All posts by Angela Scott

CMA Alert – February 14, 2019

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  1. 6th Annual National Voices of Medicare Summit Welcomes Congressman John Lewis as the 2019 Sen. Jay Rockefeller Lecturer – Register Now
  2. Improve and Expand Medicare: CMS Should Provide Objective Information About Medicare Options
  3. Practice Tip: Office of Medicare Hearings and Appeals Manual Can Be a Useful Tool 
  4. There’s Nothing Special About How CMS Treats Special Focus Nursing Facilities

6th Annual National Voices of Medicare Summit Welcomes Congressman John Lewis as the 2019 Sen. Jay Rockefeller Lecturer – Register Now

Rep. John Lewis

2019 Sen. Jay Rockefeller Lecturer, Rep. John Lewis.

Health Care is a Human Right:
Medicare’s Role in Making it a Reality
(Past, Present, Future)

Support the Center for Medicare Advocacy! Join us for our 6th annual National Voices of Medicare Summit and Senator Jay Rockefeller Lecture. This year’s program will connect leading experts and advocates to discuss access to health care as a human right, the challenges and successes of Medicare, and where we can go moving forward.

Congressman John Lewis
will deliver this year’s
Sen. Jay Rockefeller Lecture

Rep. Lewis will then be joined by Sen. Rockefeller and others for a panel discussion.


Join Us For This Historic Program!

May 9, 2019 8:30 AM – 3:30 PM, EDT​
Kaiser Family Foundation
1330 G. Street, NW Washington, DC

Early-Bird Registration, through March 15, 2019: $200.00
Individual registration thereafter: $225.00

You won’t want to miss this Incredible day!
Space is limited. Register now.


Sponsorship and advertising opportunities are also available via the registration page or by contacting Scott Perkins, Development Director, at sperkins@medicareadvocacy.org or (202) 293-5760.


As in prior years, the Center has reserved a block of rooms at the Washington Marriott at Metro Center, just a few minutes walk from the venue. These rooms will only be held through April 18, 2019, so reserve yours now at https://aws.passkey.com/e/49829939.


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Improve and Expand Medicare: CMS Should Provide Objective Information About Medicare Options

Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations to improve Medicare for all beneficiaries, now and in the future, is the need to preserve and expand consumer protections and quality coverage for all Medicare Beneficiaries – including parity between traditional Medicare and private Medicare Advantage (MA) plans. We previously wrote about limited access to Medigap policies, oral health care, lack of an out-of-pocket cap on beneficiary expenses in traditional Medicare, and the need for comprehensive long-term services and supports (LTSS, also known as long term care).  Last week, we discussed the ongoing payment imbalance between traditional Medicare and MA.

Another critical parity issue between traditional Medicare and MA plans is the manner in which Medicare options are presented to the public by the agency charged with running the Medicare program, the Centers for Medicare & Medicaid Services. As the Center has documented elsewhere, since Fall of 2017 CMS’ outreach and enrollment materials have encouraged beneficiaries to choose a private Medicare plan over traditional Medicare, instead of objectively presenting enrollment options. Rather than presenting differences between traditional Medicare and MA in a neutral, unbiased manner, CMS is overplaying the pluses of MA and downplaying any minuses in a manner that is highly misleading, at best. Our concerns include certain revisions to Medicare & You, online comparison tools, and education and outreach materials, including an enrollment period email campaign that downplayed or entirely left out the option of traditional Medicare altogether.

As noted in a December 2018 New York Times article by Robert Pear, MA plans have been getting “an unpublicized boost from the Trump administration, which [during the Fall enrollment period] extolled the virtues of the private plans in emails sent to millions of beneficiaries.” According to the article, a former chief actuary of CMS “said the emails sounded ‘more like Medicare Advantage plan advertising than objective information from a public agency.’”

CMS leadership has repeatedly denied that they are favoring private plans or steering Medicare beneficiaries towards enrolling in such plans, however actual experience and recently released materials from CMS suggest otherwise.

At a February 8, 2019 meeting of CMS’ National Medicare Education Program (NMEP), the agency released information about the 2018 Annual Coordinated Election Period (ACEP), sometimes referred to as “Open Enrollment” or “OP.” (Note: this is a downloadable “zip” file containing several items. See, in particular, the Powerpoint slide presentation entitled “Medicare OEP Outreach”). According to CMS, in 2018 it “tested targeted messaging to determine if we could have an impact on overall awareness and knowledge of Medicare Advantage among a limited set of People with Medicare.” (Slide 2)

CMS engaged in a “General Medicare Open Enrollment Email Outreach” campaign that went to approximately 7 million unique email subscribers nationwide. It consisted of 12 general Open Enrollment email bulletins that included messaging focused on deadline reminders and promoting eMedicare tools to compare plans and estimate costs. (Slide 11) While the Center’s analysis of this material showed that it downplayed or left out the option of traditional Medicare altogether, and could be interpreted by recipients to imply that they had no choice but to enroll in or stay in a private plan, CMS has engaged in even more blatant favoring of the MA program.

In addition to the general open enrollment campaign in the Fall of 2018, CMS engaged in targeted messaging through eight Medicare Advantage specific emails sent to approximately 1.2 million individuals in eight states with messaging that “[e]mphasized extra benefits of MA Plans and promoted Medicare Plan Finder tool to compare all options.” (Slide 12) This targeted messaging that emphasized MA included the following:

  • “With Medicare Advantage, you can choose the coverage that’s right for you. Pick from a variety of plans to get the benefits that matter to you.
  • Get more benefits for your money. Medicare Advantage plans include extra benefits like hearing, vision, and dental coverage.
  • 4 out of 5 people pay a premium of less than $50 per month for their Medicare Advantage health and prescription drug plan.” (Slide 10)

By changing the tenor of its general outreach materials, and particularly with its targeted MA campaign, CMS is abdicating its duty to provide objective, balanced information about Medicare coverage options. Instead of continuing to tip the scales in favor of the Medicare Advantage program, we urge policymakers to advance complete equity between MA and traditional Medicare, including both the scope of services provided, programmatic spending, and CMS education and outreach.  Congress should oversee CMS’ activities regarding Medicare Advantage to ensure the information it provides is complete and accurate, and to ensure all Medicare beneficiaries are treated equally.

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Practice Tip: Office of Medicare Hearings and Appeals Manual Can Be a Useful Tool 

The Office of Medicare Hearings and Appeals (OMHA) is the agency that administers the Administrative Law Judge (ALJ) hearing program for Medicare Parts A, B, C and D appeals. OMHA has a Case Processing Manual that sets out day-to-day procedures for carrying out adjudicative functions, in accordance with applicable statutes, regulations, and OMHA directives. Importantly for many, it gives the staff at OMHA direction for processing ALJ appeal requests.

Most recently, on February 1, 2019, OMHA released the revised Chapter 9 that addresses “Request and Correspondence Intake, Docketing, and Assignment.” (See: https://www.hhs.gov/sites/default/files/request-and-correspondence-intake-docketing-and-assignment-02-01-2019.pdf).

