed-health-watchdog-cuts
[15] 42 C.F.R. §483.60(c).
[16] Ibid.
[17] 76 Fed. Reg. 63017, 63038-63041 (Oct. 11, 2011), http://www.gpo.gov/fdsys/pkg/FR-2011-10-11/pdf/2011-25844.pdf.
[18] Ibid.
[19] 77 Fed. Reg. 22071, at 22110-22107 (Apr. 12, 2012), http://www.gpo.gov/fdsys/pkg/FR-2012-04-12/pdf/2012-8071.pdf.
[20] 77 Fed. Reg., 22106.
[21] 77 Fed. Reg., 22106.


You may remove your address from our mailing lists at any time. If you would like an address corrected, or would like to add an address, please contact Matthew Shepard.  If you would like to receive a text-only version of this alert, please reply to this message with the subject "text only".

Matthew E. Shepard
Communications Coordinator
Center for Medicare Advocacy, Inc.
PO Box 350
Willimantic, CT 06226
mshepard@medicareadvocacy.org
(860) 456-7790 (860) 456-2614 (fax)


The information in this electronic communication is intended only for the use of the individual(s) or entity named above, and may be legally privileged and confidential under applicable law. If the recipient of this message is not the above-named intended recipient(s), you are hereby notified that any dissemination, copy or disclosure of this communication is strictly prohibited. If you have received this communication in error, please notify the sender above and purge the communication immediately without making any copy or distribution.

Copyright © The Center for Medicare Advocacy, Inc. www.medicareadvocacy.org    

empowered by Salsa



--

Nicci Meadow, J.D. 
Director 
Elder Services
abcd_logo
Action for Boston Community Development, Inc.
Office Address: 2 Boylston St. 2nd Fl., #208 
Boston, MA 02111-1093

Mailing Address:
178 Tremont Street,
 Boston, MA  02116-4737

Phone: (617) 348-6340

nicci.meadow@bostonabcd.org

http://bostonabcd.org


Celebrating 50 Years of Helping People out of Poverty
Support our Programs by making a secure online donation or volunteering.

Follow us:   twitter  facebook  youtube_logo

--
--
You received this message because you are subscribed to the Google
Groups "MEAC" group.
To post to this group, send email to meac@bostonabcd.org
To unsubscribe from this group, send email to
meac+unsubscribe@bostonabcd.org
For more options, visit this group at
http://groups.google.com/a/bostonabcd.org/group/meac?hl=en
 
Please ensure that you are not sending any confidential client information with your message!
 
To unsubscribe from this group and stop receiving emails from it, send an email to meac+unsubscribe@bostonabcd.org.
Gerhard, Wynn
To Arlene GermainDobak, KarenMe and 1 More...
Today at 9:32 AM

 

 

Wynn A. Gerhard

Senior Attorney

617 603-1577

Elder, Health and Disability Unit

Greater Boston Legal Services

 














Description: Description: cid:image001.png@01CD2D35.0C68E510Description: Description: cid:image002.png@01CD2D35.0C68E510Description: Description: cid:image003.jpg@01CD2D35.0C68E510

CREDO action


Sign the petition ►
We demand Medicare for All.


Sign the petition ►


FB
Tw









HEALTH CARE LAW MARKETPLACES

posted Jul 31, 2013, 6:12 AM by Frank Baskin   [ updated Jul 31, 2013, 6:19 AM ]

Each state will set up market places where consumers can purchase health insurance as required by federal law. Below is a Q & A by Kaiser Health ...FOR MORE CLICK TITLE...News about this new system.

Benefits On Health Marketplace Plans Will Be Similar But Costs Will Vary

By Michelle Andrews | Kaiser Health News, Tuesday, July 30.
As the state health insurance marketplaces, also called exchanges, get set to launch in October, many people have questions about the coverage that will be offered there. Here are a few that were posed to me recently.

Q. Are there unintended consequences of shopping through an exchange? For example, are the benefits of a plan with a lower monthly premium less comprehensive than the benefits of an expensive plan? And are there plans available only to people who qualify for subsidies, so that once income increases, the consumer must switch to a different plan?

A. All plans sold on the exchanges must cover 10 so-called essential health benefits, including prescription drugs, emergency and hospital care, and maternity and newborn care.

