Short-Term Junk Plans; OIG Hospice Report Finds Issues; Don’t Trust SNF Ratings || Center for Medicare Advocacy

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  1. Main Well being Care Sabotage: HHS Points Remaining Rule on Short-Term Restricted-Period Insurance coverage
  2. Inspector Common Studies Considerations About Medicare Hospice Care
  3. New Guidelines for Medicare Nursing Residence “Improvement Standard” Denials
  4. Nursing Amenities’ “Quality Measures” Do Not Mirror Precise High quality of Care Offered to Residents

Main Well being Care Sabotage: HHS Points Remaining Rule on Short-Term Restricted-Period Insurance coverage

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Final week, the U.S. Division of Well being and Human Providers (HHS) launched the ultimate rule increasing using Short-Term Restricted-Period Insurance coverage. For months, we have now been highlighting how these “Junk Plans” would adversely influence each the Reasonably priced Care Act (ACA) Market and shoppers with complicated care wants. Brief-term insurance coverage is supposed to be a stopgap for shoppers who expertise a short lived lapse in protection. These naked bones plans have been by no means meant for use as long-term or complete medical insurance. Use of those plans had been appropriately restricted to 90 days, however the present administration’s last rule expands their use as much as a yr, with the potential of renewal for as much as three years.

A senior advisor to the Secretary of HHS was truly reported as admitting the bounds of those plans: “We make no representation that it’s equivalent coverage. These policies will not necessarily cover the same benefits or extend coverage to the same degree.” As a result of the plans aren’t “equivalent coverage” they don’t seem to be required to abide by protection requirements set forth within the Reasonably priced Care Act, and won’t shield shoppers who discover themselves in want of complete care. As well as, the plans usually are not required to cowl important well being advantages, can deny protection based mostly on well being standing, gender or age, and may impose annual or lifetime limits on protection.  And, though they provide insufficient protection, the plans have excessive out-of-pocket prices.

As youthful and more healthy individuals are drawn to those short-term plans, older individuals and people who find themselves sicker will face greater prices for remaining within the ACA Market. Thus, the “Junk Plans” will undermine their advantages, destabilize the Market and additional inflate prices.     

Politico reviews that “In 2017, insurers that sold short-term plans spent an average of [only] 65 percent of premium revenues on medical costs, according to the National Association of Insurance Commissioners, far below the 80 percent threshold that Obamacare plans must meet.”

We name on HHS to make sure shoppers perceive the bounds of those insufficient plans and make it clear that they don’t seem to be ACA plans. Shoppers should perceive precisely what they’re getting with these plans – which, sadly, isn’t a lot.

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Inspector Common Stories Considerations About Medicare Hospice Care

Final week, the Workplace of Inspector Basic (“OIG”) revealed a report[1] of its research on the expansion in hospice utilization and reimbursement since 2005.  The Report summarizes key vulnerabilities within the Medicare hospice program affecting high quality of care and program integrity, and presents suggestions to the Division of Well being and Human Providers for defending beneficiaries and enhancing this system.

Medicare’s hospice profit covers care designed for the palliation and administration of terminal sickness. The care ought to “allow the patient to remain at home as long as possible by providing support to the patient and family, and by keeping the patient as comfortable as possible while maintaining his or her dignity and quality of life.”[2]

OIG discovered that infirmaries don’t all the time present adequate providers or drugs to successfully handle sufferers’ signs, leading to pointless ache.  Hospices additionally don’t all the time present households and caregivers with info wanted to make selections a few affected person’s care. The Report highlights inappropriate hospice billing practices, together with enrolling ineligible beneficiaries, and billing for providers by no means offered or for a costlier degree of care than wanted. As well as, OIG discovered that the present cost system creates incentives for hospices to attenuate providers and cherry-pick beneficiaries who’ve fewer or much less complicated care wants.