The Case Processing Manual can help answer questions not otherwise found in applicable statutes, regulations or Centers for Medicare & Medicaid Services (CMS) Policy Manuals. For example, we recently had an inquiry from a beneficiary asking how to consolidate two separate appeals that dealt with two different services from two different providers, but with both services related to the same condition. Other than requesting aggregation to meet the amount in controversy requirement, which was not the issue in this case, we found no answer in the regulations or CMS Policy Manual. However the Case Processing Manual, provided some answers.  Chapter 9, section 9.3.6.2 discusses how to group appeals and appears to provide some guidance when an appellant requests that cases be consolidated prior to ALJ assignment.

The Case Processing Manual chapters also addresses, among other things, issues such as the role of representatives in the appeals process, case prioritization, the administrative record, and the scheduling and noticing for pre-hearing conferences and hearings. The Case Processing Manual is an excellent resource. New and revised chapters can be accessed at https://www.hhs.gov/about/agencies/omha/the-appeals-process/case-processing-manual/index.html. Chapters that were published before May 10, 2018, can be accessed at: https://www.hhs.gov/about/agencies/omha/the-appeals-process/case-processing-manual/2017/index.html.

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There’s Nothing Special About How CMS Treats Special Focus Nursing Facilities

In cooperation with states, the Centers for Medicare & Medicaid Services (CMS) regularly identifies a subset of nursing facilities, generally one to two facilities per state, that are among the most poorly performing facilities in the country. These nursing facilities, which CMS calls Special Focus Facilities (SFFs), have “more problems” than other facilities, “more serious problems” than other facilities, and “A pattern of serious problems that has persisted over a long period of time” (i.e., the prior three years).[1]

CMS requires states to conduct surveys at SFFs twice as often as at other facilities and to impose more stringent enforcement actions “the longer the problems persist.” Within 18-24 months of a facility’s designation as an SFF, CMS generally expects that the facility will either: improve and graduate; or be terminated from participating in the Medicare and Medicaid programs. Each month, CMS identifies five categories of SFFs: newly-designated SFFs, SFFs that have not improved, SFFs that have improved, SFFs that have graduated, and SFFs that are no longer participating in the federal payment programs.

As demonstrated below, CMS has not followed through on these requirements for SFFs.  CMS is not imposing serious enforcement actions against SFFs that it cites with actual harm or immediate jeopardy deficiencies, or both. To the contrary, CMS is not imposing any sanctions at all or is imposing only small financial penalties, averaging less than $20,000, against SFFs that it finds have not improved.

The Center for Medicare Advocacy’s Evaluation

On February 5-7, 2019, the Center looked at CMS’s most recent list (dated January 19, 2019) of 37 SFFs that CMS identified as not having improved. CMS had originally designated these facilities as SFFs between 5 and 30 months earlier. The Center looked at the federal website, Nursing Home Compare, to determine whether CMS imposed civil money penalties (CMPs) or denials of payment for new admissions (DPNAs), or both, against them.

Findings

The 37 SFFs that had not improved had few enforcement actions taken against them and these actions were limited:

  • 28 of the 37 SFFs were cited with actual harm or immediate jeopardy deficiencies in 2018.
  • 14 of the 28 SFFs that were cited with harm or jeopardy deficiencies, or both, in 2018 did not have CMPs or DPNAs imposed for deficiencies cited in 2018 (although CMPs had been imposed for deficiencies cited in earlier surveys).
  • Only 14 of the 28 SFFs that were cited with actual harm or jeopardy deficiencies, or both, in 2018 had either CMPs or DPNAs, or both, imposed against them.
    • Only 9 of the 28 SFFs that had not improved had CMPs imposed for actual harm or immediate jeopardy deficiencies that were cited in 2018. Only 1 CMP exceeded $100,000. The remaining 8 CMPs ranged from $10,400 to $53,089 and averaged $19,616.50. In all instances, the CMPs were considerably lower in 2018 than the CMPs imposed against these facilities in 2016 and 2017.
    • 3 of the 9 SFFs with CMPs also had DPNAs imposed against them.
    • 5 of the 28 SFFs had only DPNAs imposed against them. In 2016 or 2017, or both, these 5 SFFs had CMPs imposed against them.
  • 9 of the 37 SFFs were not cited with harm or jeopardy deficiencies in 2018.
    • 2 of these 9 SFFs had CMPs imposed.

Conclusion

The Center concludes that the Special Focus Facility Program is failing to achieve its goals of focusing additional attention and enforcement resources on nursing facilities with a history and record of extremely poor care. CMS is not imposing significant penalties against SFFs that have not improved, even when it cites them with actual harm and immediate jeopardy deficiencies.

The extraordinarily limited enforcement against even the most poorly performing nursing facilities in the country underscores how weak enforcement has become. CMS must change course and impose meaningful financial penalties against facilities that fail to provide residents with the care they need.

The Center’s full report, with charts describing the 28 SFFs that were cited with actual harm or immediate jeopardy deficiencies in 2018 and enforcement actions that CMS imposed against them in 2018 as well as in 2016 and 2017, is available at: https://www.medicareadvocacy.org/report-theres-nothing-special-about-how-cms-treats-special-focus-nursing-facilities/

 ______________

[1] CMS, “Special Focus Facility (“SFF”) Initiative,” https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/SFFList.pdf.

 top

Go to Source

Improve and Expand Medicare: CMS Should Provide Objective Information About Medicare Options

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Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations to improve Medicare for all beneficiaries, now and in the future, is the need to preserve and expand consumer protections and quality coverage for all Medicare Beneficiaries – including parity between traditional Medicare and private Medicare Advantage (MA) plans. We previously wrote about limited access to Medigap policies, oral health care, lack of an out-of-pocket cap on beneficiary expenses in traditional Medicare, and the need for comprehensive long-term services and supports (LTSS, also known as long term care).  Last week, we discussed the ongoing payment imbalance between traditional Medicare and MA.

Another critical parity issue between traditional Medicare and MA plans is the manner in which Medicare options are presented to the public by the agency charged with running the Medicare program, the Centers for Medicare & Medicaid Services. As the Center has documented elsewhere, since Fall of 2017 CMS’ outreach and enrollment materials have encouraged beneficiaries to choose a private Medicare plan over traditional Medicare, instead of objectively presenting enrollment options. Rather than presenting differences between traditional Medicare and MA in a neutral, unbiased manner, CMS is overplaying the pluses of MA and downplaying any minuses in a manner that is highly misleading, at best.  Our concerns include certain revisions to Medicare & You, online comparison tools, and education and outreach materials, including an enrollment period email campaign that downplayed or entirely left out the option of traditional Medicare altogether.

As noted in a December 2018 New York Times article by Robert Pear, MA plans have been getting “an unpublicized boost from the Trump administration, which [during the Fall enrollment period] extolled the virtues of the private plans in emails sent to millions of beneficiaries.” According to the article, a former chief actuary of CMS “said the emails sounded ‘more like Medicare Advantage plan advertising than objective information from a public agency.’”

