Tuesday, December 17, 2013
One of the most important changes in U.S. funding for long-term care is the move to providing financial support for care in the home or less institutional settings, through Medicaid's HCBS waiver programs.
This month the AARP Public Policy Institute, with support from The Hartford Foundation and the (new) U.S. Administration on Community Living and the (older) Administration on Aging, issued an important report on the corresponding need for assessment not just of the recipient, but of the family members who will serve as caregivers:
"Family support is often essential for helping older people and adults with disabilities continue to live at home and in the community. Yet the work of family caregivers can be demanding—physically, emotionally, and financially. If family caregiver needs are not assessed and addressed, their own health and well-being may be at risk, which may lead to burnout—jeopardizing their ability to continue providing care in the community."
Further, the study, titled "Listening to Family Caregivers: The Need to Include Family Caregiver Assessment in Medicaid Home- and Community-Based Service Waiver Programs," reviews current practices among the states, concluding that "the concept of assessing a family caregiver's own needs is not well understood in many Medicaid HCBS program."
The report makes eight specific policy recommendations, including:
"When a family caregiver assessment is conducted, family caregivers must be directly asked about their (a) own health and well-being, (b) levels of stress and feelings of being overwhelmed, (c) needs for training in knowledge and skills in assisting the care recipients, and (d) any additional service and support needs."
The report also recommends that assessment of caregivers be recorded and made a part of the HCBS client's record, including electronic records. The report compares practices among the fifty states and D.C., identifies potential best practices, and concludes that many states' current assessment tools are inadequate.
Hat tip to ElderLawGuy Jeff Marshall for "tweeting" on this important new study.
Monday, December 9, 2013
National Council on Aging Urges Public Support for This Week's Vote on "Qualified Individual" Medicare Funding
From the National Council of Aging (NCOA) a call for action, urging people to write their federal legislators:
This week, House and Senate Committees are scheduled to vote on a bill to permanently fix the longstanding problems with Medicare physician payments. The bad news is that the Medicare Qualified Individual (QI) Program may not get the fix it needs—leaving nearly half a million low-income people with Medicare facing new, unaffordable costs or reduced access to their doctors.
The QI program pays Medicare Part B premiums for beneficiaries with incomes of about $14,000-$15,500, most of whom already must spend over a quarter of their meager income on health care.
If the bills fail to make the QI program permanent, low-income seniors could be forced to drop the Part B benefit and lose access to their doctors, or pay over $1,200 in new, additional premiums.
This means that a senior with just a $14,000 income would only have $9,000 left for all their other living expenses.
The NCOA offers an easy form to use in emailing your Congressional representatives to urge them to vote to make the QI program permanent to protect seniors' economic security and access to physicians.
As readers of this blog will be aware from previous posts, Pennsylvania courts are willing to enforce the Commonwealth's filial support law. The law, at 23 Pa. C.S.A. Section 4603, makes spouses, parents or adult children potentially liable to "care for and maintain or financially assist" each other where the care-needing family member is "indigent." Pennsylvania's law has been interpreted as giving nursing homes or other third-party caregivers standing to sue.
The suits can cross state lines, usually because the target defendant is an out-of-state son or daughter of a nursing home resident in Pennsylvania, thus creating potentially interesting questions of personal jurisdiction. But the latest suit I've seen is an interesting twist on that fact pattern.
In Eades v. Kennedy, P.C. Law Offices, filed in United States District Court for the Western District of New York, a New York husband and daughter are the plaintiffs, suing a Pennsylvania law firm that attempted to collect a nursing home debt "by means of at least one item of correspondence and at least one telephone call." The plaintiffs in the New York suit are also apparently defendants in a Pennsylvania lawsuit filed by the nursing home. At issue is a bill for $8,000. The nursing home in question, located in Corry, Pennsylvania, is just a few miles south of the New York state line.
