Category Archives: Medicare

Self-Help Packet for Medicare “Observation Status”

August 30, 2019

NAELA eBulletin:

  1. Introduction
  2. How to Use This Packet
  3. Observation Status Self-Help
  4. Federal Regulations – Requirements for Medicare Coverage for Skilled Nursing Facility Care
  5. Pertinent Federal Regulations for Medicare Appeals
INTRODUCTION

Dear Medicare Patient:

The Center for Medicare Advocacy has produced this Self-Help Packet to help you understand Observation Status and options for beneficiaries who are placed on Observation Status.

Medicare is the national health insurance program to which many disabled individuals and most older people are entitled under the Social Security Act.  All too often, Medicare claims are erroneously denied.  It is your right to appeal an unfair denial; we urge you to do so.

However, the situation for Observation Status appeals is unique. Medicare currently has no official method to appeal Observation Status. This may be illegal. As of August 2017, the Center is pursuing a class action lawsuit on behalf of Medicare beneficiaries to establish a way to appeal Observation Status. Sign up for the Center’s Alerts and follow us on social media for important updates to the case. In the meantime, if you are placed on Observation Status, use this Packet to understand and review your options.

If you have any questions, contact the Center for Medicare Advocacy at (860) 456-7790.


HOW TO USE THIS PACKET

We’ve organized this packet so that it provides you with the information needed to understand observation status and to attempt to rectify the problems created by it.

    1. Read the document entitled, Observation Status Self-Help included in this packet.
    2. If you decide to file an appeal, follow each of the steps in the following Self-Help document.
    3. Review the enclosed regulations to assist you with the appeal.
    4. If you have questions, contact the Center for Medicare Advocacy at (860) 456-7790.

OBSERVATION STATUS SELF-HELP

Typical Experience

You are a Medicare beneficiary hospitalized for three or more days.  At the hospital, you signed paperwork, slept in a hospital bed, underwent many tests, and saw various physician specialists.  At some point during the hospitalization, you were told that you were not admitted as an inpatient but were, instead, an outpatient receiving “observation services.” (“Observation services” is the term Medicare uses for “observation status.”)  You should have received the Medicare Outpatient Observation Notice(MOON) discussed below and it should have been explained to you.  The MOON informs you that Medicare will not pay for care in a skilled nursing facility (nursing home) if you need that type of care after you are discharged from the hospital.

Introduction

Observation status is not new.  However, its use by hospitals to avoid losing money, financial penalties, and accusations of Medicare fraud is growing.  Observation status seriously affects Medicare beneficiaries’ access to care and finances.  Attempts have been made to remedy the problem legislatively.  For instance, bills have been introduced in Congress to eliminate the problem.  In addition, the Center for Medicare Advocacy (Center) filed a nationwide class action lawsuit, now known as Alexander v. Price (formerly Barrows v. Burwell and Bagnall v. Sebelius), that is currently pending and seeks to establish a right for Medicare patients to appeal placement on observation status.  While we wait for action on the legislation and the lawsuit, individual beneficiaries continue to be negatively affected by observation status.

This Packet includes information about observation status and outlines steps you might take if you are considered a hospital outpatient in observation status.  For more information about observation status, visit the Center’s webpage at:  www.medicareadvocacy.org.  The process of challenging observation status is complicated and confusing.  If you have questions, call the Center for Medicare Advocacy at (860) 456-7790.

  1. Inpatient Admission

Medicare Part A pays for hospital inpatient care.In traditional Medicare, there is an initial deductible and, if you are hospitalized for more than 60 days, there are daily copayments.While you are hospitalized as an inpatient, Medicare Part B pays for the care provided by physicians, usually covering 80% of the Medicare-approved cost.Medigap policies or other supplemental insurance usually pays for the hospital deductible, copayments, and Part B cost-sharing.

Medicare Part A will pay for hospital care only if a physician orders inpatient care.  To assist physicians with determining whether a patient/beneficiary should be admitted to the hospital as an inpatient, the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers Medicare, published the following guidance in its policy manuals:

The physician or other practitioner responsible for a patient’s care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient. Physicians should use the expectation of the patient to require hospital care that spans at least two midnights period as a benchmark, i.e., they should order admission for patients who are expected to require a hospital stay that crosses two midnights and the medical record supports that reasonable expectation. However, the decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient’s medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital’s by-laws and admissions policies, and the relative appropriateness of treatment in each setting.[1]

This language reflects new regulations that created a “two-midnight rule” – the direction to physicians to order inpatient admission for patients whom they expect will be hospitalized for at least two midnights.[2] Note that the two-midnight rule did not change the requirement that patients be hospitalized as an inpatient for three days, not including the day of discharge, in order for Medicare to cover post-hospital skilled nursing facility care.

If a hospital participates in the Medicare program, all of its physician inpatient admission orders must be reviewed by the hospital’s Utilization Review Committee (URC).  The URC has the power to overturn any admitting physician’s admission order and to reassign patients to observation status, with the physician’s consent.

  1. Observation Status

Observation status is defined by CMS in its policy manuals as:

…a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.  Observation status is commonly assigned to patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge.  Observation services are covered only when provided by the order of a physician or other individual authorized by State licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient tests.  In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours.  In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours.[3]

However, despite this language, there are actually no services that are specifically observation services.  CMS in fact tells physicians that they can order whatever care and services their patients need, whether they are inpatients or outpatients.  In the Center for Medicare Advocacy’s  view, observation status is actually a Medicare billing issue (the question is whether a hospital will bill Medicare Part A or Medicare Part B for a patient’s care), not a question of medical necessity or appropriateness of care.

When a Medicare patient is placed on observation status, despite the fact that the patient may be physically in the hospital for many days, for Medicare billing purposes the stay is considered outpatient care.  The hospital bills Medicare Part B for each service provided (such as lab tests, intravenous medications, MRIs, EKGs).

If you are put on observation status, you will be responsible for the hospital Part B copayments and for the cost of any self-administered (prescription or over-the-counter) medications you receive while hospitalized.[4]  On the other hand, you will not be responsible for the Part A inpatient deductible.  If you do not have Part B, the hospital services will not be covered.

  1. The Heart of the Problem

When Medicare beneficiaries are put on observation status, Medicare Part B generally covers most of their care.  The Part B cost-sharing is usually paid for by a Medigap policy or some other form of supplemental health insurance.  However, if the beneficiary has opted out of Medicare Part B entirely, the hospitalization under observation could be very expensive because nothing will be covered by Medicare.

As a general rule, most beneficiaries are not burdened with the financial cost of the hospital stay, except for medications, but by the care they receive after the hospitalization in a nursing home.

Medicare Part A will pay for care in a skilled nursing facility (nursing home) only if the care follows a Medicare Part A covered three day inpatient stay in a hospital.  For purposes of measuring days, the Medicare program uses calendar days, not 24-hour periods.  For example, if a person is admitted to the hospital at 11:50 p.m., Medicare will count that day as the first day of admission, even though the person was “admitted” for only ten minutes. Also, the day of discharge is not counted toward the three-day period.  The shorthand way of describing the three-day qualifying hospital stay requirement is “three midnights.”

Any “midnight” on observation status does not count towards the three day qualifying hospital stay.  Thus, if the patient requires care in a nursing home after a hospital stay on observation status, even if that stay was for three or more days, Medicare will not pay for it.  Of course nursing home care is very expensive.

What You Can Do

Step One: Find Out Your Admission Status

Understandably, patients think that if they are kept in the hospital and spend the night in a hospital room, they are inpatients.  Now that hospitals are increasingly using observation status, however, you cannot make this assumption.  So when you are hospitalized, find out whether you have been admitted as an inpatient or on observation status.

Since March 8, 2017, hospitals have been required to give patients the Medicare Outpatient Observation Notice (MOON) within 36 hours if the patients are in observation status for 24 hours.[5]  Hospitals must also orally explain observation status and its financial consequences for patients.  The MOON cannot be appealed to Medicare.

Step Two: Try to Get Your Status Changed

If you find out that you are on observation status and are concerned about Part B cost-sharing, the cost of self-administered medications, and/or Medicare payment for care in a skilled nursing facility after you leave the hospital, try to get the status changed while you are at the hospital.  This will be difficult to do.  Your best chance of success is having your community physician (regular doctor) talk to your treating physician at the hospital.  Ask your community doctor to intervene on your behalf.  He or she knows your medical history and speaks the same medical jargon as the hospital physician.  Your community doctor might be able to convince the hospital physician that your status at the hospital should be changed from observation to inpatient.

You can try to use Medicare’s “two-midnight rule” to show the doctor or hospital that inpatient admission is appropriate.[6]  The two-midnight rule is supposed to be a way for doctors and hospitals to decide whether a patient should be admitted as an inpatient or not.  Medicare states that if the doctor reasonably expects that a patient requires hospital care that will cross two midnights, she can admit the patient as an inpatient and Medicare should pay the claim under Part A.[7] The documentation in the medical record should support the expectation of the physician. Remember that any inpatient stay is only counted from the time of the inpatient order. Time already spent in observation is not counted toward the inpatient stay even if inpatient admission is eventually ordered. So it’s important to address this question early in the hospitalization.  Also remember that there is no prohibition against changing a patient’s status from observation to inpatient if, for example, his medical condition worsens.