CMS leadership has repeatedly denied that they are favoring private plans or steering Medicare beneficiaries towards enrolling in such plans, however actual experience and recently released materials from CMS suggest otherwise.

At a February 8, 2019 meeting of CMS’ National Medicare Education Program (NMEP), the agency released information about the 2018 Annual Coordinated Election Period (ACEP), sometimes referred to as “Open Enrollment” or “OP.” (Note: this is a downloadable “zip” file containing several items. See, in particular, the Powerpoint slide presentation entitled “Medicare OEP Outreach”). According to CMS, in 2018 it “tested targeted messaging to determine if we could have an impact on overall awareness and knowledge of Medicare Advantage among a limited set of People with Medicare.” (Slide 2)

CMS engaged in a “General Medicare Open Enrollment Email Outreach” campaign that went to approximately 7 million unique email subscribers nationwide. It consisted of 12 general Open Enrollment email bulletins that included messaging focused on deadline reminders and promoting eMedicare tools to compare plans and estimate costs. (Slide 11) While the Center’s analysis of this material showed that it downplayed or left out the option of traditional Medicare altogether, and could be interpreted by recipients to imply that they had no choice but to enroll in or stay in a private plan, CMS has engaged in even more blatant favoring of the MA program.

In addition to the general open enrollment campaign in the Fall of 2018, CMS engaged in targeted messaging through eight Medicare Advantage specific emails sent to approximately 1.2 million individuals in eight states with messaging that “[e]mphasized extra benefits of MA Plans and promoted Medicare Plan Finder tool to compare all options.” (Slide 12) This targeted messaging that emphasized MA included the following:

  • “With Medicare Advantage, you can choose the coverage that’s right for you. Pick from a variety of plans to get the benefits that matter to you.
  • Get more benefits for your money. Medicare Advantage plans include extra benefits like hearing, vision, and dental coverage.
  • 4 out of 5 people pay a premium of less than $50 per month for their Medicare Advantage health and prescription drug plan.” (Slide 10)

By changing the tenor of its general outreach materials, and particularly with its targeted MA campaign, CMS is abdicating its duty to provide objective, balanced information about Medicare coverage options. Instead of continuing to tip the scales in favor of the Medicare Advantage program, we urge policymakers to advance complete equity between MA and traditional Medicare, including both the scope of services provided, programmatic spending, and CMS education and outreach.  Congress should oversee CMS’ activities regarding Medicare Advantage to ensure the information it provides is complete and accurate, and to ensure all Medicare beneficiaries are treated equally.

February 2019 – D. Lipschutz

Go to Source

Practice Tip: Office of Medicare Hearings and Appeals Manual Can Be a Useful Tool

Print Friendly, PDF & Email

The Office of Medicare Hearings and Appeals (OMHA) is the agency that administers the Administrative Law Judge (ALJ) hearing program for Medicare Parts A, B, C and D appeals. OMHA has a Case Processing Manual that sets out day-to-day procedures for carrying out adjudicative functions, in accordance with applicable statutes, regulations, and OMHA directives. Importantly for many, it gives the staff at OMHA direction for processing ALJ appeal requests.

Most recently, on February 1, 2019, OMHA released the revised Chapter 9 that addresses “Request and Correspondence Intake, Docketing, and Assignment.” (See: https://www.hhs.gov/sites/default/files/request-and-correspondence-intake-docketing-and-assignment-02-01-2019.pdf).

The Case Processing Manual can help answer questions not otherwise found in applicable statutes, regulations or Centers for Medicare & Medicaid Services (CMS) Policy Manuals. For example, we recently had an inquiry from a beneficiary asking how to consolidate two separate appeals that dealt with two different services from two different providers, but with both services related to the same condition. Other than requesting aggregation to meet the amount in controversy requirement, which was not the issue in this case, we found no answer in the regulations or CMS Policy Manual. However the Case Processing Manual, provided some answers.  Chapter 9, section 9.3.6.2 discusses how to group appeals and appears to provide some guidance when an appellant requests that cases be consolidated prior to ALJ assignment. The Case Processing Manual chapters also addresses, among other things, issues such as the role of representatives in the appeals process, case prioritization, the administrative record, and the scheduling and noticing for pre-hearing conferences and hearings.

The Case Processing Manual is an excellent resource. New and revised chapters can be accessed at https://www.hhs.gov/about/agencies/omha/the-appeals-process/case-processing-manual/index.html. Chapters that were published before May 10, 2018, can be accessed at: https://www.hhs.gov/about/agencies/omha/the-appeals-process/case-processing-manual/2017/index.html.

February 14, 2019 – M. Ashkar

Go to Source

There’s Nothing Special About How CMS Treats Special Focus Nursing Facilities

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In cooperation with states, the Centers for Medicare & Medicaid Services (CMS) regularly identifies a subset of nursing facilities, generally one to two facilities per state, that are among the most poorly performing facilities in the country. These nursing facilities, which CMS calls Special Focus Facilities (SFFs), have “more problems” than other facilities, “more serious problems” than other facilities, and “A pattern of serious problems that has persisted over a long period of time” (i.e., the prior three years).[1]

CMS requires states to conduct surveys at SFFs twice as often as at other facilities and to impose more stringent enforcement actions “the longer the problems persist.” Within 18-24 months of a facility’s designation as an SFF, CMS generally expects that the facility will either: improve and graduate; or be terminated from participating in the Medicare and Medicaid programs. Each month, CMS identifies five categories of SFFs: newly-designated SFFs, SFFs that have not improved, SFFs that have improved, SFFs that have graduated, and SFFs that are no longer participating in the federal payment programs.

As demonstrated below, CMS has not followed through on these requirements for SFFs.  CMS is not imposing serious enforcement actions against SFFs that it cites with actual harm or immediate jeopardy deficiencies, or both. To the contrary, CMS is not imposing any sanctions at all or is imposing only small financial penalties, averaging less than $20,000, against SFFs that it finds have not improved.

The Center for Medicare Advocacy’s Evaluation

On February 5-7, 2019, the Center looked at CMS’s most recent list (dated January 19, 2019) of 37 SFFs that CMS identified as not having improved. CMS had originally designated these facilities as SFFs between 5 and 30 months earlier. The Center looked at the federal website, Nursing Home Compare, to determine whether CMS imposed civil money penalties (CMPs) or denials of payment for new admissions (DPNAs), or both, against them.

Findings

The 37 SFFs that had not improved had few enforcement actions taken against them and these actions were limited:

  • 28 of the 37 SFFs were cited with actual harm or immediate jeopardy deficiencies in 2018.
  • 14 of the 28 SFFs that were cited with harm or jeopardy deficiencies, or both, in 2018 did not have CMPs or DPNAs imposed for deficiencies cited in 2018 (although CMPs had been imposed for deficiencies cited in earlier surveys).
  • Only 14 of the 28 SFFs that were cited with actual harm or jeopardy deficiencies, or both, in 2018 had either CMPs or DPNAs, or both, imposed against them.
    • Only 9 of the 28 SFFs that had not improved had CMPs imposed for actual harm or immediate jeopardy deficiencies that were cited in 2018. Only 1 CMP exceeded $100,000. The remaining 8 CMPs ranged from $10,400 to $53,089 and averaged $19,616.50. In all instances, the CMPs were considerably lower in 2018 than the CMPs imposed against these facilities in 2016 and 2017.
    • 3 of the 9 SFFs with CMPs also had DPNAs imposed against them.
    • 5 of the 28 SFFs had only DPNAs imposed against them. In 2016 or 2017, or both, these 5 SFFs had CMPs imposed against them.
  • 9 of the 37 SFFs were not cited with harm or jeopardy deficiencies in 2018.
    • 2 of these 9 SFFs had CMPs imposed.