In the New York suit, Eades asserts that the collection attempts violated the Fair Debt Collection Practices Act (FDCPA) and further that the law firm's allegations of their liability under Pennsylvania's filial support law is "preempted" by federal Medicare/Medicaid law, under a provision of the Nursing Home Reform Act (NHRA) that bars a nursing home from requiring "a third party guarantee of payment to the facility as a condition of admission."
The New York federal district court dismisses the suit, concluding that there is no "jurisdiction," apparently both on subject matter jurisdiction and personal jurisdiction grounds. But then the ruling gets more interesting. The court proceeds to address the substantive claims by the family members, and seems to conclude that a cause of action under the FDCPA is not triggered by a "support" claim, including a filial support claim. Further, the court suggests there is no preemption under federal law for the following reasons:
"The NHRA holds that nursing homes may not require an individual's relatives to assume personal liability for the individual's care as a condition of admission or continued residence in the facility. The Pennsylvania indigent statute cannot be said to cover the same territory: it merely holds that where a resident is or becomes indigent, a nursing home may seek payment or reimbursement for the resident's care from their spouse, children or parents. It does not bypass the NHRA by permitting or excusing the assumption of personal liability by a relative for a nursing home resident's care as a consideration of admission or continued residence -- the sole evil that the NHRA ... appears to have been intended to prevent."
On December 3, 2013, the New York court dismissed the father/daughter's amended complaint for failure to "state a claim." The case is Eades v. Kennedy, P.C. Law Offices, No. 12-CV-66801, 2013 WL 6241272 (W.D. N.Y. 2013).
Wednesday, November 20, 2013
Question: When is a hospital "stay" not a hospital "admission?" Answer: When someone has a financial incentive to treat it that way.
My colleague Becky Morgan has blogged several times on the serious problem with seemingly fictional "observation status" labels attached to hospital stays, as well as the so-called "3 Midnight" requirement. See Sept. 20 Post and Sept. 5 Post. For patients, the observation status fiction impacts on whether Medicare Part A will cover the care in the hospital. Further, without three nights of covered care in the hospital, Medicare may not cover subsequent care at a skilled care facility for rehabilitation.
Why do hospitals use "observation status" labels? Well, at last one reason is because the label may reduce the potential for regulation-based penalties to attach to later readmissions to the hospital. Why do regulatory authorities indulge in the fiction? Probably because -- on some level -- the consequences are seen as reducing Medicare costs.
Several bills are pending in Congress that would impact affected parties if enacted. Here's an inventory, complete with clever names. Let's hope the clever names are not more important than actually finding a solution:
- CARES Act: The "Creating Access to Rehabilitation for Every Senior" Act, H.R. 3531, introduced by Rep. Jim Renacci (R-OH), would eliminate the 3-midnight rule for transfers to certain "qualified" centers. This bill was introduced on November 19, 2013.
- Fairness for the Beneficiaries Act: Under H.R. 3144, a physician could certify that a resident requires skilled care for rehabilitation as a prequisite to Medicare Part A coverage. This bill was introduced by Rep. Jim McDermot (D-WA) on September 19, 2013
- Improving Access to Medicare Coverage Act: Rep. Joe Courtney (D-CT), introduced H.R. 1179 on March 14, 2013, would treat outpatient observation status services in a hospital as inpatient services for purposes of satisfying the 3-day requirement for extended care services in a skilled nursing facility. Senator Sherrod Brown (D-OH), sponsored parallel legislation, S. 569, in the Senate on the same day.
Any other pending legislation on this topic? Of course, some of the bills were also introduced in 2011, but generated no significant action.
Some interim administrative changes through CMS have generated opposition, as insufficient or unworkable. as reported in McKnights.
Thursday, November 7, 2013
Effective this year, a new law enacted in New Hampshire declares that under certain circumstances a "fiduciary who possesses or controls the income or assets of a resident and has the authority and duty to file an application for Medicaid. . . shall be liable . . . to the long-term care facility for all costs of care which are not covered by Medicaid due to the fiduciary's negligence in failing to promptly and fully complete and pursue an application for Medicaid benefits for the resident."