Step Three: Prepare For Discharge

In the event that you are not successful with changing your hospital observation status, but need follow up medical care, you have some decisions to make. If you can safely return home, ask your hospital or community physician to order home health care.As long as you are “homebound,” (leaving home requires considerable effort (“taxing” effort, in the language of Medicare) and occurs infrequently) and you require skilled care (skilled nursing or physical or speech therapy), Medicare should pay for this care.Have this care set up for you by the hospital before you leave.You can find out more about home health care on the Center’s website at www.medicareadvocacy.org.

If you need more medical care and therapy than you can get at home, ask your physician about going to an inpatient rehabilitation hospital (IRH, also known as an inpatient rehabilitation facility, IRF).This type of hospital does not require a three-day inpatient hospital stay.Unfortunately, not every community has an IRH and the more rigorous therapy provided by an IRH may be more intense that you can handle.But if you can participate in the level of therapy that an IRH offers, you will not need to worry about observation status and, a bonus, you may get better more quickly (and go home) than if you go to a SNF.

Step Four: Understand that Medicare Will Not Pay for Nursing Home Care After a Hospitalization on Observation Status

If you cannot safely return home, you can’t go to an IRH, and the hospital physician has ordered care for you in a nursing home, check to see if the nursing home participates in the Medicare program, as most do.However, since you were not admitted to the hospital as an inpatient, Medicare will most likely not pay for this necessary care without a significant effort on your part. Even with significant effort it is very difficult to get Medicare coverage in these circumstances.

There is currently no official way to appeal observation status.[8] Medicare claims that “only the doctor” at the hospital can decide whether you should have been admitted as an inpatient or placed on observation status and that a beneficiary cannot appeal this issue to Medicare. However, we outline some steps below that you can try. Once in a while, people succeed, though it’s important to understand that is very rare.

You might be able to appeal the denial of coverage for your nursing home care as long as you spent at least three midnights in the hospital (not in the emergency room).Unfortunately, this appeal process can take a year or longer to resolve and, if you can manage to get a case into the appeal system, winning the case is difficult.  Also, filing an appeal does not prevent the nursing home from requiring you to pay for your care pending the outcome of the appeal.  Remember that an appeal is worth trying only if you receive the level of care that Medicare covers in the skilled nursing facility – five days a week of therapy or seven days a week of skilled nursing or a combination of therapy and nursing equaling seven days a week.  If you are not in a Part A stay, the nursing home can bill Medicare Part B for your therapy services.

Patients who receive five days of therapy per week in the nursing home have a better chance of winning their appeals than patients who are relying on claims of skilled nursing care, since most care is provided by unlicensed aides.

Step Five: Start the Nursing Home Appeal

If you decide to get care in a nursing home and it will be provided on a daily basis (five days a week of therapy or seven days a week of skilled nursing), let the nursing home know that you are going to appeal the denial of Medicare coverage.  Medicare will only pay for a nursing home stay if it includes daily skilled care.  Skilled care is care that is so inherently complex that it must be done by a skilled professional.  The skilled nursing and/or therapy can be to improve or maintain your condition.  Medicare will not pay for care in a nursing home when it is only custodial.  Examples of custodial care include the administration of oral medications or assisting a patient with bathing or toileting.  For more information about Medicare coverage of skilled nursing facility care, and how to appeal a denial visit our website at www.medicareadvoacy.org.

To start the appeal, ask the nursing home to submit a “demand bill” to Medicare for your entire stay.  You can make this request after you leave the nursing home.  However, note that nursing homes must bill Medicare within one year of the time the care began, so do not wait too long to make this request.  In response to the nursing home’s demand bill, CMS will issue a denial of payment from which you can appeal.  You can also ask the nursing home to give you a Notice of Exclusion from Medicare Benefits – Skilled Nursing Facility (NEMB-SNF),[9] which is a form for so-called “technical denials” of coverage.

A technical denial means that you need the care the nursing home provides but that you do not qualify for Medicare coverage for technical reasons, such as not having a three-day inpatient hospital stay (the first box) or having used all 100 days in a benefit period.  Check Option 1 so that the nursing home will submit the claim to Medicare for a decision about coverage.

Step Six: Request a Redetermination for the Nursing Home Denial 

You will receive a Medicare Summary Notice (MSN) in the mail which will reflect the nursing home’s bill to Medicare.  The MSN will indicate that Medicare has denied payment for your care in the nursing home because you did not have a three day qualifying hospital stay.  Read the last page of the MSN.  It will tell you that you have 120 days to appeal the denial of coverage.  Follow the instructions on how to and file an appeal.  Circle the denial of payment for your nursing home care.  Write that you are appealing because you did receive three days of hospital inpatient care.  If you have a copy of your hospital discharge summary reflecting that you were hospitalized for three days, send a copy of it with your MSN requesting an appeal.

If you have submitted the NEMB-SNF, you will receive a response that will tell you how to appeal the decision.

Step Seven: Gather Hospital Records

Write to the hospital and ask for a copy of your medical record.  Ask that it send you the following documents: emergency room records; admission records; physician orders; consultation reports; lab reports; diagnostic imaging; medical records; nursing narratives; discharge summary; and social service documentation.  The hospital may charge you for copying and sending the documents, although charges for records in support of Medicare claims are not allowed in some states, including Connecticut and Massachusetts.  When you get the records, give a copy of them to your community physician.  Ask your physician to review the records and to write a statement explaining that the care you received while hospitalized was inpatient hospital care.

Check the records carefully for any inpatient orders. If you were actually admitted as an inpatient for a period of time that crossed three midnights, that is the strongest type of appeal you can make.  Without such an order, it will be exceedingly difficult to win your appeal. You can try to argue that the care you received was inpatient hospital care, but Medicare’s position is that without an inpatient order, there can be no inpatient coverage under Part A.

Step Eight: Gather Nursing Home Records

Write to the nursing home and ask for a copy of your medical record.  Ask for the following documents:  MDS forms; physician orders; physician progress notes; medication records; therapy records (physical, occupational, and speech), nursing narrative notes; and physician certifications.  As with the hospital medical records, the nursing home may charge you for copying and sending these documents.  Also write to the nursing home physician and ask that he or she write a letter for you explaining that while you were a patient at the nursing home, you required and received a skilled nursing facility level of care.

Step Nine: Request a Reconsideration for the Nursing Home Denial

You should receive a “Redetermination” decision in the mail for your nursing home care.  It will be “unfavorable.”  You will have 180 days to appeal.  Follow the directions on the form for requesting a “Reconsideration.”  On the nursing home appeal request, write that you are appealing because you were hospitalized and received an inpatient level of care for three consecutive days prior to receiving care at the skilled nursing facility.  If you have letters from physicians in support of your case, send copies with your request.

Step Ten: Request an ALJ Hearing

You should receive a “Reconsideration” decision in the mail for your nursing home care.  Again this will be a denial.  You will have 60 days to appeal.  Follow the directions on the form for requesting an administrative law judge (ALJ) hearing.  ALJ appeals are often successful.

Step Eleven: Respond to the Notice of Hearing

You will receive a written notice of hearing in the mail.  Respond to the notice as directed.  Note: Unrepresented beneficiaries have a right to hearing by video teleconference, which is generally a more effective method for making a case than a telephone hearing. Make sure that the notice states that a video teleconference is scheduled.  If it does not, contact the ALJ and request that the hearing be rescheduled as a video teleconference.  In addition, ask the judge to send you a copy of the exhibit list and hearing file.

Step Twelve: Prepare for the Hearing

When you receive the hearing file, make sure that it includes all the medical records that you have obtained from the hospital and the skilled nursing facility.  If it does not, send the missing records to the ALJ.  Be sure and send a copy of the letters of support you received from your physicians.  Contact the nursing home and ask if a therapist or nurse will testify at the hearing on your behalf.

Step Thirteen: Argue your Case

Attend the hearing.  Make sure the judge has the additional records that you sent in.  If you can, have someone from the nursing home testify that the care you received while there was skilled care and that it was performed on a daily basis.  Explain to the judge that your care at the skilled nursing facility was not covered by Medicare because the hospital erroneously billed your inpatient hospital level of care to Medicare Part B rather than Part A.  Ask the judge to find that your hospital care was an inpatient level of care and that you’ve met the three day qualifying hospital stay requirement for skilled nursing facility care.  Then ask the judge to find that your skilled nursing facility care was medically reasonable and necessary and coverable by Medicare Part A.

Step Fourteen: If You Lose the Appeal

You will receive the Administrative Law Judge’s decision in the mail.  If it is favorable, send a copy to the nursing home and ask that it reimburse you if you previously paid for any care or ask that it stop any collection efforts started against you.  If it is unfavorable, follow the directions on the hearing decision for filing a Medicare Appeals Council request.

Conclusion

Trying to fix placement on observation status is very difficult and, in the rare cases where people succeed, it generally takes a long time.  Should you have questions during the process, you can call the Center for Medicare Advocacy at (860) 456-7790.  You can also report your difficulties with observation status to your Senators and Representative in Congress, as it’s important that they understand the hardships people are facing. Finally, please continue to monitor our website www.medicareadvocacy.org for updates on proposed changes to the law and on our lawsuit.