For the most part, the plans will differ not in which benefits they cover but in the proportion of costs that consumers will be responsible for paying.

There will be four basic types of plans: Platinum plans will pay 90 percent of the cost of covered medical services, on average, while consumers will be responsible for 10 percent; gold plans will pay 80 percent; silver plans will pay 70 percent; and bronze plans, 60 percent. Premiums will vary based on those percentages, so platinum plans generally will be pricier than bronze ones.

Individuals and families with incomes up to 400 percent of the federal poverty level ($45,960 for an individual and $94,200 for a family of four in 2013) may be eligible for federal tax credits to help pay premiums.

Consumers “can use the premium subsidy to purchase any plan,” says Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities.

If your income increases during the year, you may no longer qualify for the same level of assistance, but you won't have to switch plans. However, you may have to repay any overpayments that were made to insurers if your projected income turns out to be higher than your actual income. On the other hand, if your income falls, you may be eligible for a larger tax credit. That's why it's important to report any income changes to the exchange promptly.

second type of subsidy available on the exchanges will reduce the amount that people owe in co-payments, deductibles and other out-of-pocket costs. The cost-sharing subsidy is available to individuals and families with incomes up to 250 percent of the poverty level ($28,725 for an individual and $58,875 for a family of four in 2013). To qualify for this subsidy, you must buy a silver plan, Park says. If your income changes, however, you won't be responsible for any overpayments.

Q. Once the exchanges open, how much will an insurer be allowed to increase premiums annually? And are those increases based on claims?

A. Premium increases are driven by many factors, including medical costs and the health of the people covered by a particular plan.

The Affordable Care Act discourages insurers from imposing unreasonable premium increases in a couple of ways. Insurers in the small-group and individual markets that want to raise premiums by 10 percent or more must submit data, projections and other information to justify the increase to state or federal regulators, who review the requests and make the information available to the public. Asking insurers to justify why they want to increase rates should act as a deterrent to unreasonable increases, experts say.

But the law doesn't give regulators new authority to refuse rate increases, says Timothy Jost, a law professor at Washington and Lee University in Lexington, Va. It does, however, provide funding for states to beef up their rate-review processes.

The Department of Health and Human Services says that increased scrutiny of insurance rates has led to a decrease in rate increases, says Jost, “and that's probably true.”

In addition, the law requires insurers to spend at least 80 percent of the money they collect in premiums on medical claims and quality improvements rather than on administrative activities such as marketing. If they exceed that limit, they must rebate the excess to consumers. Insurers will return $500 million to 8.5 million consumers -- about $100 per eligible family -- by mid-August of this year for overcharges in 2012, according to the Obama administration. Rebates may come in various ways, including a check or a reduction in the following year's premium.

Q. My parents are legal immigrants over 65 but not yet eligible to buy into Medicare because they haven't lived in the United States for five years. Will they be able to buy health insurance on the federal exchange?

A. Yes, legal immigrants will be able to shop for coverage on the exchanges, where they may be eligible for premium tax credits if their income is no more than 400 percent of the federal poverty level ($62,040 for a couple in 2013). Immigrants living in the United States without legal permission, on the other hand, are not permitted to buy coverage on the exchanges even if they wish to pay the entire premium out of pocket.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

 

Hospital Observation Status and CMS

posted May 1, 2013, 8:15 AM by Frank Baskin   [ updated May 15, 2015, 5:53 AM ]

CMS Invites Public Comment on Observation Status

As part of a notice of proposed rulemaking published in the Federal RegisAs part ter on March 18, 2013 CMS is ....FOR MORE CLICK TITLE... for public comments on potential policy changes related to observation status. This Alert describes observation status, CMS's discussion in the Federal Register, a discussion of the comments that NAPGCM will submit, and information about how to submit comments to CMS.

Observation Status

Observation status refers to the classification of a patient in an acute care hospital as an outpatient, even though, just like an inpatient, the person is placed in a bed in the hospital, stays overnight, and receives medically necessary nursing, medical care, diagnostic tests, treatments, therapy, prescription and over-the-counter medications, and food. Until now, classification as an outpatient may make a patient ineligible for Medicare coverage of subsequent skilled nursing facility (SNF) care because the Medicare statute requires three days of inpatient status (not counting the day of discharge) as a precondition to Medicare coverage of care in a SNF.

