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CMA Alert – Expand & Improve Medicare

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  1. Improve and Expand Medicare: Guarantee Medigap Entry
  2. Goal Medicare Appeals Jeopardized By New ALJ Choice Course of
  3. CMA Report: Nurse Staffing Deficiencies In Nursing Amenities
  4. Well being Affairs Research Requires Medicare Protection of Listening to Care Providers
  5. Senator Cardin Introduces Invoice to Add Oral Well being Protection to Medicare

Improve and Expand Medicare: Guarantee Medigap Entry

Lately, the Middle for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of many core issues to enhance Medicare for all beneficiaries, now and sooner or later, is the necessity to protect and increase shopper protections and high quality protection for all Medicare Beneficiaries – together with parity between conventional Medicare and personal Medicare plans. One of many key points at present limiting selection and protection for Medicare beneficiaries is restricted entry to Medigap plans.

Medicare Complement Insurance coverage, extra generally known as Medigap, is insurance coverage that helps pay for “gaps” in Medicare cost. Medigap doesn’t usually pay for gaps in providers not coated by conventional Medicare, however fairly for value-sharing when protection is offered by Medicare Elements A and B. Given the excessive prices of well being care and Medicare value-sharing, Medigap insurance policies are key to affording look after individuals in conventional Medicare.

Sadly, nevertheless, there are limitations on accessing these essential plans:

  • Federal regulation requires Medigap “guaranteed issue” protections for individuals age 65 and older solely through the first six months of their Medicare Half B enrollment and sure different restricted conditions, together with throughout a “trial” Medicare Benefit enrollment interval. Beneficiaries who miss these home windows of alternative might not be capable of buy a Medigap coverage later in life if their wants or priorities change.
  • Beneficiaries underneath age 65 with disabilities who qualify for Medicare haven’t any assured challenge in any respect. (Particular person states might supply various levels of shopper safety, however many don’t).

Rights to buy Medigap supplemental insurance coverage insurance policies must be expanded to individuals beneath 65 and will embrace ongoing entry for all with a purpose to present actual, significant decisions for all Medicare beneficiaries.

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Goal Medicare Appeals Jeopardized By New ALJ Choice Course of

On July 10, 2018, the President signed an Government Order undermining the neutral hiring of Medicare Administrative regulation Judges (ALJs). The Order states that “conditions of good administration make necessary an exception to the competitive hiring rules and examinations for the position of ALJ.”  What this implies is that ALJs will now be employed instantly by every particular person company, together with the Division of Well being and Human Providers (which administers CMS) for Medicare appeals. This can be a dramatic change from the present centralized system that selects candidates deemed certified via a aggressive examination and choice procedures administered by the Workplace of Personnel Administration (OPM).

Advocates and legislators are involved. When the change was introduced, Rep. John Larson of Connecticut stated that People “deserve an impartial hearing by a highly-qualified, independent judge. But under the Administration’s new policy, they will face a judge beholden to ideology and politics rather than one selected through a competitive process designed to ensure qualification and neutrality.”

By statute, Medicare ALJs have to be unbiased of CMS. The Medicare Prescription Drug, Enchancment and Modernization Act of 2003 ((MMA), Public Regulation 108-173, §931) transferred the perform for Medicare ALJ appeals from the Social Safety Administration to the Division of Well being and Human Providers. The regulation particularly states that ALJs are to be “organizationally and functionally independent of CMS.”[1] The Government Order conflicts with this statutory requirement.  We worry that equity and objectivity shall be threatened, and the independence of ALJs appointed via this course of shall be in query.

The method for screening and placing ahead candidates might, at first look, look affordable.  However we stay involved because the final choice can be made by HHS – the company answerable for the insurance policies beneath evaluation at ALJ hearings.  This can be a vital departure from the present centralized system that selects candidates deemed certified via a aggressive examination and choice procedures administered by OPM. 