Conclusion

The Center concludes that the Special Focus Facility Program is failing to achieve its goals of focusing additional attention and enforcement resources on nursing facilities with a history and record of extremely poor care. CMS is not imposing significant penalties against SFFs that have not improved, even when it cites them with actual harm and immediate jeopardy deficiencies.

The extraordinarily limited enforcement against even the most poorly performing nursing facilities in the country underscores how weak enforcement has become. CMS must change course and impose meaningful financial penalties against facilities that fail to provide residents with the care they need.

The Center’s full report, with charts describing the 28 SFFs that were cited with actual harm or immediate jeopardy deficiencies in 2018 and enforcement actions that CMS imposed against them in 2018 as well as in 2016 and 2017, is available at: https://www.medicareadvocacy.org/report-theres-nothing-special-about-how-cms-treats-special-focus-nursing-facilities/

February 14, 2019 – T. Edelman

 ______________

[1] CMS, “Special Focus Facility (“SFF”) Initiative,” https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/SFFList.pdf.

Go to Source

Report: There’s Nothing Special About How CMS Treats Special Focus Nursing Facilities

Print Friendly, PDF & Email

In cooperation with states, the Centers for Medicare & Medicaid Services (CMS) identifies a subset of nursing facilities, generally one to two facilities per state, that are among the most poorly performing facilities in the country.  These nursing facilities, which CMS calls Special Focus Facilities (SFFs), have “more problems” than other facilities, “more serious problems” than other facilities, and “A pattern of serious problems that has persisted over a long period of time” (i.e., the prior three years).[1]  CMS requires states to conduct surveys at SFFs twice as often as at other facilities and to impose more stringent enforcement actions “the longer the problems persist.”  Within 18-24 months of a facility’s designation as an SFF, CMS generally expects that the facility will either improve and graduate or be terminated from participating in the Medicare and Medicaid programs.  Each month, CMS identifies five categories of SFFs: newly-designated SFFs, SFFs that have not improved, SFFs that have improved, SFFs that have graduated, and SFFs that are no longer participating in the federal payment programs.

As demonstrated below, CMS has not followed through on these requirements for SFFs.  CMS is not imposing serious enforcement actions against SFFs that it cites with actual harm or immediate jeopardy deficiencies, or both.  To the contrary, CMS is not imposing any sanctions at all or is imposing only small financial penalties, averaging less than $20,000, against SFFs that it finds have not improved.

The Center for Medicare Advocacy’s Evaluation

On February 5-7, 2019, the Center looked at CMS’s most recent list (dated January 19, 2019) of 37 SFFs that CMS identified as not having improved.  CMS had originally designated these facilities as SFFs between five and 30 months earlier.  The Center looked at the federal website, Nursing Home Compare, to determine whether CMS imposed civil money penalties (CMPs) or denials of payment for new admissions (DPNAs), or both, against them.

Findings

The 37 SFFs that had not improved had few enforcement actions taken against them and these actions were limited:

  • 28 of the 37 SFFs were cited with actual harm or immediate jeopardy deficiencies in 2018.
  • 14 of the 28 SFFs that were cited with harm or jeopardy deficiencies, or both, in 2018 did not have CMPs or DPNAs imposed for deficiencies cited in 2018 (although CMPs had been imposed for deficiencies cited in earlier surveys).
  • Only 14 of the 28 SFFs that were cited with actual harm or jeopardy deficiencies, or both, in 2018 had either CMPs or DPNAs, or both, imposed against them.
    • Only 9 of the 28 SFFs that had not improved had CMPs imposed for actual harm or immediate jeopardy deficiencies that were cited in 2018. Only 1 CMP exceeded $100,000.  The remaining 8 CMPs ranged from $10,400 to $53,089 and averaged $19,616.50.  In all instances, the CMPs were considerably lower in 2018 than the CMPs imposed against these facilities in 2016 and 2017.
    • 3 of the 9 SFFs with CMPs also had DPNAs imposed against them.
    • 5 of the 28 SFFs had only DPNAs imposed against them. In 2016 or 2017, or both, these five SFFs had CMPs imposed against them.
  • 9 of the 37 SFFs were not cited with harm or jeopardy deficiencies in 2018.
    • 2 of these 9 SFFs had CMPs imposed.

14 SFFs that Had Not Improved Were Cited with Actual Harm and Immediate Jeopardy Deficiencies in 2018, but No CMPs or DPNAs Were Imposed

Facility State Months as SFF Deficiency (standard or complaint), type (IJ or harm), and date 2017 2016
Regalcare at Southport CT   5 C, 1 IJ, 1 harm (5/24) $6821 (8/22) $3,363 (8/29)
Glen Haven Home IA 23 S: 1 harm (9/13)   $47,166 (10/5)

$88,819 (4/28)

Wellspring Health & Rehabilitation of Cascadia ID 19 S: 1 harm (8/10) DPNA (10/27) $1,127,000 (7/19)
Aperion Care Bloomington IL 13 S: 1 IJ (10/1) $64,233 (7/16)

DPNA (7/16)

 
Vernon Health and Rehabilitation IN   9 C: 2 IJ (9/6)

S: 1 harm (5/16)

$39,158 (10/17)

$31,000 (8/14)

$13,239 (2/20)

 
Woodlawn Care and Rehab KS 15 C: 2 IJ (5/8) $24,080 (6/29)

$15,286 (1/9)

$37,863 (6/14)

DPNA (6/14)

Worcester Health Center MA   7 C: 1 harm (11/13) $54,846 (8/1) $3941 (10/19)
Red Wing Health Center MN 16 S: 4 harm (2/6)   $4622 (10/31)

$2000 (3/29)

Meridian Comm. Living Center MS 15 S: 3 IJ (6/22) $35,018 (1/15)

DPNA (1/15)

 
New Grove Manor NJ 10 S: 1 IJ (9/14)    
The Heights of Summerlin NV  8 S: 1 IJ (8/3)    
Portsmouth Health and Rehab OH 10 S: 2 harm (8/3)   $120,619 (11/22)
Ambassador Manor Nursing Center OK 12 S: 1 IJ, 1 harm (9/25) $55,941 (8/10)

$160,450 (2/14)

 
Trinity Health Care of Logan WV   8 S: 3 harm (6/12) $146,510 (4/11)  

