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Breaking Federal News
JIMMO STANDARD NOT BEING IMPLEMENTED
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 appealSkilled 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:
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NEW MEDICARE STANDARD FOR SKILLED CARE
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 CareThe 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. 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 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/.
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Anti-Psychotic Medication Use/Misuse
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:
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
Nicci Meadow, J.D. 178 Tremont Street, Boston, MA 02116-4737
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Wynn A. Gerhard Senior Attorney 617 603-1577 Elder, Health and Disability Unit Greater Boston Legal Services
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HEALTH CARE LAW MARKETPLACES
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 VaryBy Michelle Andrews | Kaiser Health News, Tuesday, July 30.
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Hospital Observation Status and CMS
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:
Centers for Medicare & Medicaid Services |
President's 2014 Budget/Medicare and Social Security
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.
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CLASS ACT(LONG TERM CARE INSURANCE)
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
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.
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MEDICARE/HOSPITAL OBSERVATION DAYS
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. |