[1] Medicare Benefit Policy Manual, Publ. 100-2, Ch. 1, § 10, which can be found at:   http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html.
[2] 42 C.F.R. §412,3(d)(1).
[3] Medicare Benefits Policy Manual, Pub. 100-02, Chapter 6, § 20.6, http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html.
[4] The Office of the Inspector General (OIG) of the Department of Health and Human Services has stated that hospitals can discount or waive charges for an outpatient’s self-administered drugs. Patients who are charged for such drugs should point the hospital to this statement. https://oig.hhs.gov/compliance/alerts/guidance/policy-10302015.pdf  Also, patients who have a Part D plan may request that the plan pay for the drugs as an out-of-network pharmacy provider.  See Center, “Submitting Claims to Part D for Prescription Drugs Administered in the Hospital During an Observation Status Stay” (CMA Alert, May 1, 2014), https://www.medicareadvocacy.org/submitting-claims-to-part-d-for-prescription-drugs-administered-in-the-hospital-during-an-observation-status-stay/
[5] CMS-10611, available at https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-Items/CMS-10611.html.  The Notice of Observation Treatment and Implications for Care Eligibility (NOTICE) Act requires hospitals to inform patients, orally and in writing, that they are in observation status, not inpatients, and the consequences of that status.  Pub. L. 114-42, U.S.C. §1395cc(a)(1)(Y).
[6] A summary of the two-midnight rule put out by Medicare can be found at: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-07-01-2.html
[7] Even patients who are expected to require less than two midnights of hospital care can be admitted as inpatients on a case-by-case basis.
[8] As noted in the Introduction, this may be illegal and the Center is currently pursuing a class action case to establish a method of appeal.
[9] CMS Form 20014, https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/CMS20014.pdf.

Federal Regulations
Medicare Coverage of Skilled Nursing Facility Care
42 CFR 409.30 – 409.36

All the links below can be found at:
https://www.law.cornell.edu/cfr/text/42/part-409/subpart-D


Pertinent Federal Regulations for Medicare Appeals
42 CFR §§ 405.900 – 405.1140

All the links below can be found at:
https://www.law.cornell.edu/cfr/text/42/part-405/subpart-I

Initial Determinations (§§ 405.920 – 405.928)

Redeterminations (§§ 405.940 – 405.958)

Reconsideration (§§ 405.960 – 405.978)

Reopenings (§§ 405.980 – 405.986)

Expedited Access to Judicial Review (§ 405.990)

ALJ Hearings (§§ 405.1000 – 405.1058)

Applicability of Medicare Coverage Policies (§§ 405.1060 – 405.1063)

Medicare Appeals Council Review (§§ 405.1100 – 405.1140)

Medicare and Medicaid Programs; Revision of Requirements for Long-Term Care Facilities Arbitration Agreements (CMS-3342-F)

July 30, 2019

NAELA eBulletin:

Today, the Centers for Medicare & Medicaid Services (CMS) announced a final rule, “Medicare and Medicaid Programs; Revision of Requirements for Long-Term Care Facilities: Arbitration Agreements” (CMS-3342-F). The final rule revises the requirements for arbitration agreements when they are used by long-term care (LTC) facilities to resolve disputes with their residents. Provisions in this rule establish substantial protections for residents and their representatives and ensure transparency in the arbitration process in LTC facilities, also known as “nursing homes”. The rule is part of the agency’s five-part approach to ensuring a high-quality nursing home system that focuses on strengthening requirements for nursing homes, working with states to enforce statutory and regulatory requirements, increasing transparency of nursing home performance, and promoting improved health outcomes for nursing home residents.

This final rule repeals the prohibition on LTC facilities entering into pre-dispute, binding arbitration agreements with their residents, as proposed. However, this final rule includes protections of residents’’ rights by prohibiting LTC facilities from requiring residents to sign binding arbitration agreements as a condition of admission to, or as a requirement to continue to receive care at, that facility. It strengthens the transparency of arbitration agreements and the arbitration process with specific requirements for the LTC facility, such as the requirement that LTC facilities that resolve a dispute with a resident through arbitration retain copies of the signed arbitration agreement and the final arbitrator’s decision for five years and make such documents available for review by CMS or its designee. It also protects residents’ rights to make informed choices about their health care by ensuring that residents or their representatives have the right to understand what the arbitration agreement says and the consequences of signing the agreement.

Background

On October 4, 2016, CMS published in the Federal Register a final rule titled, “Reform of Requirements for Long-Term Care Facilities” (81 FR 68688) (2016 final rule). The rule banned binding pre-dispute arbitration agreements in LTC facilities. In 2016, the American Health Care Association (AHCA) and a group of affiliated nursing homes filed a complaint in the U.S. District court for the Northern District of Mississippi seeking a preliminary and permanent injunction enjoining CMS from enforcing the ban on LTC facilities entering into pre-dispute, binding arbitration agreements with their residents. After the court preliminarily enjoined the enforcement of that regulation, the agency determined that further analysis of the rule was warranted. On December 9, 2016, CMS issued a nationwide instruction to State Survey Agency Directors, directing them not to enforce the 2016 final rule’s prohibition of pre-dispute, binding arbitration provisions.

On June 8, 2017, CMSCMS published a proposed rule, “Medicare and Medicaid Programs; Revisions of Requirements for Long-Term Care Facilities: Arbitration Agreements” (82 FR 26649) in the Federal Register. The agency received over 1,000 public comments on the proposed rule from a number of stakeholders, including nursing homes and beneficiary advocates. That proposed rule focused on the transparency surrounding the arbitration process and proposed the following:

  • The prohibition on LTC facilities entering into pre-dispute, binding arbitration agreements with their residents would be repealed.
  • All agreements for binding arbitration must be in plain language.
  • If signing the agreement for binding arbitration is a condition of admission into the facility, the language of the agreement must be in plain writing and in the admissions contract.
  • The agreement must be explained to the resident and his or her representative in a form and manner they understand, including that it must be in a language they understand.
  • The resident must acknowledge that he or she understands the agreement.
  • The agreement must not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including federal and state surveyors, other federal or state health department employees, or representatives of the State Long-Term Care Ombudsman.
  • If the facility resolves a dispute with a resident through arbitration, it must retain a copy of the signed agreement for binding arbitration and the arbitrator’s final decision so it can be inspected by CMS or its designee.
  • The facility must post a notice regarding its use of binding arbitration in an area that is visible to both residents and visitors.

Final Rule Revisions to Arbitration Requirements

After careful consideration of the public comments, CMS is modifying our proposed changes.  We are not finalizing the requirements for plain language in the arbitration agreements and that the facility post a notice regarding its use of binding arbitration. We believe these proposed requirements are unnecessary due to other requirements finalized in this rule.  In addition, we are retaining some of the requirements finalized in the 2016 rule.  We are finalizing following provisions.  An LTC facility must:

  • Not require that a resident or his or her representative sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility.  This must be explicitly stated in the agreement to ensure.  This ensures that no resident or his or her representative will have to choose between the resident obtaining the skilled nursing care he or she needs and signing an agreement for binding arbitration.
  • Ensure that the agreement is explained to the resident or his or her representative in a form and manner that he or she understands, including in a language that he or she understands, and that the resident or his or her representative acknowledges that he or she understands the agreement.  These two requirements ensure that the arbitration agreement is transparent and the resident or his or her representative understand what he or she is agreeing to.
  • Ensure that the agreement provides for the selection of a neutral arbitrator agreed upon by both parties and a venue that is convenient to both parties.  These requirements helps to ensure that the arbitration process is fair to both parties, especially the residents.
  • Ensure that the agreement does not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including Federal or state surveyors, other federal or state health department employees, or representative of the Office of the State Long-Term Care Ombudsman. This protects the resident and his or her representative from any undue influence by the LTC facility to not discuss the circumstances surrounding a concern, complaint or grievance.
  • Retain copies of the signed agreement for binding arbitration and the arbitrator’s final decision for 5 years after the resolution of any dispute resolved through arbitration with residents, and make these documents available for inspection upon request by CMS or its designee.  This will ensure that CMS will be able to obtain information on how the arbitration process is being used by LTC facilities, and on the outcomes of the arbitrations for residents.

For more information, please visit: https://www.federalregister.gov/documents/2019/07/18/2019-14945/medicare-and-medicaid-programs-revision-of-requirements-for-long-term-care-facilities-arbitration

 

How the Democratic Candidates Responded to a Health Care Policy Survey

July 2, 2019

When the 2020 Democrats were asked the best way to improve the health care system, a split in the field was revealed. Here are full responses from 19 candidates.  The New York Times asked all 23 Democratic presidential candidates for their views on the best ways to improve the health care system. We received responses from 19 of them.

[Read our analysis of the responses here.]

The first three questions asked whether the candidates supported three possible routes for
changing how Americans receive health insurance: by creating a “Medicare for all” system
that would eliminate private insurance; by providing a choice between a “public option”
health care plan run by the government and private insurance; or by making more modest
changes to the Affordable Care Act.
Candidates could indicate support for more than one option. But in the fourth question, we
asked which of the three options would be the best way to improve the health care system,
and that is where a split in the field was revealed.
The survey also included several other questions about health insurance and coverage, how
the candidates would finance their plans, and other matters like prescription drug prices.
Below are the responses from each of the 19 candidates. Many of the questions were posed
in a yes-or-no format but also allowed the candidates to add additional comments. Some of
the responses we received were written in the first person, while others were supplied by
campaign staff members. Aside from a few corrected typos and minor punctuation changes
for clarity, these are the full, unedited answers we received.