14 SFFs that Had Not Improved Were Cited with Actual Harm and Immediate Jeopardy Deficiencies and Had CMPs or DPNAs Imposed In 2018 (But the CMPs Were Far Lower Than CMPs Imposed Against the Facilities In 2017 and 2016)

Facility State Months as SFF Deficiency (standard or complaint), type (IJ or harm), and date CMP/DPNA in 2018 2017 2016
Bethany Nursing & Rehab Center CO   5 C: 1 IJ (6/28) $11,267 (6/28) $191,732 (7/18) $18,785 (5/4)
Westminster Village Health DE 20 C: 3 harm (2/12) DPNA (2/12)   $239,168 (2/12)
Legacy Hilo Rehabilitation & Nursing Center HI 18 C: 1 IJ (3/16)

C: 2 harm (5/22)

C: 1 IJ (8/16)

$36,675 (3/16)

DPNA (8/16)
DPNA (3/16)

$46,720 (9/22) $136,555 (9/19)

DPNA (9/19)

Touchstone Healthcare Community IA 15 S: 1 harm (2/15)

S: 1 IJ (9/26)

$10,400 (1/13) $56,375 (1/26)

$22,750 (8/15)

$56,375 (1/26)

$34,348 (12/14)
Garden Valley Retirement Village KS   5 S, C: 1 harm (10/16) DPNA (10/16) $92,981 (3/8) $63,403 (11/16)
Twin Rivers Nursing and Rehab Center KY 18 C: 1 IJ (5/8) $195,845 (4/26)

DPNA (4/26)

$13,627 (4/26)

  $314,990 (5/20)
Rochester East Health Services MN 11 S, C: 2 IJ, 3 harm (9/18)

S: 2 harm (3/2)

DPNA (2/5) $28,288 (4/18)  
Isabelle Ridgway Post Acute Care Campus OH   9 S: 1 harm (1/30)

S: 2 IJ, 1 harm (8/23)

DPNA (1/30) $20,125 (2/13)  
Prestige Post-Acute & Rehab Center -McMinnville OR 15 C: 2 harm (5/18) $53,089 (3/2) $227,793 (8/11)

$11,053 (2/10)

 
The Gardens at West Short PA   9 C: 2 harm (3/16) $13,000 (3/16) $58,746 (5/18)

DPNA (10/17)

DPNA (5/18)

DPNA (8/12)
Trisun Care Center – Westwood TX 17 S,C: 2 harm (8/31)

C: 1 harm (3/1)

$21,450 (3/1)

DPNA (3/1)

  $92,034 (12/21)
Envoy of Westover Hill VA   6 S,C: 1 IJ, 6 harm (7/23) DPNA (7/23) $202,650 (5/19)  
Paramount Rehabilitation and Nursing WA 18 C: 1 harm (9/6) $36,673 (3/21) DPNA (2/7) $50,830 (11/8)

$287,430 (6/24)

Cheyenne Health Care Center WY   8 S: 1 harm (7/16) $11,053 (7/16)

$9,428 (5/4)

$98,982 (8/3) $11,726 (7/14)

Discussion

CMS is not imposing strict enforcement sanctions against SFFs that have not improved.

First, and as of February 7, 2019, CMS had not imposed any CMPs or DPNAs against 14 of 37 SFFs that were cited with actual harm or immediate jeopardy deficiencies in 2018.  This lack of enforcement is inconsistent with federal guidance requiring CMS to impose remedies immediately (that is, facilities are not given an opportunity to correct their deficiencies) if there is an immediate jeopardy deficiency, a G-level (actual harm) in the current survey and prior survey (the “double G” policy), or if the facility is an SFF and is cited with a deficiency at level F or above.[2]

For example, Vernon Health and Rehabilitation, an Indiana nursing facility, was cited with two immediate jeopardy deficiencies at a complaint survey in 2018 and a harm deficiency at the standard survey in 2018.  CMS did not impose either a CMP or DPNA.  Three surveys in 2017, before the facility was named an SFF, had resulted in three per day CMPs ($39,158 [one immediate jeopardy deficiency]; $31,000 [two actual harm deficiencies]; and $13,239 [one immediate jeopardy deficiency]) totaling $83,397.

In 2018, Ambassador Manor Nursing Center in Oklahoma was cited with an immediate jeopardy deficiency and an actual harm deficiency at its standard survey on September 25, after it had been named an SFF.  CMS did not impose either a CMP nor DPNA.  In 2017, CMS imposed two per day CMPs ($44,941 and $160,450) totaling $216,391.

Second, CMS imposed only DPNAs against five SFFs that had not improved and were cited with jeopardy or actual harm deficiencies in 2018.  Before the facilities’ designation as SFFs, CMS had imposed CMPs.

For example, Rochester East Health Services in Minnesota was cited with 22 deficiencies at its combined standard and complaint survey on September 18, 2018.  These deficiencies included two immediate jeopardy deficiencies and three actual harm deficiencies.  An earlier standard survey on March 2, 2018 cited 11 deficiencies, including two actual harm deficiencies.  CMS imposed only DNPA.  In 2017, CMS had imposed a CMP of $28,288 following a standard survey that cited 18 deficiencies, including one actual harm deficiency and one immediate jeopardy deficiency.

Envoy of Westover Hill in Virginia had a DPNA imposed in 2018, following a combined standard and complaint survey that cited an immediate jeopardy deficiency and six actual harm deficiencies.  In 2017, before it was designated an SFF, CMS imposed a CMP of $202,650, following a combined standard and complaint survey that cited three immediate jeopardy deficiencies and three actual harm deficiencies..

As of January 2019, Westminister Village Health had been an SFF for 20 months.  In 2016, CMS imposed a per day CMP totaling $239,168.  (The 2016 survey is not available on Nursing Home Compare.)  A complaint survey at the Delaware facility on February 12, 2018 cited 20 deficiencies, including three actual harm deficiencies involving failure to monitors the blood sugar levels of two residents who were taking insulin.  Both residents were hospitalized, one of them, twice.  CMS imposed only DPNA for the three actual harm-level deficiencies.

Finally, even when CMS imposes a CMP against one of the SFFs that has not improved, the CMP is small, averaging less than $20,000.  The 2018 CMPs are far smaller than the CMPs that CMS imposed against the facilities before they were designated SFFs.

For example, CMS named Bethany Nursing & Rehabilitation Center an SFF in August 2018.  The most recent annual survey at the Colorado nursing facility was conducted July 18, 2017, when CMS cited the facility with a harm-level deficiency and an immediate jeopardy deficiency and imposed a per day CMP totaling $191,732.  The state survey agency did not conduct an annual survey at the facility in 2018, but conducted two complaint surveys.  The June 28, 2018 complaint survey cited immediate jeopardy in supervision.  CMS imposed a CMP of $11,267.

Trisun Care Center – Westwood, a Texas nursing facility had a $21,450 CMP (and DPNA) imposed in 2018 for two actual harm deficiencies in neglect and supervision (a damaged walked caused a resident to fall and sustain a fractured shoulder); in 2017, CMS imposed a CMP of $92,034 for three immediate jeopardy deficiencies involving involuntary seclusion of residents.