A bit of practical background is appropriate to appreciate the significance of this new law.
Older individuals entering a nursing home have essentially three options for how to pay the bills at a facility: Medicare, Medicaid or Private Pay (and by private pay, I'm including the possibility of making a claim under long-term care insurance, family contributions or the resident or couple's income and savings).
For older individuals going directly from a hospital into skilled care or rehabilitative care, Medicare is often the first payment source, for up to 100 days per spell of illness. On a comparative basis, Medicare is relatively easy to negotiate, as the facility usually handles the initial paperwork.
It gets trickier, however, if long-term care is contemplated and Medicaid could be a possibility. Medicaid-eligible facilities prefer the higher pay rates associated with private pay, and therefore may not be highly motivated to talk with residents or families about Medicaid, unless it is the only option. But they often ask family members to pay and thus the burden of figuring out how to pay is on the family. Sometimes that family member is the out-of-town son or daughter. Sometimes that family member is a frail spouse.
As I have discussed in prior scholarship, gaps in payment sources can occur for a variety of reasons. The resident is rarely the cause of the gap as usually the frailty or illness of residents is the reason they are in a care facility to begin with. Rather, some third-party -- or the facility itself --will usually have to handle the paperwork associated with Medicaid applications. And Medicaid applications, typically requiring collection and analysis of the previous five years of the applicant's financial records, can be challenging.
So, who are these fiduciaries facing potential liability? The New Hampshire law says a "fiduciary" is a "person to whom power or property has been formally entrusted for the benefit of another such as an attorney-in-fact, legal guardian, trustee, or representative payee."
There are additional conditions and qualifications in the statute affecting the potential liability of the agent or other fiduciary. ElderLawGuy Jeff Marshall on his Blog has a thoughtful analysis of implications of the new law.
My starting question: So, what about the family member who is named as an agent under a power of attorney, has never taken action under the POA, and for whatever reason (tiredness, lack of understanding, perhaps being overwhelmed by work or other family responsibilities) does not step forward to handle the Medicaid application process. Is having the "authority" to serve as an agent enough -- under this statute -- to trigger a corresponding duty?
By the way, as I discussed in an August post, New Hampshire recently repealled its filial support laws. I am now wondering if there was some horse-trading in the halls of the N.H. legislature whereby nursing home lobbyists agreed to the repeal of filial support laws in exchange for what I might call "fiduciary support" liability? Anyone with insights into the history of this new law?
Feel free to "comment" below.
According to a November 4th Justice Department release, Hospice of the Comforter, Inc. (HOTCI), a company based in Florida, has agreed to pay $3 million to resolve claims it submitted false claims for services covered by Medicare for hospice patients. The company also has issued a statement regarding the settlement, linked on its home webpage.
The report on HOTCI is the latest in a series of settlements or agreements related to whistleblower allegations of Medicare fraud in the hospice industry. In addition to payments to be made over a period of years, the Justice Department reports that HOTCI has entered into to a "corporate integrity agreement" with the Inspector General for Health and Human Services. Further, "HOTCI’s former Chief Executive Officer Robert Wilson has agreed to a three-year, voluntary exclusion from Medicare, Medicaid and other federal health care programs," according to the Justice Department release.
The original whistleblower in the HOTCI case, a former executive, reportedly objected to the $3 million settlement, calling it unreasonably low.
On the one hand, settlements are sometimes criticized as sending the wrong message, arguing agreements to pay comparatively low figues act as a cost of doing business in otherwise still profitable industries, such as the hospice industry. On the other hand, whistleblowers under the False Claims Act stand to recover a percentage of the amounts recovered in the cases.