Proposed Rules

In July 2012, CMS asked for public comment on various approaches to revising CMS policy on observation status, but failed to adopt changes in the final rule. The proposed rule described CMS's Part A to Part B Rebilling Demonstration, which allowed hospitals to rebill Part B after a Part A inpatient stay was denied.

In the March 18th, 2013 rule, CMS notes “ongoing concern about recent increases in the length of time that Medicare beneficiaries spend as hospital outpatients receiving observation services.” CMS proposed the above change – allowing hospitals to rebill Part B when Part A is denied. CMS limited hospitals’ rebilling option, requiring that the Part B claim be filed within 12 months of the date of hospital service. The proposed rules allow hospitals that originally filed a Part A inpatient claim, using a “self-audit” procedure and also within the one-year period, to withdraw the Part A claim and rebill Medicare for medically necessary inpatient claims under Part B. Unfortunately, this approach does not help beneficiaries in outpatient observation status.

As an interim measure, and until it publishes final rules, CMS issued a Ruling, CMS-1455-R, effective March 18, that authorizes hospitals to bill Part B after a Part A claim is denied, even when the hospital services were provided more than one year earlier. In this regard, CMS is "adopting," but not endorsing, the decisions of ALJs and the Medicare Appeals Council. CMS reports that thousands of pending appeals are subject to this Ruling. Noting that hospitals cannot change a patient’s status after the patient is discharged from the hospital, CMS reports that under the Ruling, “The beneficiary is considered an outpatient for services billed on the Part B outpatient claim, and is considered an inpatient for services billed on the Part B inpatient claim.” CMS has terminated the Part A to Part B Rebilling Demonstration.

SUMMARY AND CONCLUSIONS

The proposed rules continue uncertainty for Medicare hospital patients about their status. A patient may be classified as a hospital inpatient and go to a SNF for rehabilitation, all payable under Part A. Then, up to one year from the date of service in the hospital, a Medicare contractor may reject the Part A claim or the hospital, using self-audit, may decide to withdraw its Part A claim for reimbursement and submit a Part B inpatient claim instead. At that point, the patient receives a refund of the Part A inpatient deductible and must pay the Part B co-payments and medication charges.
CMS acknowledges in its rule, “some beneficiaries who are entitled to coverage under both Part A and Part B may have a greater financial liability for hospital services compared to current policy, as they would be liable for additional Part B services billed when the inpatient admission is determined not reasonable and necessary.” CMS does not discuss what happens to the Part A-covered SNF claim when the hospital withdraws the qualifying three-day inpatient stay.

Action Step:

Please support changes in your letter to CMS about observation status that are embodied in the bipartisan legislation pending in Congress, the "Improving Access to Medicare Coverage Act of 2013. Please DO NOT support the approach outlined by CMS which creates more uncertainty and financial exposure for beneficiaries.

.

How to submit comments

Submit comments asking CMS to repeal the current observation status policy and indicating concern with the new, proposed approach. People who submit comments to CMS about their experiences with observation status should identify the state where they live and any relevant anecdotal details about clients such as the circumstances of a beneficiary's hospitalization, the length of time the person remained in the hospital, and the cost and duration of the subsequent SNF stay. If you have other experiences with observation status, please share those as well with CMS.

Comments must be received by CMS no later than 5:00 p.m. EST on May 17, 2013.

In submitting comments, it is important to refer to file code CMS-1455-P.

CMS authorizes the following ways to submit comments:

  • By regular mail. Mail written comments to

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1455-P
P.O. Box 8013
Baltimore, MD 21244-1850

President's 2014 Budget/Medicare and Social Security

posted Apr 10, 2013, 8:57 AM by Frank Baskin   [ updated Nov 18, 2013, 12:26 PM ]

The President is proposing a budget which will impact Medicare and Social Security. Medicare A and B may be combined and Social Security would .be determined ..CLICK TITLE FOR MORE...  on a new formula.
Social Security The Chained CPI would reduce the amount which reciepients receive each year.:For many older Americans, Social Security is their primary source of income.  Based on the sequester, funding for congregate meals and "Meals on Wheels" has been cut.  Should we now cut their Social Security benefits because they are now buying generic corn flakes rather than chicken to prepare for their meals???
 