No.

We need to have universal coverage, lower costs, and improve quality — those are the three objectives we should be working toward. The best path to achieve those objectives is with Medicare-X, my plan to create a strong public option that provides people with the choice of buying into that option or keeping the insurance they receive through their employer or union.

In just four years, Medicare for All would take health insurance away from about 180 million Americans who receive their insurance through their employer or their union, the vast majority of whom like it. And it would take insurance away from another 20 million people who receive insurance through Medicare Advantage.

Yes.

All Americans.

The best path to covering all Americans with high-quality, affordable health insurance is with Medicare-X, my plan to create a strong public option that provides people with the choice of buying into that option or keeping their private insurance.

Medicare-X would start in rural areas where there is one or no insurer to increase competition and lower costs. It would then expand to every ZIP code, and become available as an option on the small business exchange. Medicare-X would also, for the first time, allow the federal government to negotiate lower drug prices on behalf of the American people. By using the existing Medicare framework, it does all of this without adding any bureaucracy.

No.

We should build upon the Affordable Care Act, including by extending premium assistance to more middle-class Americans who are above the A.C.A. cliff of 400 percent of the Federal Poverty Level. My Medicare-X plan would do that, in addition to increasing support to families under the 400 percent threshold who are currently receiving tax credits to help pay for insurance.

But we shouldn’t stop there. Medicare-X would also provide everyone with the choice of purchasing a public option, and it would allow the federal government to negotiate lower drug prices. We also need to reduce the cost of health care by increasing transparency and modernizing how we care for people.

Public option.

If you went into a living room anywhere in the country and told everyone about Medicare-X, my plan to create a true public option, I believe it’s a plan they could get behind. We don’t need to blow up our current health care system to provide everyone with high-quality, affordable care. And we don’t need to take insurance away from people who receive it through their employer and like it. Medicare-X starts in rural areas where the market is failing too many people. It covers essential health benefits and uses Medicare’s network of doctors and providers. It allows the federal government to negotiate lower drug prices. And it does all of this without creating any new bureaucracy.

Yes.

All Americans should be covered by high-quality, affordable health insurance. For people who are already eligible for Medicaid and other programs, our default should be for those programs to cover them. States that have yet to take advantage of the Medicaid expansion in Obamacare should do so in the best interests of their residents. Ultimately, by offering a strong public option through Medicare-X, we can accomplish universal coverage.

My Medicare-X plan would save taxpayer dollars relative to the current health care system, even as it covers millions more people. For example, a more modest public option has previously been projected by the nonpartisan, independent Congressional Budget Office to save $158 billion for taxpayers over a decade (source: bit.ly/2MH8b1V). That’s because a public option like Medicare-X requires premiums, but also cuts health care costs relative to private health insurance. We would then take those savings and reinvest them in improving upon Obamacare, so that more middle-class Americans are able to afford health insurance.

Notably, this differs dramatically from Medicare for All, which the nonpartisan Urban Institute has suggested would cost more than $32 trillion over the next 10 years (source: urbn.is/2WEIH9H). Regardless of whether people think this is the right approach, we have to acknowledge that nobody has shown how they would specifically pay for even a significant fraction of this total cost. According to Vox, when single-payer failed in Senator Sanders’s home state of Vermont, it failed when taxpayers were confronted with the fact that it would necessitate an increase in payroll taxes of 11.5 percent and income taxes by 9 percent (source: bit.ly/2VCeMOW).

My Medicare-X plan does not require a tax increase at all, because it saves taxpayer dollars relative to private health insurance. It allows the American people to choose this high-quality, affordable option instead of taking away their current health insurance.

Yes.

Undocumented immigrants should have the option of purchasing health insurance on the exchange.

Yes.

Americans are growing older, and we need to figure out how to provide them with long-term care.

Health coverage in long-term care is fragmented, insufficient, and inefficient. Americans shouldn’t be forced to spend down their life savings in order to be covered by Medicaid for long-term care. There are a number of ways to ensure that coverage is lifelong, and we should have that discussion.

No.

The United States government should negotiate drug prices through Medicare Part D and other federal programs on behalf of the American people. Medicare-X does that.

Importation from Canada is not a sustainable solution, because the reason drugs cost less in Canada is that the Canadian government uses its leverage to negotiate prices downward. Even if Canada allowed us to import all of its drugs (which it will not), we would still not be able to supply the demand in the United States, and it would have a limited effect on overall prices. We are nine times the size of Canada, and Canada would be left with drug shortages, which it would never allow.

After writing and passing legislation to secure our supply chain, I’m also concerned about counterfeit medications sold through supposedly Canadian online pharmacies, which are often not even based in Canada.

Yes.

I support allowing the United States government to negotiate drug prices through Medicare Part D and other federal programs. That’s the only way to get drug prices under control for the American people. Medicare-X does that.

Public option.

[The Biden campaign did not complete the survey, but indicated that Mr. Biden preferred a public option and referred to his statements on the campaign trail.]

Yes.

I support Medicare for All. There are different ways we can get there. Right now, there are several bills in the United States Senate that move our country closer to Medicare for All, and I’m a sponsor of them. The most important thing is to keep the ultimate goal in mind: affordable health care for every American, because health care is a human right.

Yes.

All Americans.

I am a co-sponsor of several bills in the Senate to create a public option, a powerful tool to introduce real competition into the market and drive down costs for consumers.

Yes.

I support strengthening the A.C.A., including by extending premium assistance to more middle-class Americans and undoing the Trump administration’s sabotage around enrollment, as one part of a broader effort to improve care and lower costs.

“Medicare for all.”

I believe our country needs to work towards Medicare for All and have co-sponsored several bills to help do just that, including through a public option and lowering the Medicare eligibility age.

Yes.

It is important that every American has health insurance not only to keep individuals and families healthy, but also to help keep health costs stable.

High out-of-pocket costs for people with insurance is one of the most concerning problems in our current system. On the path to Medicare for all, I support concrete steps to increase access and lower costs — including lowering the Medicare eligibility age and introducing a public option — all of which would be financed differently. Whatever the plan, we must do more to help low- and middle-income Americans, many of whom can’t afford to go to the doctor or get even basic preventative care due to prohibitive cost-sharing.

Our country already spends trillions of dollars on health care every year. By directing existing spending into a more efficient system, reducing the outrageous cost of many prescription drugs, and leveraging Medicare’s lower cost structure system, we can achieve savings that offset many of the costs of improving affordability and access. We can also raise taxes on the wealthiest Americans, while ensuring that most families are paying less for better care.

Yes.

Access to quality, affordable health care is a human right. We need to make our health care system more effective and efficient, and we must pass comprehensive immigration reform that creates a pathway to citizenship for those already living in the United States.

Yes.

Long-term care is an integral part of health care, especially for people with disabilities.

Yes.

I wrote and introduced the Affordable and Safe Prescription Drug Importation Act along with Senators Bernie Sanders and Bob Casey to allow for the safe importation of prescription drugs.

Yes.

I am an original co-sponsor of the Affordable Medications Act, which includes a number of provisions to bring transparency and competition to pharmaceutical companies responsible for outrageous drug prices. By allowing Medicare to directly negotiate with manufacturers, we can leverage the federal government’s buying power and cut costs for taxpayers and beneficiaries.

No.

Everyone should have access to health care — and it should be affordable to the individual and to the taxpayers. Access to health care shouldn’t depend on the size of your paycheck. It should be a right for all.

Through the A.C.A., we have been able to make great strides in ensuring coverage for more Americans, beginning to reduce the growth in health care costs, and providing better care inclusive of prevention, drug and alcohol treatment, screenings, and mental health care.

Yet even after the A.C.A., many people still can’t access care. And most of us are paying too much. More can be done.

About 156 million Americans are enrolled in employer-sponsored health insurance plans. Moving immediately to a Medicare for All system would both undermine existing employer sponsored health care, upset a significant portion of the economy, and result in significant payroll tax increases for working Americans to cover Medicare for All.

At the same time, 25 million Americans still lack coverage, and the Trump administration is only making things worse.

I believe that we can increase access and affordability by providing a public option for Americans who want to buy into government insurance which will also ensure competition in the private market; allowing the federal government to negotiate drug prices and bring down the costs of prescription drugs; automatically enrolling Medicaid eligible people in Medicaid; and ending surprise billing and out of network charges.

Yes.

All Americans.

Yes.

The Affordable Care Act began to put America on a path toward significantly improved health care coverage, better health prevention and results, and reduced expenses. The Trump administration has worked aggressively to block the important changes brought about by the Affordable Care Act resulting in reduced coverage, lower quality coverage options, and increased costs to consumers.

I believe by fully implementing the Affordable Care Act, providing a public option, allowing the federal government to negotiate drug prices, automatically enrolling people eligible for Medicaid, and ending surprise billing and out of network charges, we can significantly improve health care for all Americans.

Public option.

