CMA Alert – October 18, 2018

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  1. 2019 Medicare Cost-Sharing Announced
  2. Government Watchdog Agency Raises Concerns About Medicare Advantage Denials
  3. Home Health Issue Brief #10 – Plans to Address and Resolve the Medicare Home Care Crisis
  4. New Checklist for Medicare Home Health Care “Improvement Standard” Denials

2019 Medicare Cost-Sharing Announced

#SaveMedicareNow

The #SaveMedicareNow initiative seeks to educate and raise awareness about current proposed threats to Medicare this election season.

Voters must know where candidates stand on issues like Medicare privatization. Candidates must be committed to a strong Medicare program and to resisting threats to Medicare, including increasing efforts to privatize the program.

Learn How You Can Help

Last week the Centers for Medicare & Medicaid Services released the Medicare premium, deductible and co-pay amounts for 2019.  Below are the 2019 cost-sharing amounts.

Part A Premium (For those not automatically enrolled)

  • 0-29 qualifying quarters of employment: $437.00
  • 30-39 quarters: $240.00

Inpatient Hospital

  • Deductible, Per Spell of Illness: $1,364.00
  • Co-pay, Days 1 – 60: $0
  • Co-pay, Days 61 – 90: $341.00/day
  • Co-pay, Lifetime Reserve Days: $682.00/day

Skilled Nursing Facility

  • Co-pay, Days 1 – 20: $0
  • Co-pay, Days 21 – 100: $170.50

Standard Monthly Part B Premium

  • $135.50 for new enrollees and those not “held harmless”
  • While most Medicare recipients will pay the new $135.50 standard monthly premium, an estimated 2 million (3.5%) will pay less because of a “hold harmless” provision that limits certain beneficiaries’ increase in their Part B premium to be no greater than the increase in their Social Security benefits.

Part B Deductible

  • $185.00 for all Part B beneficiaries.

Part B Income-Related Premiums

  • Income less than or equal to $85,000 ($170,000 /couple): $135.50
  • Greater than $85,000 and less than $107,000 ($170,000 – $214,000/couple): $189.60
  • Greater than $107,000 and less than or equal to $133,500 ($214,000 – $267,000 /couple): $270.90
  • Greater than $133,500 and less than or equal to $160,000 ($267,000 – $320,000/couple): $352.20
  • Greater than $160,000 and less than or equal to $500,000 ($320,000 – $750,000/couple): $433.40
  • Greater than $500,000 ($750,000/couple): $460.50

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Government Watchdog Agency Raises Concerns About Medicare Advantage Denials

The Department of Health and Human Services (DHHS) Office of Inspector General (OIG) recently issued a report entitled “Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials” (OEI-09-16-00410) (see summary and full report).

Among the report’s findings are that when beneficiaries and providers appealed preauthorization and payment denials, MA plans “overturned 75 percent of their own denials.” However, OIG found that during the time period analyzed, “beneficiaries and providers appealed only 1 percent of denials to the first level of appeal.”

In an explanation of why the OIG conducted this study, the agency states:

“[a] central concern about the capitated payment model used in Medicare Advantage is the potential incentive for [Medicare Advantage Organizations, or MAOs] to inappropriately deny access to services and payment in an attempt to increase their profits. An MAO that inappropriately denies authorization of services for beneficiaries, or payments to health care providers, may contribute to physical or financial harm and also misuses Medicare Program dollars that CMS [Centers for Medicare & Medicaid Services] paid for beneficiary healthcare. Because Medicare Advantage covers so many beneficiaries (more than 20 million in 2018), even low rates of inappropriately denied services or payment can create significant problems for many Medicare beneficiaries and their providers.”