OIG’s findings affirm what the Middle for Medicare Advocacy repeatedly hears from beneficiaries and their caregivers about their expertise with hospice.[3]  We urge the Division of Well being and Human Providers to deal with the considerations recognized by the Report, take steps to tie cost to high quality of care, and assist be sure that all terminally-ill beneficiaries have entry to hospice providers.

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New Guidelines for Medicare Nursing Residence “Improvement Standard” Denials

With help from the John A. Hartford Basis, the Middle for Medicare Advocacy has produced a brand new Guidelines to assist Medicare beneficiaries and their households reply to unfair Medicare denials for nursing residence care based mostly on an misguided “Improvement Standard.” The Guidelines outlines the protection standards for care at a talented nursing facility and emphasizes language from the Jimmo Settlement Settlement.  Per the Settlement, the Facilities for Medicare & Medicaid Providers (CMS) revised the Medicare Profit Coverage Guide to obviously disavow any notion that residents of a talented nursing facility should enhance so as for their care to be coated by Medicare. 

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Nursing Amenities’ “Quality Measures” Do Not Mirror Precise High quality of Care Offered to Residents

The Middle for Medicare Advocacy needed to find out whether or not nursing amenities that had one-star of their well being survey scores on Nursing House Examine have been capable of increase their general scores from one star to 2 stars via the designation of 5 stars within the self-reported high quality measure area.  The discovering – that many amenities within the 5 states reviewed have been capable of increase their general scores on this approach – undermines the validity of “quality measures” as reflecting the precise high quality of care offered to residents by nursing amenities.

When amenities which might be challenged with poor efficiency cite their “quality measures,” beware.  High quality measures don’t mirror the standard of care residents obtain.


The Facilities for Medicare & Medicaid Providers’ (CMS’) web site Nursing Residence Examine supplies public details about nursing amenities that take part in Medicare or Medicaid or each.  It offers details about three domains – well being surveys, staffing, and high quality measures – and an general score. 

  • The well being survey score is predicated on unannounced annual and grievance surveys carried out by state survey businesses, beneath contract with CMS;
  • The nurse staffing score is predicated on complete nurse staffing (registered nurses (RNs), licensed sensible nurses and nurse aides) and RN staffing; and
  • The standard measures score is predicated totally on self-reported and unaudited resident evaluation info offered by amenities.   

CMS assigns star scores to every of the three domains, and an general rating which begins with the well being survey score and revises the general score downward or upward to mirror, respectively, one-star and five-star scores on the staffing and high quality measure domains.  Scores in every area and within the general score vary from one to 5 stars, with one star reflecting the bottom efficiency (“much below average”) and 5 stars, the very best efficiency (“much above average”).

The three domains are individually scored, every with extremely complicated scoring guidelines.  As described in CMS’s Technical Customers’ Information,[1] the score system is predicated on the next rules:

  • The well being survey area “calculates a health inspection score based on points assigned to deficiencies identified in each active provider’s two most recent recertification health inspections prior to November 28, 2017, as well as on deficiency findings from the most recent two years of complaint inspections prior to November 28, 2017.”[2]  Scores are “fixed” for every state: the highest 10% obtain 5 stars; the center 70% of amenities obtain a score of two, three, or 4 stars, with an equal quantity (roughly 23.33%) in every star score class; and the underside 20% obtain one star.[3]  

    CMS “froze” the survey area for a yr, efficient November 27, 2017, to mirror implementation of the brand new federal survey course of.[4]  Deficiencies which are cited in surveys carried out after November 27, 2017 are reported on Nursing House Examine, however they don’t seem to be utilized in calculating the well being survey score.