Conclusion

CMS designed the Special Focus Facility Program to focus additional attention and enforcement resources on nursing facilities with a history and record of extremely poor care.  The Program is failing to achieve these goals.  CMS is not imposing significant penalties against SFFs, even those that it cites with actual harm or immediate jeopardy deficiencies.

The extraordinarily limited enforcement against even the most poorly performing nursing facilities in the country underscores how weak enforcement has become. CMS must change course and impose meaningful financial penalties against facilities that fail to provide residents with the care they need.  The lives of vulnerable nursing home residents are at stake.

February 2019 – T. Edelman

____________________

[1] CMS, “Special Focus Facility (“SFF”) Initiative,” https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/SFFList.pdf.
[2] State Operations Manual, Chapter 7, §7304.1, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107c07.pdf  (scroll down to unnumbered p. 60.)

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2019 National Voices of Medicare Summit And Senator Jay Rockefeller Lecture

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Sen. Chris Murphy
2018 Sen. Jay Rockefeller Lecturer,
Sen. Chris Murphy of Connecticut.

Don’t Miss It!

The Center for Medicare Advocacy’s 6th annual National Voices of Medicare Summit & Senator Jay Rockefeller Lecture will connect leading experts and advocates to discuss best practices, challenges and successes in efforts to improve access to quality health coverage and care. This year’s Summit will focus on health care as a human right. Senator Corey Booker has been invited to be this year’s Sen. Jay Rockefeller Lecturer, joined by Sen. Rockefeller himself.

Join Us For This Incredible Program!

May 9, 2019
8:30 AM – 3:00 PM, EDT​
Kaiser Family Foundation
1330 G. Street, NW
Washington, DC

  • Early Bird Registration (Through March 15, 2019): $200.00
  • Individual Registration: $225
  • Start the day with remarks from Tricia Neuman (VP, Kaiser Family Foundation)
  • Participate in a conversation on Today’s Health Care and Civil Rights Challenges with guests from the American Association of People with Disabilities, Association for Retired Americans, and more.
  • Hear from a panel of experts regarding Civil Rights and Care Giving, from SEIU, Caring Across Generations, and more.
  • Senator Corey Booker (D. NJ) has been invited to present the Rockefeller Lecture with an introduction by Senator Rockefeller and a follow-up discussion and Q&A.

You won’t want to miss this energizing day!

Space is limited. Register now.

Early-Bird Rate Ends March 15 —


The Center has reserved a block of rooms at the Washington Marriot Metro Center, just a few minutes walk from the venue. These rooms will only be held through February 21, 2018, so reserve yours now at https://aws.passkey.com/e/49463912.


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CMA Alert – February 7, 2019

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  1. Improve and Expand Medicare: Create Parity Between Medicare Advantage and Traditional Medicare
  2. 2019 Federal Poverty Levels Released: New Income Limits for Medicare Savings Programs
  3. State of the Union: Want More Affordable Prescription Drugs? Start with Medicare. 
  4. Home Health Outreach Materials Available

Improve and Expand Medicare: Create Parity Between Medicare Advantage and Traditional Medicare

Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations to improve Medicare for all beneficiaries, now and in the future, is the need to preserve and expand consumer protections and quality coverage for all Medicare Beneficiaries – including parity between traditional Medicare and private Medicare Advantage plans. We previously wrote about limited access to Medigap policies, oral health care, lack of an out-of-pocket cap on beneficiary expenses in traditional Medicare, and the need for comprehensive long-term services and supports (LTSS, also known as long term care).  These parity concerns are increasingly important since recent changes in law and policy have expanded the scope of both medical and non-medical services that Medicare Advantage (MA) plans can cover.

Another ongoing imbalance between traditional Medicare and Medicare Advantage relates to payment. While the Affordable Care Act reined in significant overpayments to MA plans and brought average payment more in line with what traditional Medicare spends on a given beneficiary, payment inequity lingers, some of which, as described below, is arguably inappropriate. Such extra funds, if redirected toward the Medicare program as a whole, could be used to strengthen and expand the traditional Medicare program, including with respect to the gaps in coverage and access to services outlined above.

As noted in a previous Alert summarizing a New England Journal of Medicine article entitled “Medicare Advantage Checkup” (November 2018), after many years of Medicare payments to MA plans being “considerably higher,” payment to MA plans today are “roughly equal to the per capita costs in traditional Medicare (101% of those costs, on average)” but “some questions remain as to whether the current system is putting sufficient downward pressure on program spending and encouraging plan efficiency” (including incentives that promote, e.g., plan choice and extra benefits at the expense of Medicare savings). The article notes: “[c]urrent methods that are used to compare [MA] payments with traditional Medicare costs may overstate the true costs to plans or provider Medicare benefits” for example, the current risk-adjustment system may allow MA plans to “boost[..] their payments by as much as 2% (on average) in 2018, on the basis of how they code their enrollees’ health conditions.”

Some analysts have tried to quantify how much MA plans are being overpaid based upon how they code their enrollees’ health status. A 2017 study published in Health Affairs found that coding intensity practices could result in overpayments to MA plans totaling $200 billion over the next decade.  Similarly, in April 2016, the General Accounting Office (GAO) issued a report stating that CMS estimates that about 9.5% of its annual payments to Medicare Advantage (MA) organizations were improper – totaling $14.1 billion in 2013 alone – “primarily stemming from unsupported diagnoses submitted by MA organizations.”

A February 4, 2019 article in The New Yorker entitled “The Personal Toll of Whistle-Blowing” notes that, due to coding practices, Medicare Advantage “is at the center of a growing number of fraud cases, some of which involve the biggest names in the health care industry. The regulations around the issue are complicated, however, and legal questions about what constitutes prosecutable fraud are still the subject of debate.” According to the article, Harvard Professor Malcolm Sparrow notes that “unchecked fraud could lead to the wholesale destruction of government health-care programs. Systemic theft creates cost inflation […] which increases political pressure to make cuts, often affecting both the healthy and unhealthy parts of a program.”

Despite coding practices that can inflate payment to MA plans, many policymakers continue to promote the MA program without regard to growing inequity between MA and traditional Medicare. For example, every year, CMS issues a draft Call Letter which includes proposed policy changes and payment rates for Part C Medicare Advantage and Part D plans for the following calendar year. Every year, the insurance industry gathers support in Congress to ensure that MA plans receive steady payment. As noted by Politico, in the draft 2020 Call Letter “CMS proposed to hike rates a modest 1.59 percent for 2020, but some analysts think a two-month lobbying effort from insurers could nudge that figure higher.” (“Private Medicare plans face few threats from 2020 proposal” By Paul Demko, 2/06/19.)

In response to the draft Call Letter, the insurance industry is touting letters to CMS signed by 66 Senators and 302 members of the House of Representatives urging support of the MA program.  The Senate letter concludes:

“For plan year 2020, we encourage the Administration to implement policies that promote innovation, provide predictable funding to support long-term, value-based arrangements, and ensure that any substantive changes include sufficient time for thorough evaluation and stakeholder engagement.”