As a Governor, I am on the front lines of implementing health care solutions. I will never forget testifying in front of the U.S. Senate about implementation of the Affordable Care Act and Medicaid Expansion, and how they had meaningfully impacted health care in our states. At the same time, as we were testifying, Republicans were trying to repeal the A.C.A. and take our country backward. While some have the luxury of debating the ideal health care system, governors must implement effective systems that work for our constituents — and that’s what I have been doing in Montana.

Estimates indicate that a Medicare for All system would require between $2.5 and $3 trillion in new revenue each year. When you consider that the U.S. government is expected to bring in $3.6 trillion in 2020, an additional $2.5 to $3 trillion is a 69 percent to 83 percent tax increase.

The Affordable Care Act increased access to health care, behavioral health care, stabilized rural hospitals, improved health care in Indian country, provided preventative care, increased access to substance abuse treatment, and provided incredible improvements throughout Montana. Continuing to strengthen the Affordable Care Act while adding a public option and automatic enrollment for people eligible for Medicaid will go a long way toward full coverage, reduced costs, and improved health outcomes throughout the country.

No.

The vast majority of health insurance is provided by employers. We must make it both more affordable to employees, and for employers to offer health care. Those who are not covered by employer-based health care must be incentivized to have coverage through a public option — and we should help with the incentives. A mandate, however, is not an incentive.

The first thing we have to address is health care costs — for employers and families. Improving affordability will make it easier for everyone to access health care whether it is employer-based or publicly available.

Businesses that choose not to provide their employees with benefits, or businesses avoiding employee benefits through excessive use of contract employees, need to be examined.

No.

Comprehensive immigration reform that protects our border, helps the Dreamers who have known no other home than ours, and provides a path to citizenship for immigrants who have been part of the fabric of our country for many years is the best way to address health coverage for people who want to become American citizens.

No.

Long-term care is an increasingly important challenge for many families, and we should explore ways to make long-term care more affordable and accessible for all Americans without adding crushing costs to working families.

No.

Americans pay more for prescription drugs than nearly anyone else, yet we have nothing to show for it. Rather than focusing on importing drugs from other countries, we need to get our pharmaceutical companies to charge Americans less for vital medicines. If these efforts are unsuccessful, moving toward a safe drug reimportation program would remain an option.

Yes.

As Governor of Montana, I negotiated health care costs between our hospitals and the state employee insurance plan resulting in significant cost savings. It is long past time that the federal government did the same to lower pharmaceutical costs. With the purchasing power of the federal government and its many health care systems — Department of Veterans Affairs, Indian Health Service, Medicare, Medicaid, Federal Employee Health Benefits Program — we have significant leverage in these negotiations.

[This yes-or-no response was left blank, but the campaign left additional comments.]

I support universal health care and believe that a Medicare-type buy in provides the best glide path to a Medicare for All environment. Even then, private insurance can play a role, but only on a supplemental basis. Medicare for All is our goal because it represents a fairer, more efficient health care system that will spend less money on profits and bureaucracy and more on patient care.

Yes.

All Americans.

The path to Medicare for All that I believe makes Americans better off along the way is one that starts with a Medicare-like plan as a public option for people who want it. It will challenge private options to become more affordable and efficient; I am skeptical that they will be able to do so, and expect that this will lead to a Medicare for All environment in the future as more Americans opt in to the Medicare-like plan.

No.

I am in favor of strengthening the Affordable Care Act while we work to implement full reform.

Public option.

Yes.

New health spending should be financed by a combination of premiums and tax-based funding to ensure it is affordable.

Federal spending that makes health insurance affordable could be offset by taxes on the wealthy and on corporate profits.

Yes.

Undocumented immigrants should be able to buy coverage through the public option.

[This yes-or-no response was left blank, but the campaign left additional comments.]

America needs a comprehensive, universal insurance program for long-term care. This can either be done within a universal Medicare plan, or in parallel to it, but the United States must establish such a program so that families can count on long-term care.

Yes.

Such importation must be done in a way that ensures safety and quality.

Yes.

No.

I support Medicare for all with a role for private insurance for individuals that choose it.

Yes.

All Americans.

I support universal health care with Medicare as the foundation. Americans should have options to choose either a complementary or supplementary private insurance.

No.

[This multiple choice response was left blank, but the campaign left additional comments.]

The best way to improve the health care system is to provide Medicare for all, with an option to choose either a complimentary or supplementary private insurance.

Yes.

An expanded Medicare program should be financed mostly through a restructured tax code. Premiums and co-payments may still exist, but my proposal will prioritize keeping these payments low.

I would support repealing the Trump tax plan and replace it with one that asks corporations and the wealthiest elite to contribute their fair share.

Yes.

Undocumented immigrants pay taxes and are contributing members of our communities. I believe they should be eligible for government health care support and put on a pathway to citizenship. I look forward to putting forward a health care plan that addresses the health care gap for undocumented families.

Yes.

Yes.

Yes.

No.

I support the Universal Healthcare plan that I have crafted, which provides health care to every American as a right. It will allow Americans to have the option of having private insurance.

link: https://www.johndelaney.com/issues/health-care/

Yes.

All Americans.

No.

The first thing that the next President should do is fix the A.C.A. The A.C.A. was a good law and has been under attack from Republicans since the day it was signed. Our primary obligation should be to first stabilize our health care system before we begin overhauling it.

A.C.A. fixes.

Your question does not fully capture my views — I would first fix the A.C.A. and then work to create universal health care. The A.C.A. has been under attack from Republicans since the day it was signed. The best way to improve the A.C.A. is to stabilize premiums and bring down costs.

No.

Every American should have health care as a right via a federal program but have the option of purchasing health insurance.

A combination of revenues is the best path forward. Americans who are struggling financially should not have to pay co-payments that will restrict their ability to receive proper care whereas Americans with more resources would contribute. I also believe a government-only (single-payer) system would result in lower quality and more limited access.

My universal health care plan is fully paid for by eliminating the deductibility of employer-provided health care. https://www.johndelaney.com/issues/health-care/

No.

I support comprehensive immigration reform which provides a pathway to citizenship.

Yes.

Yes.

We should also tax big pharma when they charge other countries less than they charge Americans, thereby inflating the price of prescriptions drugs for Americans. https://www.johndelaney.com/issues/prescription-drugs/

Yes.

“Medicare for all.”

[The Gabbard campaign did not complete the full survey, but provided additional comments.]

I support Medicare-for-All. It is unacceptable that in our country we pay far more for health care than any other country in the world, yet we have far worse outcomes. No one in this country should be sick and in need of care and not able to get that care simply because they don’t have enough money.

We have to address the high cost of prescription drugs and hold pharmaceutical companies like Purdue accountable for deceptive sales practices. Right now, Medicare today still can’t negotiate with prescription drug companies to bring down the cost of health care. That has to change.

Like many other countries in the world that have universal health care, I believe there is a role for private insurance but we have to re-evaluate what that looks like — we need to create transparency in the system, break up what is essentially an oligarchy in the pharmaceutical and health care industries and ensure Americans aren’t being gouged for services they need to live.

[This yes-or-no response was left blank, but the campaign left additional comments.]

Senator Gillibrand is a co-sponsor of the Senate Medicare for All bill and wrote the transition piece in the legislation. She supports the goals of that legislation and believes a single-payer system is the best way to achieve universal health care coverage, and to guarantee high quality and low-cost health care to all Americans.

Senator Gillibrand believes that a Medicare for All system will eventually displace the private insurance industry from providing health care. She believes that private insurers are welcome to compete with Medicare, but because Medicare is a nonprofit program, without shareholders or high C.E.O. pay, their prices will consistently be lower than private insurers, who will no longer have a role in health care.

Private insurers could still have a role in providing consumers additional elective medical services that they want to pay for individually, such as cosmetic plastic surgery.

Yes.

All Americans.

Senator Gillibrand’s overarching goal is to get Americans to universal coverage, and supports several pieces of legislation to that end. While she believes that Medicare for All is the ideal and best way to accomplish universal coverage, she also co-sponsors both Senator Stabenow’s Medicare at 50 Act, and Senator Schatz’s State Public Option Act.

[This yes-or-no response was left blank, but the campaign left additional comments.]

Senator Gillibrand would of course support modifications to improve the cost and access to health care provided through the Affordable Care Act. But her main focus is achieving universal coverage and she believes the best way to do that is through a single-payer system like Medicare for All, with a critical public option as a transition.

“Medicare for all.”

Senator Gillibrand believes that a single-payer system like Medicare for All will get America to universal coverage quickest, while also providing the most affordable and highest quality health care. She believes that a nonprofit health care system that focuses solely on its patients’ health and well-being, and that does not have to worry about shareholder value or C.E.O. pay, will deliver the best care to the American people.

Yes.

Senator Gillibrand believes that extending health care coverage to all Americans is the most efficient way to ensure low prices. Moving to a single-payer system, where everyone is covered, will provide all Americans with health insurance they can afford.

Under Senator Gillibrand’s ideal system, health care would be financed through a combination of employer-matched co-payments and taxes.

Senator Gillibrand supports a financial transaction tax, repealing the corporate tax cuts, eliminating subsidies for excessive C.E.O. pay and for companies that ship jobs overseas, and restoring the estate tax.