Other recently reported settlements with hospice providers:
- Hospice of Arizona L.C. and related companies ($12 million, May 2013)
- Multi-state provider Odyssey HealthCare ($25 million, March 2012)
- South Carolina's Harmony Care Hospice Inc. ($1.2 million, November 2012)
- Alabama-based, multi-state SouthernCare Inc. ($24.7 million, January 2009)
Tuesday, November 5, 2013
Pharmaceutical giant Johnson & Johnson will plead guilty to a criminal misdemeanor and pay $2.2 billion, thus concluding a long federal criminal investigation into the company's alleged marketing of certain antipsychotic drugs for off-label, unapproved uses, including allegations the drugs were promoted for use by the elderly with dementia.
The original charges flow from whistleblower reports under the False Claims Act, involving Risperdal and other drugs. Details of the deal are widely reported in the New York Times, Bloomberg and the Justice Department has issued a press release.
Monday, November 4, 2013
On October 28, 2013, the office of HHS Intergovernmental and External Affairs announced Medicare deductible and cost-sharing information for 2014. The official federal register announcement should be forthcoming shortly. Questions should be directed to HHS IEA (OS/IEA), HHSIEA@hhs.gov.
The Medicare Part A deductible per spell of illness (or benefit period) for hospital coverage be $1,216 in 2014 (an increase of $32 from the 2013 deductible of $1,184).
Hospital copayment amounts (2014):
Day 1- 60: $0.
Day 61 – 90: $304 per day
Day 91-150: $608 per day.
Skilled Nursing Facility copayment amounts (2014)
Day 1 -20: $0
Day 21- 100: $152.00
The Medicare Part A premium (2014)
The Medicare Part A premium in 2014 is $426 per month. Part A covers inpatient hospital, skilled nursing facility, and some home health care services. Most beneficiaries do not pay a premium for Part A because they have at least 40 quarters of Medicare-covered employment. In 2014 beneficiaries who have between 30 and 39 quarters of Medicare-covered employment may buy into Part A at a reduced monthly premium rate of $234.
The standard Medicare Part B monthly premium will be $104.90 in 2014, the same as it was in 2013. The Medicare Part B deductible will also remain unchanged at $147.
For 2014, the income-related monthly premium rates will remain the same as they were in 2013. States have programs that pay some or all of beneficiaries' premiums and coinsurance for certain people who have Medicare and a limited income. Information is available at 1-800-MEDICARE (1-800-633-4227) and, for hearing and speech impaired, at TTY/TDD: 1-877-486-2048.
For more information about the 2014 Medicare Part B premium and Medicare in general, please go to www.Medicare.gov.
Wednesday, October 23, 2013
Following last week's USA Today article exposing thefts by nursing home employees from resident trust accounts, Senator Bill Nelson, chair of the U.S. Senate Special Committee on Aging, has called upon the Inspector General to investigate management and oversight practices and to reommend corrective action by the Centers for Medicare and Medicaid (CMS). CMS has oversight authority over nursing homes.
In a letter dated October 21, Senator Nelson targets the absence of standard protocals for safeguarding such accounts:
"Widespread negligent oversight allowed some of these theft and embezzlements schemes to go on undetected for years, and in some instances the losses totaled more than $100,000. Several of these trust fund culprits were caught merely by accident or due to the suspicions of a co-worker, and not by systematic financial auditing or tight management controls."
If, as the saying goes, no good deed goes unpunished, no bad deed by a nursing home goes uninvestigated by Congress. Stay tuned, but don't hold your breath.
Thursday, October 10, 2013
Center for Medicare Advocacy Alert: Proposed Legislation Would Implement Home Health Episode Payment Caps
Caution: Home Health Episode Payment Caps Legislation was introduced on October 4th that could lead to a cap on the home health services available to a Medicare beneficiary. In the midst of a government shutdown, Representatives Matheson (D-Utah) and Guthrie (R-Kentucky) introduced the "Medicare Home Health Fraud Reduction Act" (H.R. 3245). This bill would establish maximum annual reimbursements to Medicare home health agencies. Instead of a payment cap for each beneficiary, such as the current annual cap on Medicare-covered outpatient therapy, this bill would impose an aggregate payment cap for each home health agency's caseload. While promoted as an anti-fraud measure that would have little impact on beneficiaries, to the contrary, the Matheson-Guthrie proposal is a dangerous policy that would create barriers to care for individuals with long-term, chronic conditions. Further, it would jeopardize implementation of the Jimmo v. Sebelius settlement. That settlement reiterates Medicare policy that medical improvement is not the deciding factor in determining the availability of Medicare-covered nursing and therapy services for persons with chronic conditions.