Instead of continuing to favor Medicare Advantage regardless of cost, we urge policymakers to advance complete equity between MA and traditional Medicare, including both the scope of services provided and programmatic spending. Wasteful spending on MA should be reinvested into the Medicare program to the benefit of all enrollees, not just those who choose to enroll in private plans.

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2019 Federal Poverty Levels Released: New Income Limits for Medicare Savings Programs

Medicare Savings Programs (MSP) offer assistance with meeting the costs of Medicare premiums and deductibles. The MSPs include the Qualified Medicare Beneficiary program (QMB), Specified Low-Income Medicare Beneficiary program (SLMB), and Qualified Individual program (QI).  All of these help Medicare beneficiaries of modest means pay all or some of Medicare’s cost sharing amounts (ie. premiums, deductibles and copayments). To qualify an individual must be eligible for Medicare and must meet certain income guidelines which change annually.  Please note that the eligibility criteria listed below are federal standards; states may have more, but not less, generous standards.

QMB (Qualified Medicare Beneficiary Program)

Coverage

  • Payment of Medicare Part A monthly premiums (when applicable).
  • Payment of Medicare Part B monthly premiums and annual deductible.
  • Payment of co-insurance and deductible amounts for services covered under both Medicare Parts A and B.

Requirements and Monthly Income Limits for 2019 (up to 100% FPL+ $20)*

  • Must be eligible for Medicare Part A (even if not currently enrolled).
  • Income at or below $1,061 for an individual and $1,430 for a couple in 2019.*
  • Resources below $7,730 for an individual and $11,600 for a couple in 2019.*
  • Must undergo redetermination for the benefit every year.

SLMB (Specified Low-Income Medicare Beneficiary Program)

Coverage

  • Payment of the Medicare Part B monthly premium only.

Requirements and Monthly Income Limits for 2019 (less than 120% FPL+ $20)*

  • Must be eligible for Medicare Part A (even if not currently enrolled).
  • Income between $1,269 for an individual and $1,711 for a couple in 2019.*
  • Resources below $7,730 for an individual and $11,600 for a couple in 2019.*
  • Must undergo redetermination for the benefit every year.

QI (Qualified Individual Program – also known as ALMB)

Coverage

  • Payment – through the SLMB program – of Medicare Part B premium for the calendar year. (NOTE: the funds for this program come from a “block-grant,” so are finite. Once they are gone, even eligible individuals will not be able to access the program, so apply early.)

Requirements and Monthly Income Limits for 2019 (less than 135% FPL+ $20)*

  • Income between $1,426 for an individual and $1,923 for a couple in 2019.*
  • Resources below $$7,730 for an individual and $$11,600 for a couple in 2019.*
  • Must re-apply every year for these benefits;
  • Not available to those who qualify for any other kind of Medicaid

* $20 = monthly SSI general income exclusion. Individual states may be more generous with the income and resource amounts above.

Obtaining QMB, SLMB, and QI Benefits

Requests for applications for QMB, SLMB, or QI benefits are made to the state Medicaid agency. Eligibility for QMB is effective on the first day of the month following the month in which the Medicaid agency has all the information and verification necessary to determine eligibility. SLMB and QI entitlement may be retroactive. For more information, please telephone your local Medicaid office. You can find your local Medicaid office at https://www.medicaid.gov/about-us/contact-us/index.html.

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State of the Union: Want More Affordable Prescription Drugs?  Start with Medicare. 

While the President’s State of the Union Address was short on substance concerning health care, he did mention a desire to work with Congress to “lower the cost of health care and prescription drugs.” While the President focused on “global freeloading” there is one common sense solution that would make drugs more affordable for individuals, and save taxpayers and Medicare billions of dollars: Allow Medicare to negotiate the price of Prescription Drugs.

Other plans, such as the President’s plan to “inject more competition into the market” and switch coverage of some expensive drugs from Medicare Part B Medicare to Part D could actually significantly increase out-of-pocket costs for some of the sickest people in Medicare.

To truly lower drug costs for Medicare beneficiaries, the Medicare program, and taxpayers, the administration should negotiate prices overall, not one plan at a time. As every big box company knows, that’s how to drive down costs. Health economists and Medicare beneficiary advocates have called for overall negotiations since Part D was passed in 2003. The President even claimed he would do so during his campaign. At best, other approaches whittle away at the edges of the cost problem. It’s high time to negotiate drug prices on behalf of all 60 million Medicare beneficiaries.

It’s as simple as removing one word – “not” – from the Medicare Prescription Drug, Improvement, and Modernization Act.  Then, rather than wastefully forbidding negotiations, the Act would encourage the government to use its massive purchasing power to negotiate prices overall, ensuring that Medicare and those who rely on it are really getting the best possible deals.

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Home Health Outreach Materials Available

Ossen TrainingAs part of the Center for Medicare Advocacy’s Medicare Outreach, Education and Advocacy Project with the Jeffrey P. Ossen Family Foundation, we hosted a seminar on January 29th for Eastern Connecticut health care coordinators, case managers, human service professionals, and family care givers. The seminar focused on Medicare-covered home health care, law, and realities. Together we hope to build a community effort to help advance Medicare home health access for individuals, and to improve access system-wide. The Center has developed an array of resources, also available in Spanish, to help beneficiaries, and those who help beneficiaries, understand and access Medicare home health coverage.

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Improve and Expand Medicare: Create Parity Between Medicare Advantage and Traditional Medicare

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Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations to improve Medicare for all beneficiaries, now and in the future, is the need to preserve and expand consumer protections and quality coverage for all Medicare Beneficiaries – including parity between traditional Medicare and private Medicare Advantage plans. We previously wrote about limited access to Medigap policies, oral health care, lack of an out-of-pocket cap on beneficiary expenses in traditional Medicare, and the need for comprehensive long-term services and supports (LTSS, also known as long term care).  These parity concerns are increasingly important since recent changes in law and policy have expanded the scope of both medical and non-medical services that Medicare Advantage (MA) plans can cover.

Another ongoing imbalance between traditional Medicare and Medicare Advantage relates to payment. While the Affordable Care Act reined in significant overpayments to MA plans and brought average payment more in line with what traditional Medicare spends on a given beneficiary, payment inequity lingers, some of which, as described below, is arguably inappropriate. Such extra funds, if redirected toward the Medicare program as a whole, could be used to strengthen and expand the traditional Medicare program, including with respect to the gaps in coverage and access to services outlined above.

As noted in a previous Alert summarizing a New England Journal of Medicine article entitled “Medicare Advantage Checkup” (November 2018), after many years of Medicare payments to MA plans being “considerably higher,” payment to MA plans today are “roughly equal to the per capita costs in traditional Medicare (101% of those costs, on average)” but “some questions remain as to whether the current system is putting sufficient downward pressure on program spending and encouraging plan efficiency” (including incentives that promote, e.g., plan choice and extra benefits at the expense of Medicare savings). The article notes: “[c]urrent methods that are used to compare [MA] payments with traditional Medicare costs may overstate the true costs to plans or provider Medicare benefits” for example, the current risk-adjustment system may allow MA plans to “boost[..] their payments by as much as 2% (on average) in 2018, on the basis of how they code their enrollees’ health conditions.”