[This yes-or-no response was left blank, but the campaign left additional comments.]

As is outlined in the Senate Medicare for All bill, Senator Gillibrand supports extending health care coverage to all U.S. residents as defined by H.H.S. Residents will receive coverage provided that they are paying into the health care system, and are on a pathway to citizenship.

Yes.

Yes.

Senator Gillibrand supports the importation of generic drugs and is a co-sponsor of the Affordable and Safe Prescription Drug Importation Act.

Yes.

Senator Gillibrand supports giving the federal government the ability to negotiate drug prices for Medicare. Medicare for All would empower the government to negotiate all prescription drug prices. She also co-sponsors the Medicare Drug Price Negotiation Act, which would allow the Secretary of Health and Human Services to negotiate drug prices in Medicare, and the Empowering Medicare Seniors to Negotiate Drug Prices Act, which would allow Medicare to negotiate for prescription drugs.

Yes.

Medicare for All will guarantee access to health care, with no premiums or co-pays, for every single American. Private supplemental insurance for procedures not covered under the Medicare for All plan would still be allowed, but it is time to stop letting big insurance companies put profit over people’s health care.

Yes.

All Americans.

Medicare for All is my preferred plan. I am also supportive of other measures to expand insurance to more Americans, which is why I am a co-sponsor of the State Public Option Act, the Choose Medicare Act, and the Medicare-X Choice Act.

No.

Protecting the A.C.A. from repeal is one of the proudest moments I’ve had in the Senate, and I am for strengthening it and building on its success. That’s why I support Medicare for All, so that we can ensure every American has access to health care.

“Medicare for all.”

Medicare for All will extend health insurance to every single American, with no co-pays or premiums. It will cover most procedures, as well as dental, vision and hearing aids, and will allow you to choose your doctor, without worrying about who’s in-network or not. We have to change a system that allows big insurance companies to put profit over people’s health.

Yes.

Republicans’ decision to repeal the Affordable Care Act’s individual mandate has destabilized our health care system, made costs go up for families, and increased the number of uninsured Americans.

I support the system set up under the Medicare for All bill I sponsor, where every American can have access to health care with no co-pays or premiums.

The U.S. spends more on health care than any country. In the next decade, we’ll spend $50 trillion on our current health care system. We simply can’t afford to do nothing. Budget estimates of Medicare for All show the system would save the system money.

Yes.

I support the process outlined in the Medicare for All bill, which ensures universal coverage.

Yes.

Too often, elderly Americans and people with disabilities are forced to leave their homes, live in poverty, or go without critical long-term care. It’s unacceptable. That’s why I’m proud to support Medicare for All, which would provide much-needed support for millions of Americans.

Yes.

I co-sponsor legislation to allow importation of prescription drugs from countries with safety standards as strong as the U.S., such as Canada. It will help lower costs for Americans who need access to medicine.

Yes.

I co-sponsor legislation to allow Medicare to negotiate drug prices, which would significantly reduce costs for our seniors.

[This yes-or-no response was left blank, but the campaign left additional comments.]

I believe that health care is a right for all Americans. As president, I am committed to achieving the goal of universal coverage. This week, I signed into law the nation’s first public health care option to create another pathway for delivering affordable coverage. I believe the public option should be a key first step toward delivering universal health care in our country. We must also lower the age of enrollment for Medicare, allow Americans to buy into or automatically enroll in Medicare, allow Medicare to import and negotiate the price of drugs, and end the Trump administration’s outrageous effort to strip millions of Americans of their health care. I am proud of my record as governor in expanding health care to 800,000 Washingtonians, passing the first public option in the country and passing the first long-term care insurance program in the country. As president I will build on this record of success to achieve universal health coverage for all Americans.

Yes.

All Americans.

Yes, and I believe the unprecedented accomplishments we have made in Washington State show that we are able to get this done. I believe that we must lower the age of enrollment for Medicare, including allowing all Americans to buy into Medicare or automatically enrolling in Medicare at birth. The Cascade Care public option plan that I have signed into law makes public health plans available to all Washingtonians, regardless of income, by 2021. It also requires establishing cost-sharing agreements that will reduce, by up to 10 percent, the cost of plans on the health care insurance exchange, which currently serves 266,000 Washingtonians.

No.

I am the only candidate in this race who has both voted for and implemented Obamacare, which now provides health insurance to over 800,000 Washingtonians. Because of Obamacare, we slashed our uninsured rate from 14 percent to 5.5 percent. I support efforts to shore up the Affordable Care Act, and when I am president, I will end the Trump administration’s persistent undermining of Obamacare that threatens the health care of millions of Americans. But we must also do more to build upon the progress we’ve made thanks to Obamacare with policies such as lowering the Medicare enrollment age, allowing Americans to buy into or automatically enroll in Medicare, and allowing Medicare to import and negotiate the price of drugs.

Public option.

Yes.

Health insurance should be financed through a combination of public subsidization for those who need assistance to obtain health insurance and premiums that are affordable. Our fundamental goal must be providing health insurance and health care to everyone in America.

[This response was left blank.]

[This yes-or-no response was left blank, but the campaign left additional comments.]

Our goal must be to ensure that everyone in America has health insurance and enjoys a right to health care. To help accomplish this, we must also quickly create a path to citizenship for undocumented immigrants, and I will do so as president.

Yes.

I signed into law the nation’s first publicly funded long-term care benefit, and I believe this is a model for national policy. Washington State’s Long-Term Care Trust Act leads the nation by providing support to care for an aging loved one, or for people of any age to receive long-term care for unexpected injuries or illnesses. It will provide dignity and peace of mind for people everywhere in our state, and it’s the right thing to do.

Yes, and I voted to do so repeatedly in Congress.

Yes, and I voted to do so in Congress.

[This yes-or-no response was left blank, but the campaign left additional comments.]

The Senator wants to see universal health care and there are many ways to get there. She believes the smartest transition right now would be to do a public option — which could be done by expanding Medicaid or Medicare — and that this will get us there more quickly.

Yes.

All Americans.

[This yes-or-no response was left blank, but the campaign left additional comments.]

The Senator supports a public option and she favors modifications to the Affordable Care Act, including extending premium assistance to more Americans.

Public option.

Yes.

Combination.

[This response was left blank.]

[This response was left blank.]

[This yes-or-no response was left blank, but the campaign left additional comments.]

The Senator believes that all seniors should have access to high-quality long-term care.

Yes.

The Senator leads the bipartisan bill that allows for the importation of safe, less-expensive drugs from countries like Canada.

Yes.

The Senator leads the bill on lifting the ban on Medicare negotiating prices directly with drug companies on behalf of the 43 million seniors in the Part D program.

No.

Every American deserves excellent, affordable care. But as the only candidate in the race who receives single-payer health care today (through the V.A.), I’ve experienced such a system firsthand — and there are serious problems with it.

There are 150 million Americans who currently receive private health care, and they should be able to choose public health care if they want it — but they shouldn’t be forced onto a plan if they don’t. That’s why the right answer is a public option, exactly what President Obama had in the original plans for the Affordable Care Act, not Medicare-for-All.

Yes.

All Americans.

A public option would force public and private insurers to compete against each other for our business, which would give Americans the benefits they deserve: better coverage, cheaper prescriptions, lower costs, and health care that isn’t tied to a job.

Imagine having Congress and the next President force UPS and FedEx out of business, making everyone use the U.S. Postal Service whether they wanted to or not. Does anyone honestly believe that lack of competition would improve the U.S.P.S.? Just as we have choices for delivering packages, we should have choices for delivering health care. It’s a better, healthier, more efficient, and fundamentally more American system.

Yes.

I would be happy to sign premium assistance into law. It would extend benefits to the middle class, making health care more affordable for millions of Americans.

But we also need to go further; premium assistance is a great step forward, but it won’t drive costs down far enough, or for enough Americans. We need a public option to truly fix our system.

Public option.

I had private insurance growing up but now get my health care from the V.A. — one of the closest things we have to Medicare-for-All today — so I’ve seen the ups and downs of both systems firsthand. Neither one is good enough on its own.

The right answer is an aggressive public option, where all Americans can buy into a Medicare-like program if they want and keep their current insurance if they don’t. Competition between the private sector and a public option will drive improvements to both.

Yes.

For health care to be affordable, both healthy and sick folks need to be covered on our plans. Everyone does. That’s because if only sick or injured people received health care, the cost of health care would spiral out of control. And any of us can get sick or injured at any moment, so everyone needs coverage to drive down costs and keep everyone healthy. Having everyone enrolled in health care is also critical for preventative care, which saves lives and keeps down costs.

A combination of taxes, co-payments and premiums.

Our system is currently funded through a combination of taxes, co-payments, and premiums, all of which totaled 18 percent of G.D.P. in 2017. That’s twice as much as nearly every other wealthy country in the world. A well-designed system, including an aggressive public option, will address that problem and reduce the overall taxes needed to fund the system. For plans to compete, they will need to bring down the astronomically high bureaucratic costs in our current health care system.

Yes.

They would be allowed to buy into my public option. Under current law, hospitals in the U.S. cannot refuse to treat patients who need care. Therefore, our system already pays for health care for undocumented immigrants — usually through emergency rooms, which are the most expensive form of care.