Over the past several years, legislators, think tanks, and other entities have offered policy proposals to reduce Medicare expenditures. Many of these proposals purport to save federal dollars by shifting additional costs directly to Medicare beneficiaries. Examples include: raising premiums for middle and higher income people; increasing deductibles and copays; prohibiting or discouraging the purchase of the most generous Medigap plans; and instituting copays (cost-sharing) for home health services. Many players potentially affected by proposals to reduce Medicare expenditures – including provider groups – act to thwart proposals that would adversely impact them. The home health industry opposes requiring copays on home health services, a position with which the Center for Medicare Advocacy strongly agrees. In an effort to ward off home health copays, elements of the home health industry have offered alternative proposals that could potentially save federal dollars by limiting the home health benefit for beneficiaries.
Wednesday, August 28, 2013
Robert L. Kane, Andrea Wysocki, Shriram Parashuram, Tetyana Shippee, and Terry Lum, researchers at the University of Minnesota School of Public Health and the University of Hong Kong, have released their study, "Effect of Long-term Care Use on Medicare and Medicaid Expenditures for Dual Eligible and Non-dual Eligble Elderly Beneficiaries," comparing the effects on costs by level of care and location, including nursing home or community care. The report offers findings that may be surprising for critics of nursing home cost, suggesting that nursing homes may actually be "subsidizing Medicare by reducing hospital use and lowering medical expenditures." The report is published in the peer-reviewed, on-line Medicare & Medicaid Research Review, a publication of CMS, the Centers for Medicare & Medicaid Services.
Tuesday, August 27, 2013
We are seeing a lot of information coming out from the federal government as a result of the Windsor ruling. Most recently, a colleague sent me a link from the IRS site with Answers to Frequently Asked Questions for Same-Sex Couples (last updated July 2, 2013). Among the 8 FAQ (in no particular order) are: "Can same-sex partners who are legally married for state law purposes file federal tax returns using a married filing jointly or married filing separately status?"; "Can a taxpayer use the head-of-household filing status if the taxpayer’s only dependent is his or her same-sex partner?"; and "If a taxpayer adopts the child of his or her same-sex partner as a second parent or co-parent, may the taxpayer (“adopting parent”) claim the adoption credit for the qualifying adoption expenses he or she pays or incurs to adopt the child?".
Meanwhile, over at Social Security, Acting Commissioner Carolyn W. Colvin issued a statement on August 9th "that Social Security is now processing some retirement spouse claims for same-sex couples and paying benefits where they are due." SSA offers several articles on benefits for same-sex couples.
The U.S. Department of Labor (by the way, they have a nifty little intro page about their upcoming 100 year anniversary) issued a revision to Fact Sheet 28F that includes in the definitions spouses in same-sex marriages. LexisNexis Legal Newsroom on Labor and Employment Law, has an interesting article on the extension of FMLA as a result of Windsor, written by Barran Liebman LLP attorneys.
Further, on August 14th, 2013, the Department of Defense announced that it was extending spousal benefits to same-sex spouses of civilian employees as well as uniformed service members. The DoD indicated the benefits would be available no later than September 3, 2013 for those with a valid marriage certificate.
"Entitlements such as TRICARE enrollment, basic allowance for housing (BAH) and family separation allowance are retroactive to the date of the Supreme Court's decision. Any claims to entitlements before that date will not be granted. For those members married after June 26, 2013, entitlements begin at the date of marriage."
The Secretary of Defense sent a memo that explained the actions and noted that since not all jurisdictions allow same-sex marriage, the DoD will issue a "non-chargeable leave" policy for military personnel who have to travel to a state to be married, with an immediately-effective memo supplementing the existing leave policy.