Social Security benefits are paid from the trust fund created by the FICA taxes paid by workers.  The only impact that Social Security can have on the federal deficit is that the trust funds are invested in government bonds--and obviously if the bonds are redeemed, then the federal deficit would increase.  There is no immediate need to consider redeeming any of these bonds--and if the cap ($113,700 in 2013) on FICA taxes were to be increased or eliminated, there would be no need to consider this in the foreseeable future. The following shows how social security benefits would decrease over time:
Over 5 years, the loss would be 4.9%
Over 10 years, the loss would be 19.6%
Over 15 years, the loss would be 47%
Over 20 years, the loss would be 90.7%
Over 25 years, the loss would be 155%
 
The percentages were calculated by comparing the loss over that period to the base benefit amount(Note - Thanks to Regina Curren for this calculation).
 Medicare - In the President's proposal Medicare A(Hospital and nursing home insurance) and Medicare B(out-patient benefits) premiums would be combined. This would increase the monies beneficiaries have to spend for health care.
 
 

CLASS ACT(LONG TERM CARE INSURANCE)

posted Jan 7, 2013, 12:33 PM by Frank Baskin   [ updated Jan 9, 2013, 8:26 AM ]

The President and Congress dealt with the fiscal cliff on 1/1. In the process they took the CLASS act out of the budget and.the....FOR MORE CLICK TITLE...   ACA .Had it been maintained it would have provided an opportunity for anyone to buy into long term care insurance(home care, assisted living, nursing home care). There were no age or financial requirements but there would be a monthluy premium. There will be a study commission consisting of  members appointed by leaders of the House and the Senate along wiith the President.

MEDICARE AND SKILLED CARE

posted Oct 25, 2012, 6:14 AM by Frank Baskin   [ updated Oct 25, 2012, 6:17 AM ]

CMS(Center for Medicare and Medicaid Services) has agreed to change its eligibility rules for those who need skilled nursing home and also in-home and ...CLICK TITLE FOR MORE.... outpatient care. Individuals will no longer have to show that they are improving in order to receive skilled care(in a nursing home or in the commnity).
 
Read the following:
 

Under the agreement, which amounts to a significant change in Medicare coverage rules, Medicare will pay for such services if they are needed to “maintain the patient’s current condition or prevent or slow further deterioration,” regardless of whether the patient’s condition is expected to improve.

Federal officials agreed to rewrite the Medicare manual to make clear that Medicare coverage of nursing and therapy services “does not turn on the presence or absence of an individual’s potential for improvement,” but is based on the beneficiary’s need for skilled care.

This agreement was based on a class action law suit which was brought against the Federal government.
Look for  more information later about specifics and implementation date.
 
Clearly, some  residents will be able to stay longer in their Medicare A bed. This does not impact the maximum number of days allowed on one stay. Others will be able to continue their community based rehab services.
It will cost the Federal government additional dollars tho there may be some savings if services prevent admission to a nursing home or keep someone out longer.
 

MEDICARE/HOSPITAL OBSERVATION DAYS

posted Aug 29, 2012, 12:10 PM by Frank Baskin   [ updated Nov 18, 2013, 12:24 PM ]

Following is information about a bill in Congress which would address the hosptial "observation day" issue. Some individuals may go to a hospital for several days.....FOR MORE CLICK TITLE...  or longer and not be admitted. They are on "observation status". If they are sent to a nursing home those "observation days " do not count as hosptial days and so Medicare will not pay for their nursing home admission. the individual and he family are left with a very large bill which they did not expect.
Sen. John Kerry and Rep. Joe Courtney recently introduced the Improving Access to Medicare Coverage Act (S. 818) in the U.S. Senate and H.R. 1543 in the U.S. House of Representatives.

The bill would specify that a Medicare beneficiary hospitalized under observation for more than 24 hours would be deemed to have been an inpatient and would be considered to have been discharged upon leaving the hospital. Under these circumstances, the beneficiary would be eligible for Medicare Part A coverage of post-acute care.

Contact your legislators and urge them to cosponsor the corrective legislation.

1-10 of 76