By allowing everyone to buy into a public option, more folks will be covered, the risk pool will be younger and healthier, and fewer hospital bills will go unpaid. Everyone deserves good health care, and it makes the system stronger and more efficient overall.

No.

We should fund long-term care through government programs, as most other nations do. We should also invest more in home care and senior-adapted home technology to increase the quality and quantity of housing for seniors.

No.

Importing cheaper prescriptions from other countries is not the solution to our high drug costs. Prescriptions are cheaper in other nations because they negotiate drug prices. We should import their system, not their drugs. Importing their drugs has the potential to undermine safety, and more than that, it would risk exporting our drug prices to other nations — thus spreading the problem instead of solving it.

Yes.

Negotiating drug prices will make prescriptions more affordable for all Americans.

I made a commitment to continue receiving my health care through the V.A. even as a Member of Congress. Because the V.A. negotiates drug prices, any prescription I get is 40 percent less expensive than the same medications on private insurance. We should be doing that in all of our health systems to keep costs down for all Americans.

[This yes-or-no response was left blank, but the campaign left additional comments.]

Beto supports universal, guaranteed, high-quality health care. He believes the surest, quickest way to get there is a proposal like the Medicare for America bill, which says that everyone who does not have insurance today is enrolled in Medicare and that everyone who has insurance they cannot afford, premiums they cannot pay, a deductible they cannot bridge, is free to choose Medicare while letting Americans have the choice of keeping the employer-sponsored and private insurance plans that work for their family’s needs.

Yes.

All Americans.

No.

The Affordable Care Act allowed millions of people to get insurance, see a doctor, afford their medications, receive lifesaving procedures that allow them to live up to their full potential. Beto believes that we need to build on that success by getting to a place where there is guaranteed, universal, high-quality health care. He believes the surest and quickest way of getting there is through a plan like Medicare for America.

Public option.

Beto supports universal, guaranteed, high-quality health care. He believes the surest, quickest way to get there is a proposal like the Medicare for America bill.

[This yes-or-no response was left blank, but the campaign left additional comments.]

Beto supports a system like the one proposed under Medicare for America which would automatically enroll every uninsured individual and provide universal coverage. Those insured through their employer could choose to stay on that plan or enroll in the Medicare for America system.

Under the current system, the costs of health care are increasingly being shifted onto consumers. Beto is committed to reducing out of pocket costs. Beto supports a plan like Medicare for America which eliminates out of pocket costs for lower-income families, eliminates deductibles for all families, and limits out of pocket costs for middle income and upper income families to levels far below costs under the ACA or the current Medicare program. Such a plan would also set premiums based on a sliding scale as a percentage of income — with free care or subsidies for low- and middle-income Americans. Overall, we will reduce what America will pay on health care costs.

At a time when corporations and the wealthiest among us received a $2 trillion tax cut, we know we have the means to achieve universal, guaranteed, high-quality health care. By using existing allocations more wisely, controlling costs, and letting working families take the money they pay to private insurers and instead let them pay into a public option at a lower cost, we can ensure that every person can see a doctor, afford a prescription, and be well enough to live up to their full potential.

[This yes-or-no response was left blank, but the campaign left additional comments.]

This issue is one of many reasons Beto believes that comprehensive immigration reform must be a top priority. Because our laws rightly require hospitals to provide care to everyone, the cost of care for uninsured individuals is currently shifted onto other consumers. Therefore, it is in everyone’s interest to provide a pathway for obtaining insurance.

Yes.

Beto supports a plan like Medicare for America, which covers long-term care, including nursing homes as well as home and community-based services. By providing an option to every business and individual to buy into this system at an affordable cost, we ensure people can get the coverage they need.

Yes.

Beto has supported legislation that facilitates the import of safe, low-cost medicine from Canada and Europe where the same medications are available for cheaper.

Yes.

Yes.

Yes.

All Americans.

Yes.

“Medicare for all.”

We need to think big when it comes to making health care more accessible and affordable, which is why I am a long time supporter of Medicare for All. But as we move towards that ultimate goal, we need to be realistic on how we get there. That is why I also support making modifications to the Affordable Care Act and adding public option that would allow Americans to buy into Medicare without eliminating private health insurance options until we as a country can implement Medicare for All in a way that will move our country forward.

Yes.

A combination of taxes, co-payments and premiums.

A surcharge on very wealthy people. But we also need to reform these broken system so we are not throwing money at things that aren’t working. We need more revenue, but we also need to maximize what we have through deep reforms to how our government works.

No.

Yes.

Yes.

Yes.

Yes.

Bernie is running for president because the time is long overdue for the United States to join every other major country on Earth and guarantee health care to all people as a right, not a privilege, through a Medicare-for-all program. Health care is not a commodity. It is a human right. The goal of a sane health care system should be to keep people well, not to make stockholders rich. That is why we need Medicare for All. Bernie’s Medicare for All program would provide comprehensive health coverage to all with no premiums, deductibles, co-payments, or surprise bills.

No.

The question we face is whether we will guarantee health care as a human right. The only way to do that is to pass Bernie’s Medicare for All plan. The current system is completely dysfunctional, and in the current profit-driven health care system, we are at the mercy of the private insurance and pharmaceutical companies, whose greed dictates the cost of health care. The U.S. federal government has failed to rein in health care costs, which many of our peer nations have successfully done.

A public option or other buy-in plans fail to address the underlying problem in the U.S. health care system: corporate greed and profiteering off of the sick. The other proposals do not address skyrocketing prescription drug prices. They fail to simplify the current confusing and dysfunctional administrative system that makes up 17 percent of health care expenditures. Under Bernie’s Medicare for All plan, we slash administrative costs by relying on one payment and billing entity — the federal government — instead of hundreds.

Buy-in and other option plans still leave millions of Americans at the whim of their employers. 30% of employers change plans every year. On top of that, 66 million people separated from their job sometime last year, and by age 50, the average worker has held 12 different jobs. Medicare for All provides stability. After a four-year transition period, every man, woman, and child in the United States will have health care coverage from birth, with no changes or confusing “open enrollment,” no networks, and no surprise bills.

Medicare for All completely eliminates premiums, deductibles and co-payments for services. Under Medicare for All, health care is free at the point of service for all people in the U.S. regardless of income.

No.

Making only minor tweaks to the status quo is not enough. More than 30 million people do not have insurance. 41 million people are underinsured, meaning they have insurance but cannot afford to use it because the deductibles and other cost-sharing is too high. Keep in mind that 40 percent of Americans cannot afford a $400 emergency, yet deductibles routinely run into the thousands of dollars. Making small tweaks to the system may help a few of those tens of millions Americans, but small tweaks are not enough to solve the fundamental problems underlying our health care system.

[This response was left blank, but it was not applicable, since Mr. Sanders indicated support only for “Medicare for all.”]

Yes.

Bernie will guarantee health care as a human right, not a privilege or commodity. The United States must join the rest of the major countries in the world to guarantee health care to every person regardless of income. The only way to do that is to pass Bernie’s Medicare for All plan. Under Medicare for All, every American would be guaranteed care as a right and automatically enrolled in this new system.

Completely by taxes.

Let’s be clear, study after study shows that Medicare for All will save workers and average families thousands of dollars every year on health care, all while making sure corporations like Amazon and the ultra-wealthy pay their fair share.

Health care costs are a crushing tax for middle class families right now. If you count health care premiums as taxes, the United States is the second-highest taxed nation in the world. We can guarantee health coverage to all Americans while bringing down costs, just like every other developed country.

For decades, the American people have been told a lie: that we cannot afford to do what every other major country already does, and guarantee health care to all our people as a right, not a privilege. What the insurance industry’s lies fail to mention is that we already spend more per capita on health care than any other major country, with worse health outcomes, and that moving to a Medicare-for-all, single-payer system would actually end up saving the American people trillions of dollars.

By cutting unnecessary administrative costs, bringing down the outrageous prices of prescription medication, and ensuring large corporations and the wealthy pay their fair share in taxes, we can afford to bring the United States, the richest country in the world, in line with every single other industrialized nation and guarantee quality health care coverage to all Americans.

Yes.

Medicare for All means just that: all. Bernie’s plan would provide coverage to all U.S. residents, regardless of immigration status.

Yes.

Bernie believes that as a nation, we have a moral responsibility to ensure that all Americans have the supports and services they need. Under Medicare for All, health care will be guaranteed as a right and home and community based services and supports will be fully covered.

Yes.

We pay the highest prices in the world for prescription drugs. It does not have to be that way. Bernie introduced the Affordable and Safe Prescription Drug Importation Act, which would allow the importation from Canada and other major countries.

Yes.

If the pharmaceutical industry will not end its greed, which is literally killing Americans, then we will end it for them. Bernie’s Medicare for All plan will allow drug prices to be negotiated by the Secretary of Health and Human Services under Medicare Part D. Bernie also introduced the Prescription Drug Price Relief Act, which will index the price of prescription drugs in the U.S. to the median price of the same drug in five other major countries.

No.

I support coverage for all, i.e., Medicare for all who want it. This would serve as a public option for any American, operating alongside and competing with private insurance plans, in order to drive prices down for everyone. If you’re sick you should be seen, and if you’re seen you shouldn’t go broke.