As summarized in the report’s conclusion,

“MAOs may have an incentive to deny preauthorization of services for beneficiaries, and payments to providers, in order to increase profits. High overturn rates when beneficiaries and providers appeal denials, and CMS audit findings about inappropriate denials, raise concerns that some beneficiaries and providers may not be getting services and payment that MAOs are required to provide. These findings are particularly concerning because beneficiaries and providers rarely use the appeals process designed to ensure access to care and payment, and CMS has repeatedly cited MAOs for issuing incorrect or incomplete denials letters, which can impair a beneficiary’s or provider’s ability to mount a successful appeal. Additionally, because audit violations will no longer be reflected in Star Ratings, beneficiaries may be unaware of MAO performance problems when selecting a plan. Although CMS uses several compliance and enforcement tools to address MAO performance problems, more action is needed to address these widespread and persistent problems in Medicare Advantage.”

As noted in a New York Times article about the OIG report, these findings “come as policies in Washington are creating new incentives for older Americans to enroll in Medicare Advantage plans.”  The article states: “[s]everal factors have contributed to a favorable environment for Medicare Advantage plans, allowing them to reduce premiums or add benefits [including] [t]he Trump administration approved a big increase in payments to private plans for 2019, saying it was ‘committed to unleashing and strengthening the Medicare Advantage program.’”

The Center shares the OIG’s concerns about unfair Medicare Advantage denials. Further, as the Times notes, this is particularly important as MA plans are paid more and consumer protections are reduced.

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Home Health Issue Brief #10 – Plans to Address and Resolve the Medicare Home Care Crisis

This is Part Ten of a ten-part CMA Issue Brief Series examining the growing crisis in access to Medicare home health coverage and necessary care – and outlining the Center for Medicare Advocacy’s work to address these issues. We invite you to follow this Issue Brief Series and submit Medicare home health stories to the Center at http://www.medicareadvocacy.org/submit-your-home-health-access-story/.


CMA Issue Brief Series: Medicare Home Health Care Crisis

  1. Overview – The Crisis in Medicare Home Health Coverage and Access to Care
  2. Medicare Home Health Coverage, Legally Defined
  3. Medicare Coverage for Home Care Is Based On a Need For Skilled Care – Improvement Is Not Required
  4. Misleading and Inaccurate CMS Medicare Home Health Publications
  5. The Home Care Crisis: An Elder Justice Issue
  6. Beneficiary Protections Expanded in Revised Home Health Conditions of Participation
  7. Barriers to Home Care Created by CMS Payment, Quality Measurement, and Fraud Investigation Systems
  8. Proposed CMS Rules and Systems Will Worsen the Home Care Crisis
  9. Statistical Trends and Published Articles with Studies and Research from 2002-2017
  10. Plans to Address and Resolve the Medicare Home Care Crisis

Plans to Address and Resolve the Medicare Home Care Crisis

There is a crisis in access to Medicare-covered home health care. Earlier editions of this Issue Brief Series have detailed the home health benefit and the access obstacles facing patients, particularly those with longer term and chronic conditions. This Brief summarizes what is at stake, some of what’s been done thus far, and what’s needed to remove the obstacles.

Under the law, beneficiaries qualify for home health coverage when they are under the care of a physician, are homebound, and need skilled nursing or therapy care. There is no required end-point to coverage; it can continue so long as the beneficiary meets the coverage criteria. In practice, however, beneficiaries are regularly unable to obtain the coverage, and care, provided by law.

In recent years, access to the benefit has rapidly diminished and a growing number of beneficiaries have been unable to obtain home health services, even when they meet Medicare coverage criteria, (See CMA Issue Brief #5). While the Centers for Medicare & Medicaid Services (CMS) online and print materials now more accurately reflect Medicare home health coverage law, (See CMA Issue Brief #4), CMS continues to administer the benefit as if it is for patients with acute care needs. Further, although some beneficiary protections have been expanded, (See CMA Issue Brief #6), CMS payment policies, quality measures, and fraud investigations create disincentives for home health agencies to provide care to all who qualify; patients with longer-term needs are particularly disfavored, (See CMA Issue Brief #7). Recently proposed rules would only accelerate this trend towards turning Medicare home health coverage into a short-term, post-acute care benefit – contrary to clearly expressed Congressional intent, (See CMA Issue Brief #8).