Some analysts have tried to quantify how much MA plans are being overpaid based upon how they code their enrollees’ health status. A 2017 study published in Health Affairs found that coding intensity practices could result in overpayments to MA plans totaling $200 billion over the next decade.  Similarly, in April 2016, the General Accounting Office (GAO) issued a report stating that CMS estimates that about 9.5% of its annual payments to Medicare Advantage (MA) organizations were improper – totaling $14.1 billion in 2013 alone – “primarily stemming from unsupported diagnoses submitted by MA organizations.”

A February 4, 2019 article in The New Yorker entitled “The Personal Toll of Whistle-Blowing” notes that, due to coding practices, Medicare Advantage “is at the center of a growing number of fraud cases, some of which involve the biggest names in the health care industry. The regulations around the issue are complicated, however, and legal questions about what constitutes prosecutable fraud are still the subject of debate.” According to the article, Harvard Professor Malcolm Sparrow notes that “unchecked fraud could lead to the wholesale destruction of government health-care programs. Systemic theft creates cost inflation […] which increases political pressure to make cuts, often affecting both the healthy and unhealthy parts of a program.”

Despite coding practices that can inflate payment to MA plans, many policymakers continue to promote the MA program without regard to growing inequity between MA and traditional Medicare. For example, every year, CMS issues a draft Call Letter which includes proposed policy changes and payment rates for Part C Medicare Advantage and Part D plans for the following calendar year. Every year, the insurance industry gathers support in Congress to ensure that MA plans receive steady payment. As noted by Politico, in the draft 2020 Call Letter “CMS proposed to hike rates a modest 1.59 percent for 2020, but some analysts think a two-month lobbying effort from insurers could nudge that figure higher.” (“Private Medicare plans face few threats from 2020 proposal” By Paul Demko, 2/06/19.)

In response to the draft Call Letter, the insurance industry is touting letters to CMS signed by 66 Senators and 302 members of the House of Representatives urging support of the MA program.  The Senate letter concludes:

“For plan year 2020, we encourage the Administration to implement policies that promote innovation, provide predictable funding to support long-term, value-based arrangements, and ensure that any substantive changes include sufficient time for thorough evaluation and stakeholder engagement.”

Instead of continuing to favor Medicare Advantage regardless of cost, we urge policymakers to advance complete equity between MA and traditional Medicare, including both the scope of services provided and programmatic spending. Wasteful spending on MA should be reinvested into the Medicare program to the benefit of all enrollees, not just those who choose to enroll in private plans.

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State of the Union: Want More Affordable Prescription Drugs? Start with Medicare.

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While the President’s State of the Union Address was short on substance concerning health care, he did mention a desire to work with Congress to “lower the cost of health care and prescription drugs.” While the President focused on “global freeloading” there is one common sense solution that would make drugs more affordable for individuals, and save taxpayers and Medicare billions of dollars: Allow Medicare to negotiate the price of Prescription Drugs.

Other plans, such as the President’s plan to “inject more competition into the market” and switch coverage of some expensive drugs from Medicare Part B Medicare to Part D could actually significantly increase out-of-pocket costs for some of the sickest people in Medicare.

To truly lower drug costs for Medicare beneficiaries, the Medicare program, and taxpayers, the administration should negotiate prices overall, not one plan at a time. As every big box company knows, that’s how to drive down costs. Health economists and Medicare beneficiary advocates have called for overall negotiations since Part D was passed in 2003. The President even claimed he would do so during his campaign. At best, other approaches whittle away at the edges of the cost problem. It’s high time to negotiate drug prices on behalf of all 60 million Medicare beneficiaries.

It’s as simple as removing one word – “not” – from the Medicare Prescription Drug, Improvement, and Modernization Act.  Then, rather than wastefully forbidding negotiations, the Act would encourage the government to use its massive purchasing power to negotiate prices overall, ensuring that Medicare and those who rely on it are really getting the best possible deals.

Go to Source

2019 Federal Poverty Levels Released: New Income Limits for Medicare Savings Programs

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Medicare Savings Programs (MSP) offer assistance with meeting the costs of Medicare premiums and deductibles. The MSPs include the Qualified Medicare Beneficiary program (QMB), Specified Low-Income Medicare Beneficiary program (SLMB), and Qualified Individual program (QI).  All of these help Medicare beneficiaries of modest means pay all or some of Medicare’s cost sharing amounts (ie. premiums, deductibles and copayments).

To qualify an individual must be eligible for Medicare and must meet certain income guidelines which change annually.  Please note that the eligibility criteria listed below are federal standards; states may have more, but not less, generous standards.

QMB (Qualified Medicare Beneficiary Program)

Coverage

  • Payment of Medicare Part A monthly premiums (when applicable).
  • Payment of Medicare Part B monthly premiums and annual deductible.
  • Payment of co-insurance and deductible amounts for services covered under both Medicare Parts A and B.

Requirements and Monthly Income Limits for 2019 (up to 100% FPL+ $20)*

  • Must be eligible for Medicare Part A (even if not currently enrolled).
  • Income at or below $1,061 for an individual and $1,430 for a couple in 2019.*
  • Resources below $7,730 for an individual and $11,600 for a couple in 2019.*
  • Must undergo redetermination for the benefit every year.

SLMB (Specified Low-Income Medicare Beneficiary Program)

Coverage

  • Payment of the Medicare Part B monthly premium only.

Requirements and Monthly Income Limits for 2019 (less than 120% FPL+ $20)*

  • Must be eligible for Medicare Part A (even if not currently enrolled).
  • Income between $1,269 for an individual and $1,711 for a couple in 2019.*
  • Resources below $7,730 for an individual and $11,600 for a couple in 2019.*
  • Must undergo redetermination for the benefit every year.

QI (Qualified Individual Program – also known as ALMB)

Coverage

  • Payment – through the SLMB program – of Medicare Part B premium for the calendar year. (NOTE: the funds for this program come from a “block-grant,” so are finite. Once they are gone, even eligible individuals will not be able to access the program, so apply early.)

Requirements and Monthly Income Limits for 2019 (less than 135% FPL+ $20)*

  • Income between $1,426 for an individual and $1,923 for a couple in 2019.*
  • Resources below $$7,730 for an individual and $$11,600 for a couple in 2019.*
  • Must re-apply every year for these benefits;
  • Not available to those who qualify for any other kind of Medicaid

* $20 = monthly SSI general income exclusion. Individual states may be more generous with the income and resource amounts above.

Obtaining QMB, SLMB, and QI Benefits

Requests for applications for QMB, SLMB, or QI benefits are made to the state Medicaid agency. Eligibility for QMB is effective on the first day of the month following the month in which the Medicaid agency has all the information and verification necessary to determine eligibility. SLMB and QI entitlement may be retroactive.

For more information, please telephone your local Medicaid office. You can find your local Medicaid office at https://www.medicaid.gov/about-us/contact-us/index.html.

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