Stay tuned-we will keep you posted with further updates.
Photo by Kim Dayton, © 2013
Monday, August 19, 2013
Pennsylvania has become the hotbed of "filial support law" enforcement suits, with health and long-term care facilities leading the charge.
In 2012, in Health Care & Retirement Corp.(HCR) v. Pittas, an intermediate court of appeals held an adult son liable for more than $92k in nursing home costs incurred by his mother under Pennsylvania's filial support law, 23 Pa.C.S.A. Section 4603. For a brief video analysis of the Pittas case and Pennsylvania law, see here.
The Pittas case was controversial in part because the court did not point to any fault on the part of the son as justification for enforcement. For example, there was no discussion of "improper" transfers or theft of the parent's assets, facts that had sometimes been the background of previous cases.
The Pennsylvania trend certainly has not gone unnoticed by the media or courts and legislatures in other states. I receive regular calls from attorneys and parties on all sides of the "filial support" enforcement controversies asking me to compare their state's (or even foreign countries') laws to Pennsylvania. For more on comparative analysis of filial support enforcement issues, see my recent Elder Law Journal (University of Illinois School of Law) article here.
Perhaps we are now seeing the pendulum swing the other way, rejecting modern enforcement attempts. One of the latest rulings on filial support law occurred in Montana. In a July 2013 decision, the trial court granted summary judgment in favor of a son on a nursing home's claim of close to $15k incurred for his mother's care. The court declined to enforce a cause of action for filial support, citing a bar on "third-party guarantees" under federal Medicare and Medicaid law, and thus suggesting enforcement of the state's separate filial law was preempted. For a scanned copy of the decision in Heritage Place, Inc. v. Jarrell, Case No. DV-11-430(D), in the 11th Judicial District Court, Flathead County, Montana, see the link available through ElderLawAnswers.
Perhaps even more significant is recent action by the New Hampshire legislature, changing state law to eliminate a statutory basis for an adult child to be held liable to support his or her parents. See 2013 New Hampshire Laws Ch. 212 (H.B. 481), approved July 10, 2013 and effective on January 1, 2014, amending N.H. Rev. Stat. Sections 167.2 and 546.A:2.
Will Pennsylvania legislators take similar action? For an answer to that question, follow Pennsylvania Senate Bill 70 and House Bill 224, for the 2013-2014 legislative session. Both the nursing home industry and the Pennsylvania Department of Public Welfare have opposed repeal efforts in recent years, while the Pennsylvania Bar Association has supported repeal.
Tuesday, August 13, 2013
The 66th Annual Meeting for the Gerontological Society of America (GSA) takes place in New Orleans on November 20-24, 2013. As lawyers and law professors are aware, "Elder Law" is an inherently multi-disciplinary field. The GSA meeting is an opportunity to discover and share the latest in interdisciplinary research on medicine, clinical care, basic science, social science, behavioral science, and public policy for issues connected to aging. The meeting attracts an international audience, with more than 4,000 attendees, and some 400 substantive sessions.
The theme for this year's meeting is "Optimal Aging through Research," and there is a special workshop on the topic of family caregiving for persons with dementia, which should be particularly interesting for those seeking the latest in evidentiary bases for state or federal legislation to support caregivers. Further, the deadline for "late-breaking" abstracts for poster submissions is September 15.
Full details on the annual meeting are available at GSA's website.
Wednesday, July 18, 2012
Richard Kaplan (Illinois) has published an article entitled “Top Ten Myths of Medicare,” which has just appeared in The Elder Law Journal, vol. 20, no. 1 (2012). Full text is available at: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=211153
It's a must-read, IMHO.