The brand new choice course of that ties ALJ appointments to HHS doesn’t bode properly for Medicare beneficiaries who search a good, unbiased evaluation of Medicare protection denials. The Middle for Medicare Advocacy’s expertise with hundreds of Medicare appeals demonstrates that the decrease ranges of attraction have turn into all however rubber stamps of Medicare denials. The ALJ degree of attraction is the one actual probability for beneficiaries to acquire an unbiased evaluation. The equity and objectivity of the appeals course of can be gravely broken by granting HHS the ultimate say within the choice course of and choice of Medicare ALJs.

For extra dialogue on the significance ALJ Independence, see:

[1] (5 USC §554(d); 70 Fed Reg 11420-499 (March eight, 2005).

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CMA Report: Nurse Staffing Deficiencies In Nursing Amenities

The Nursing House Reform Regulation (1987) established the federal requirements for nurse staffing in nursing amenities: registered nurses eight consecutive hours per day; licensed nurses 24 hours per day; and “sufficient” nursing employees to satisfy residents’ wants.[1]

Most nursing amenities wouldn’t have enough numbers of nurses to offer the care that residents want.  The result’s poor care outcomes for residents – avoidable strain ulcers, medicine errors, inappropriate use of psychotropic drugs, failure to help residents with actions of day by day dwelling, avoidable weight reduction, falls, and extra.  

In 2014, the Middle for Medicare Advocacy checked out nurse staffing deficiencies that the Facilities for Medicare & Medicaid Providers (CMS) cited within the 4-yr interval 2010-2013.  In an Alert entitled “Staffing Deficiencies in Nursing Facilities: Rarely Cited, Seldom Sanctioned,” the Middle reported that CMS cited few staffing deficiencies and that monetary penalties for even probably the most critical deficiencies – these labeled “immediate jeopardy” – have been rare.[2]

In December 2018, the Middle once more reviewed deficiencies cited by CMS for inadequate nurse staffing, this time, between November 28, 2017 (the efficient date of the brand new, uniform federal survey course of) and December 18, 2018.[3]  Whereas CMS cited extra staffing deficiencies than it did within the Middle’s earlier assessment, it continued to categorise most of them as “no-harm” and to impose few enforcement actions for these it labeled “actual harm” or “immediate jeopardy.”

The overwhelming majority of the 781 deficiencies (96.eight%) have been cited as “no harm,” a degree of noncompliance that CMS usually doesn’t sanction with monetary penalties.

Staffing Deficiencies, Nov. 28, 2017-Dec. 18, 2018
Complete: 781 Deficiencies

Degree of staffing deficiency

Variety of amenities cited with deficiency at this degree

Proportion of complete staffing deficiencies cited at this degree

Speedy jeopardy



Precise hurt



No hurt



Substantial compliance



CMS imposed few cures on the 23 amenities whose staffing deficiencies it referred to as jeopardy or precise hurt.

  • CMS didn’t impose a civil cash penalty (CMP) or denial of cost for brand spanking new admissions (DPNA) on 10 of the 17 amenities that it cited with fast jeopardy deficiencies.  CMS imposed DPNA solely on one facility and CMPs on six amenities.  Solely two amenities with an instantaneous jeopardy staffing deficiency had a CMP of greater than $100,000.  (It’s attainable that CMS imposed CMPs towards further amenities.  Nevertheless, if a facility appeals the CMP, CMS doesn’t publicly publish the CMP whereas the attraction is pending.)
  • CMS didn’t impose a CMP or DNPA on two of the six amenities that it cited with precise hurt deficiencies.  It imposed DPNA-solely on two amenities and CMPs-solely on two different amenities.  The CMPs for the 2 amenities averaged $28,586.