  • The staffing area studies two elements – complete nurse staffing (RN, licensed sensible nurses, and authorized nurse aides) and on RN staffing, which each are case-mix adjusted.[5]  Since Might 2018, the staffing area has been based mostly on payroll-based journal info (PBJ), not, as earlier than, on self-reported info.[6] 

    Scoring makes use of “cut points,” [7] which CMS adjusted in order that the scores appeared the identical after April 2018, when CMS first started to report PBJ-reported staffing knowledge.  The New York Occasions reported that 70% of nurse amenities had decrease staffing numbers, averaging 12% decrease underneath PBJ than beneath the prior self-reported system, and that, within the final quarter of 2017, 1 / 4 of all nursing amenities reported a minimum of someday within the three-month interval when there was no RN current within the facility.[8] 


  • Nursing Residence Examine reviews 27 high quality measures (24 assessment-based high quality measures which might be self-reported by amenities and three measures which might be each assessment-based and claims data-based),[9] however the high quality measure score is predicated on solely 16 of the 27 measures (9 long-stay self-reported measures for residents within the facility for 100 days or extra; four short-stay self-reported measures for residents within the facility for fewer than 100 days; and three claims-based short-stay measures).[10]

    Every measure is individually scored and assigned factors (20-100) based mostly on the nationwide distribution of the measure.[11]  CMS then teams amenities “into quintiles based on the national distribution of the QM,” with the lowest-performing amenities receiving 20 factors and the highest-performing amenities, 100 factors.[12]  The purpose scores for every of the 16 measures are added collectively and scores assigned in response to minimize factors.[13] 


  • A five-star score within the high quality measure area boosts a facility’s general score by one star, underneath the scoring guidelines utilized by CMS.[14] 

This Evaluation

The Middle started by figuring out nursing amenities listed on Nursing Residence Examine on August 7, 2018 with general scores of two stars.  Subsequent the Middle checked out these two-star amenities to find out what number of had 5 stars within the high quality measure area.  Lastly, the Middle calculated what number of amenities had one star within the well being survey area and 5 stars within the high quality measure area. 

Amenities with general scores of two stars report 5 stars in high quality measures, from 39% of the two-star amenities in Iowa to 80% of the two-star amenities in California. 

Much more disturbing, many amenities with general scores of two stars had one star in well being surveys however 5 stars in high quality measures, with the standard measure score boosting the general score to 2 stars.  These boosts occurred in 28 amenities (33%) in Iowa and in 167 amenities (71%) in California.


Variety of amenities with 2 stars in general score

Variety of 2-star amenities with 5 stars in high quality measure area

Proportion of 2-star amenities with 5 stars in high quality measure area

Variety of 2-star amenities with 1 star in well being survey area and 5 stars in high quality measure area

Proportion of 2-star amenities that boosted their score from 1 to 2 stars, based mostly on their high quality measure score



















New York













These findings affirm that the standard measure area overstates the “quality” of a facility, is totally unreliable, and shouldn’t be utilized in figuring out amenities’ general scores.  As The New York Occasions reported in 2014, amenities “game” the score system, notably of their misuse of the standard measure score.[15]

[1] CMS, Design for Nursing House Examine 5-Star High quality Score System: Technical Customers’ Information (July 2018) [hereafter Technical Users’ Guide], 
[2] Id. 5.
[3] Id. eight.
[4] CMS, “Temporary Enforcement Delays for Certain Phase 2 F-Tags and Changes to Nursing Home Compare,” S&C: 18-04-NH (Nov. 24, 2017),
[5] Technical Customers’ Information, supra notice 1, 9.
[6] CMS, “Transition to Payroll-Based Journal (PBJ) Staffing Measures on the Nursing Home Compare tool on and the Five Star Quality Rating System,” QSO-18-17-NH (Apr. 6, 208), 
[7] Technical Customers’ Information, supra notice 1, 14 (Desk 5).
[8] Jordan Rau, “‘It’s Almost Like a Ghost Town.’ Most Nursing Homes Overstated Staffing for Years,” The New York Occasions (Jul. 7, 2018),
[9] Technical Customers’ Information, supra observe 1, 12-13.
[10] Id. 16-17 (Desk 6).
[11] Id. 16.
[12] Id. 16.
[13] Id. 20 (Desk 7).
[14] Id. 18-19.
[15] Katie Thomas, “Medicare Star Ratings Allow Nursing Homes to Game the System,” The New York Occasions (Aug. 14, 2014),



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