In the context of changing demographics, the increasing cost of health care services, and continuing federal budgetary pressures, Medicare has become one of the most controversial federal programs. To facilitate an informed debate about the future of this important public initiative, this article examines and debunks the following ten myths surrounding Medicare: (1) there is one Medicare program, (2) Medicare is going bankrupt, (3) Medicare is government health care, (4) Medicare covers all medical cost for its beneficiaries, (5) Medicare pays for long-term care expenses, (6) the program is immune to budgetary reduction, (7) it wastes much of its money on futile care, (8) Medicare is less efficient than private health insurance, (9) Medicare is not means-tested, and (10) increased longevity will sink Medicare.
Friday, June 29, 2012
he National Senior Citizens Law Center and the National Committee to Preserve Social Security and Medicare have released an analysis detailing the positive impact the Supreme Court’s decision to uphold the Affordable Care Act will have on older Americans. Most Americans will be touched by the ruling, but America’s older adults will be impacted in these ways:
- They will continue to receive prescription drug savings through brand name and generic discounts
- The Part D prescription drug coverage gap known as the ‘donut hole’ will continue to be phased out
- Covered annual wellness visits for beneficiaries will continue to be provided in Medicare
- Older adults will pay less for preventive services. Under the ACA, Medicare will fully cover screenings like mammograms, pap smears, bone mass measurements, depression screening, diabetes screening, HIV screening and obesity screenings
- Eight years has been added to Medicare’s solvency thanks to the Affordable Care Act
The future of an estimated 3.3 million uninsured seniors, aged 50-64, who would have received health coverage under Medicaid and many of the 16 million older adults and individuals with disabilities who rely on Medicaid for long-term services and supports, is less certain with this ruling as the Court has limited the government’s ability to penalize states who do not participate in the expansion of Medicaid.
Read the complete analysis here.
Friday, December 16, 2011
Here's a summary:
Many of the almost 22 million Medicare beneficiaries age 65 and older who were enrolled in Medicare Part D in 2009 did not receive the routinely recommended vaccinations covered by Part D. CDC national survey data for 2009 show that 11 percent of Medicare beneficiaries age 65 and older had received a shingles vaccination and 53 percent had received a Td (tetanus and diphtheria) vaccination—the routinely recommended vaccinations covered under Part D. Medicare data for 2007 through 2009 show that relatively few Part D beneficiaries received these vaccinations under Part D—5 percent for shingles and less than 1 percent for Td or Tdap (which includes protection against pertussis). These data suggest that beneficiaries either received vaccinations prior to enrolling in Medicare or, once enrolled, used other health coverage or paid out of pocket for these vaccinations.
A multitude of factors affect beneficiaries’ access to routinely recommended Part D-covered vaccinations, particularly the low percentage of physicians and pharmacies that stock the relatively new shingles vaccine. Most physicians do not stock the shingles vaccine due to factors such as the cost of purchasing a supply and Part D billing challenges. More than half of physicians refer beneficiaries to pharmacies to purchase the vaccine—which may require beneficiaries to transport the vaccine back to the physician to be administered. Physicians recommend shingles vaccinations less often than other vaccinations, and even when they recommend them, beneficiaries often decline them. At the same time, due in part to a limited supply of the shingles vaccine, only about one-third of pharmacies nationwide stock it. Beneficiaries’ cost sharing—which averaged $57 for a shingles vaccination in 2009—and challenges with obtaining reimbursement from Part D plans were other reported deterrents to beneficiaries’ obtaining Part D vaccinations.
Many stakeholders—government agencies, advisory bodies, and professional organizations—have raised concerns about the administrative challenges associated with Part D and have recommended actions to improve access to Part D vaccinations. The Centers for Medicare & Medicaid Services has issued guidance on a number of approaches to help address administrative challenges, but stakeholders report that additional steps are needed, including broader use of web-based systems, that could provide real-time access to allow physicians to verify beneficiary coverage and bill Part D plans.
Recommendation: To help improve the ability of Medicare beneficiaries to obtain routinely recommended vaccinations, the Administrator of CMS should explore options and take appropriate steps to address administrative challenges, such as physicians’ difficulty in verifying beneficiaries’ coverage and billing for Part D-covered vaccinations.
Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
Tuesday, November 29, 2011
Observation Status and its Impact on SNF Coverage – An Update.
December 14, 2011, 2:00 PM Eastern
Register now for important updates on the nationwide problem of observation status in acute care hospitals. Medicare beneficiaries are placed in hospital beds and receive medical and nursing care, diagnostic tests, treatments, medications, and food for multiple days, but they are called outpatients, not inpatients. The result is a huge financial burden, particularly for beneficiaries who need post-hospital care in a skilled nursing facility and are told they did not have a qualifying three-day in-patient hospital stay. CMS' refusal to alter this policy has led advocates to litigate the issue, which will also be discussed. The webinar will be presented by Center for Medicare Advocacy Policy Attorney Toby Edelman, Attorney Terry Berthelot, and Litigation Director Gill Deford.
- A new federal Class Action lawsuit filed to challenge this practice
- The scope of the problem and its causes
- How to pursue an administrative appeal
- Strategies for legislative and administrative advocacy
Tuesday, April 5, 2011
GOP FY 2012 BUDGET PLAN SETS STAGE FOR MEDICARE, MEDICAID CHANGES
Posted April 5, 2011, 10:34 A.M. ET
The House Republican budget resolution for fiscal 2012 would decrease federal deficits by $1.649 trillion over the 2012-2021 period by cutting spending by almost $6 trillion, according to a summary of the proposal released April 5.
The plan would set the stage for major changes in the two biggest federal health care programs, Medicaid and Medicare, and put in place "enforceable spending caps" to restrain outlays. It would also make permanent the 2001 and 2003 tax cuts and repeal the 2010 health care overhaul.
In the area of changing Medicare, the House budget document said current program beneficiaries would not be affected. When younger workers become eligible for Medicare, they would be able "to choose from a list of guaranteed coverage options, enjoying the same kind of choices in their plans that members of Congress enjoy today. Medicare would then provide a payment to subsidize the cost of the plan. In addition, Medicare will provide increased assistance for lower-income beneficiaries and those with greater health risks."
And for Medicaid, the summary said the Republican budget proposal would end "an onerous, one-size-fits-all approach by converting the federal share of Medicaid spending into a block grant that gives states the flexibility to tailor their Medicaid programs to the specific needs of their residents."
According to the summary, the resolution would cut spending by $5.812 trillion compared to projections under current law by the Congressional Budget Office. In comparison, the CBO said March 18 President Obama's budget would raise outlays by about $412 billion over the same period, mostly to pay for interest costs on debt.
But the deficit-reduction impact of the spending cuts would be offset by revenue cuts almost as large. The summary showed revenues would fall by $4.162 trillion over the 2012-2021 period, much more than$2.331 trillion revenue loss seen in the Obama budget. Much of that revenue loss is in both cases is tied to the costs of extending the 2001 and 2003 tax cuts.
Even with additional tax cuts, the GOP budget would decrease the deficit, in contrast with the Obama plan. The CBO said the Obama plan would add $2.733 trillion to the deficit over the 10-year period.
Text of the budget summary will be available at http://op.bna.com/der.nsf/r?Open=csaz-8fmj2j.
Wednesday, October 13, 2010
Open Enrollment for Medicare is just around the corner. At this time of year current or newly-eligible Medicare beneficiaries, including people with original Medicare, can review their current health or prescription drug plans, compare the plans to other options, and choose the plans that best meet their current needs. With the new health care law, there are new benefits available to people with Medicare, including lower prescription costs, wellness checkups and preventive care. The new law also provides better ways to protect beneficiaries from fraud, making Medicare stronger for all of us and for future generations.
AoA is sponsoring a Webinar on this year's open enrollment process and changes to Medicare resulting from the Affordable Care Act. Join the panel members as they provide more details on these exciting new benefits so that you can help educate others during Open Enrollment.
The webinar will take place at 5:30pm EDT THURSDAY October 14 at http://www.HealthCare.gov/live.