The federal survey stories have been comparable to one another, whether or not the staffing deficiency was cited as fast jeopardy or no-hurt. Surveyors comply with the federal survey protocol that directs them in find out how to determine and cite deficiencies. However, and despite the fact that the Middle reviewed solely a small variety of survey stories, what’s most putting is how comparable the proof seems within the survey studies, whatever the degree of noncompliance recognized. Surveyors describe the failures of care by way of a number of examples of: poor resident outcomes, resident complaints about inadequate staffing, employees admissions that the power is just not adequately staffed to satisfy residents’ wants, and documentation from facility data that the power doesn’t have sufficient employees (in accordance with its personal staffing requirements). Surveyors appeared extra more likely to cite instant jeopardy in staffing once they cited further jeopardy-degree deficiencies. In these instances, they included further particulars and examples concerning the staffing deficiency. Nevertheless, as a common matter, the proof that surveyors cite seems to be the identical, whether or not the deficiency known as jeopardy or no-hurt.

For the Middle’s full report, together with descriptions of nurse staffing deficiencies at eight nursing amenities, and proposals to strengthen the federal oversight system to guard residents, see: http://www.medicareadvocacy.org/report-nurse-staffing-deficiencies/.

[1] 42 U.S.C. §§1395i-three(b)(four)(C)(i), 1396r(b)(four)(C)(i)), Medicare and Medicaid, respectively.
[2] “Staffing Deficiencies in Nursing Facilities: Rarely Cited, Seldom Sanctioned,” (CMA Alert, Mar. 7, 2014), http://www.medicareadvocacy.org/staffing-deficiencies-in-nursing-facilities-rarely-cited-seldom-sanctioned/. 
[3] For info on deficiencies between 2013 and 2017, see the Lengthy Time period Care Group Coalition’s reviews of deficiencies cited between 2014 and 2017, by state, at https://nursinghome411.org/us-nursing-home-citations-2014-2017-november-2017/. Notice: The Coalition’s state deficiency stories embrace all well being deficiency citations. Inadequate staffing deficiencies are recognized as F-353.













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Well being Affairs Research Requires Medicare Protection of Listening to Care Providers

The Medicare program has excluded protection for listening to aids and associated audiology providers since its implementation in 1965, regardless of documented dangers related to untreated listening to loss and hyperlinks to different continual circumstances. Whereas the Over-the-Counter Listening to Help Act of 2017 will quickly permit entry to listening to aids for delicate-to-average listening to loss with out the providers of an audiologist or listening to assist dispenser, a current Well being Affairs research means that ongoing socio-financial obstacles might restrict using very important listening to care providers, comparable to fittings and counseling.

In “Access to Hearing Care Services Among Older Medicare Beneficiaries Using Hearing Aids,” the research’s authors discover that older adults dually eligible for each Medicare and Medicaid had “41 percent lower odds of using hearing care services and were twice as likely to report having a lot of trouble hearing with their aids, compared to high-income Medicare beneficiaries.” Due to such findings, the authors observe that beneficiaries with decrease incomes might forgo listening to care providers that historically include the acquisition of listening to aids and “will be more likely to experience continued difficulty with hearing loss.”

The research proposes two coverage options to deal with the barrier to listening to care providers. First, listening to care providers might be included within the “mandatory benefits provided by state Medicaid programs.” Second, Congress might take away the Medicare protection exclusion. The research advocates that the latter change is probably the most applicable choice as a result of “barriers to hearing care services and poor hearing outcomes are not limited to people dually eligible for Medicaid…”

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Senator Cardin Introduces Invoice to Add Oral Well being Protection to Medicare

One of many Middle for Medicare Advocacy’s prime priorities is to broaden Medicare protection to incorporate oral and dental look after all beneficiaries.  We now have additionally lengthy advocated for protection of medically vital oral well being care, which is presently supported by the Medicare statue however is considerably restricted in apply as a result of Medicare coverage.

Within the opening days of the brand new Congress, Senator Ben Cardin (Maryland) launched the Medicare Dental Profit Act of 2019 (S. 22).  In line with a January four, 2019 press launch issued by the senator’s workplace, the proposed invoice “would repeal the statutory exclusion on Medicare coverage of dental care and dentures” within the Medicare statute, and would increase “Part B benefits to cover dental and oral health services, including routine cleanings and exams, fillings and crowns, major services such as root canals and extractions, emergency dental care, and other necessary services.”   

The Middle joined Households USA, Justice in Getting older, and Oral Well being America in providing help for this laws.

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