The Center for Medicare Advocacy (the Center) continues to develop strategies to raise awareness about the crisis in access to Medicare home care and to seek solutions. A combination of actions are necessary, including Administrative and Congressional, strategic collaboration with providers, development of stories and media attention, and, potentially, litigation.

  • The Administration and CMS should rescind proposed payments rules and develop a model intended to effectuate coverage laws, by giving home health providers appropriate financial incentives to serve all qualifying Medicare beneficiaries. Quality measures and fraud investigation triggers should also be redesigned to ensure that all patients who qualify under the law have equal access to care. The Administration, and those who advise CMS, including the Medicare Payment Advisory Commission (MedPAC), should fully understand Medicare coverage law and work to ensure the benefit is administered to implement the promise of the law: to allow homebound patients to receive necessary care at home. Oversight of the program must aim to ensure equal access to coverage for all who qualify, regardless of their conditions or ability to improve. Underserving patients who qualify should cause as much concern as overserving. Considerations should include capping maximum allowable profit margins, thus removing incentives to serve some beneficiaries who are more profitable than others.
  • Members of Congress should recognize that constituents are losing access to legally covered home care and act to ensure that coverage laws are implemented as intended – for all who qualify. Congress should insist that CMS corrects policies that restrict access to such services. Congress and the Administration should ensure that Medicare-certified home health agencies are ready to provide all services covered under the Medicare benefit. Congress should also consider lifting the 2.5% statutory cap on provider access to outlier payments.
  • Home health agencies are generally willing to provide services to all beneficiaries when they are properly reimbursed. While some Medicare-certified agencies provide services to beneficiaries with longer-term and chronic conditions, many will not for fear of claim denials, fraud investigations, audits, and financial penalties. Too often, agencies lose money, get reduced quality measures, and are targeted by audits based on criteria that do not accurately reflect the Medicare law. As a result, providers turn away beneficiaries who have chronic conditions in favor of more profitable short-term, acute care cases. Equalizing access to care may not be the home health industry’s primary concern, but the industry should join with beneficiary advocates to oppose these policies that lead to inequities in access to care. The Center will continue to work with home health agencies to understand and honor coverage laws, to gain more confidence that care provided to people with longer-term conditions will be covered, and to help prevent unfair oversight practices.
  • Media stories have helped raise awareness about the crisis in access to home health care. Some published articles have generated responses from CMS, such as a recommendation (made in the Federal Register) that agencies use outlier payments to cover higher-cost patients. While it may be appropriate in some cases to use outlier payments, they are currently underfunded and statutorily capped at 2.5% of all Medicare home health expenditures (already maximized by home health agencies). Additionally, outlier payments are not appropriate for all beneficiaries who have longer-term or chronic conditions. Many of these patients are actually less costly to agencies than short-term acute care patients.
  • Finally, as we strategize ways to resolve the inequities in access to Medicare-covered home care, the Center must also consider the possibility of strategic litigation. Some of the identified access barriers may conflict with Medicare law, the Administrative Procedures Act, and/or anti-discrimination laws. The Center for Medicare Advocacy is committed to doing all we can to advance fair access to Medicare home care.​

The Center for Medicare Advocacy welcomes assistance and inquiries from other advocates concerned about the crisis in access to Medicare-covered home care. We encourage beneficiaries to appeal denials when they are not able to obtain coverage for all the home health services they need and for which they qualify under the law. We also urge beneficiaries to let us know about their difficulties, and success, in accessing care at http://www.medicareadvocacy.org/submit-your-home-health-access-story/. Working together, we will achieve appropriate and fair access to Medicare home health care.

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New Checklist for Medicare Home Health Care “Improvement Standard” Denials

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy has produced a new Checklist to help Medicare beneficiaries and their families respond to unfair Medicare denials for home health care based on an erroneous “Improvement Standard.” The Checklist outlines the coverage criteria for home health care and emphasizes language from the Jimmo Settlement Agreement.  Per the Settlement, the Centers for Medicare & Medicaid Services (CMS) revised the Medicare Benefit Policy Manual to clearly disavow any notion that individuals receiving home health care must improve in order for their care to be covered by Medicare.

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