But we also should do what we do best as Americans: Find the unfindable, solve the unsolvable, and cure the incurable. We must invest in and commit to finding cures and more effective treatments in our lifetime, an initiative to publicly invest in genomics, targeted therapies, and data sharing. We’ll drive down the cost of care, increase our quality of life, and put a new generation of scientists to work while we’re at it.

Yes.

All Americans.

Americans should have a choice between coverage provided by private companies and that provided by the government. While I do not want to bring an end to private insurance, I support coverage for all, which would be a public option that would drive down the pressure on the private insurers and ultimately lead to more affordable plans for all Americans.

No.

It’s not the only solution, but we can and must protect, restore, and improve the protections that the Affordable Care Act gives all Americans regarding coverage for pre-existing conditions, coverage for maternity care, allowing people to remain on their parents’ plans through age 26, and so on.

Public option.

Public option, while restoring/protecting A.C.A. rules for private insurers.

Yes.

Requiring all Americans to have insurance, either public or private, means our health care system no longer has to bear the cost of treating uninsured patients.

A combination.

[This response was left blank.]

Yes.

It is in society’s interest to have everyone be as healthy as possible, and that’s achieved through access to affordable health care for everyone.

Yes.

We have the opportunity to expand a care economy in which we invest in retraining mid- and end-of-career workers, including those displaced by technology, to work in providing long-term care — jobs for those who need them, care for those who need it.

Yes.

I support importing drugs if they meet safety standards and the manufacturers can be held liable.

Yes.

I will do anything that is safe for patients — from negotiating prices to better enforcement of antitrust laws — to make prescription drugs more affordable, because prices are simply too high now for too many Americans. When my son, Nelson, got sick recently, we took him to the doctor and then I went to a chain-store pharmacy to have a prescription filled. The pharmacist told me I was lucky to have insurance because what cost me $5 would cost an uninsured person $250. Later, I talked with one of my district’s few remaining independent pharmacists; he said the prescription’s actual wholesale cost is about $80, so he would have charged an uninsured person about $100. This is a broken system.

There are a variety of additional steps the government could take, such as increasing access to generic drugs and improving access and opportunity for clinical trials, to help lower costs. Whatever is done should reduce prices, maintain incentives for innovation, and ensure drugs continue to be safe and effective.

And our public investment in finding cures, and making those available and affordable, would bring costs down too.

Yes.

I support Medicare-for-All so that everyone is covered, no one goes broke because of a medical bill, and we start treating health care like the basic human right that it is.

[This yes-or-no response was left blank, but the campaign left additional comments.]

Every proposal on the table right now would layer coverage expansions that add up over time, but there’s no excuse for stopping at half-measures. The aim has to be very clear: make sure every single person in this country has guaranteed health care coverage.

[This yes-or-no response was left blank, but the campaign left additional comments.]

I have a bill to crack down on shady behavior by insurance companies and improve the quality and affordability of health insurance purchased on the A.C.A. exchanges or provided through employer coverage. We have to protect the A.C.A., but we can’t stop there.

“Medicare for all.”

Our aim should be to cover the most people at the lowest cost, and for me that means Medicare for All. Health care is a basic human right and no one should go broke to pay a medical bill.

Yes.

Massachusetts was a leader in health care reform, including by adopting a requirement that everyone have coverage. This requirement is one of several features that has made health care coverage in Massachusetts some of the very best in the nation.

Studies show that health care costs will decrease under Medicare for All. Families are going broke today from medical bills, and Medicare for All will ensure that co-pays, deductibles, emergency room visits, and prescription drugs don’t drown families with sky-high medical expenses.

Yes.

Health care is a basic human right.

[This yes-or-no response was left blank, but the campaign left additional comments.]

Medicare for All would guarantee long-term care coverage for everyone in this country. I also believe we must fight against Republican attacks on Medicaid, which is the backbone of our long-term care system for millions of Americans.

Yes.

Yes.

No.

I want to make Medicare available to everyone as an option, but not eliminate private insurance.

Yes.

All Americans.

Yes.

We should keep and strengthen the A.C.A.

Public option.

Medicare provides good quality care at affordable rates, and should be available to those who want it. But millions of people like their private insurance and should be able to keep it. So the best is including Medicare as an option on the health exchanges, a public choice along with the private choices.

Yes.

Through a combination of taxes, co-payments and premiums.

Repeal the 2017 tax breaks for big corporations and very wealthy, retain for middle class.

Yes.

No.

Yes.

Often the same drug is less expensive in other countries. However we need strict monitoring to ensure good quality.

Yes.

Medicare could negotiate lower drug prices for consumers.

Yes.

We pay more than any other major industrialized country for our health care to worse results. When Americans get sick, they’re focused more on how to pay for their care than how to get well. Our current system is dysfunctional and we need to move towards a Medicare for All system that provides coverage for all Americans from birth. I wouldn’t eliminate private health insurance, but I don’t imagine it being an economically viable business outside of supplemental plans since it’s competing against a no-cost alternative.

Yes.

All Americans.

A public option for all would be a major step in the right direction and can serve as a good option for people during the transition from our current system to Medicare For All.

No.

Our health care system today is fundamentally broken and we need to make bigger moves to fix it — not just incremental modifications.

“Medicare for all.”

While all these policies would move us in a better direction than our current system, I believe the best path forward is Medicare for All. This system will ensure coverage for all Americans while allowing us to keep costs under control.

Yes.

By ensuring everyone has coverage, we can promote preventative care and keep costs under control, while also making administrative costs lower for both the federal government and individual providers. And, most importantly, we can make sure that all Americans are taken care of when they’re ill or injured.

A combination of taxes and co-payments, not premiums.

Employer-sponsored health care already represents a huge percent of our spending in this area, and that money can be used to largely fund Medicare for All through a payroll tax. The Medicare for All system will be cheaper because of lowered administrative and other costs, a lack of profit motive, and a focus on preventative care.

Yes.

I believe in a pathway to citizenship for all undocumented immigrants. Anyone who applied for that pathway would be eligible to buy into the Medicare for All system.

Yes.

Long-term care, especially end-of-life care, is an important part of anyone’s lifetime health care needs, and as such should be a part of a Medicare for All plan.

Yes.

Many Americans are paying as much as 8-10 times the prices as Canadians for the very same prescription drugs. While we should start by trying to control prices in the domestic market through mechanisms such as international reference pricing, forced licensing, and public manufacturing of generics, if these efforts don’t work, then we should allow for the importation of prescription drugs.

Yes.

It’s ridiculous that this isn’t allowed already.

 

 

Medicare’s Different Treatment of the Two Main Post-Hospital Care Options

July 1, 2019

Hospital patients who need additional care after being discharged from the hospital are usually sent to either an inpatient rehabilitation facility (IRF) or a skilled nursing facility (SNF). Although these facilities may look similar from the outside, Medicare offers very different coverage for each. While you may not have complete say in where you go after a hospital stay, understanding the difference between the two facilities can help you advocate for what you need and know what to expect with regard to Medicare coverage.

An IRF can be either part of a hospital or a stand-alone facility that offers intensive physical and occupational therapy under the supervision of a doctor and nurses. IRFs offer a minimum of three hours a day of rehabilitation therapy. An SNF, on the other hand, provides full-time nursing care. Patients also receive physical and occupational therapy, but the care is generally less intensive and specialized than in an IRF.

IRFs and Medicare

Medicare Part A covers a stay in an IRF in the same way it covers hospital stays. Medicare pays for 90 days of hospital care per “spell of illness,” plus an additional lifetime reserve of 60 days. A single “spell of illness” begins when the patient is admitted to a hospital or other covered facility, and ends when the patient has gone 60 days without being readmitted to a hospital or other facility. There is no limit on the number of spells of illness. However, the patient must satisfy a deductible before Medicare begins paying for treatment. This deductible, which changes annually, is $1,364 in 2019.

After the deductible is satisfied, Medicare will pay for virtually all hospital charges during the first 60 days of a recipient’s hospital stay. If the hospital stay extends beyond 60 days, the Medicare beneficiary begins shouldering more of the cost of his or her care. From day 61 through day 90, the patient pays a coinsurance of $341 a day in 2019. Beyond the 90th day, the patient begins to tap into his or her 60-day lifetime reserve. During hospital stays covered by these reserve days, beneficiaries must pay a coinsurance of $682 per day in 2019.

To qualify for care in an IRF, you must need 24-hour access to a doctor and a nurse with experience in rehabilitation. You must also be able to handle three hours of therapy a day (although there can be exceptions).

SNFs and Medicare

Medicare’s coverage of skilled nursing care is more limited. Medicare Part A covers up to 100 days of “skilled nursing” care per spell of illness. Beginning on day 21 of the nursing home stay, there is a copayment equal to one-eighth of the initial hospital deductible ($170.50 a day in 2019). However, the conditions for obtaining Medicare coverage of a nursing home stay are quite stringent. Here are the main requirements:

  • The Medicare recipient must enter the nursing home no more than 30 days after a hospital stay (meaning admission as an inpatient; “observation status” does not count) that itself lasted for at least three days (not counting the day of discharge).
  • The care provided in the nursing home must be for the same condition that caused the hospitalization (or a condition medically related to it).
  • The patient must receive a “skilled” level of care in the nursing facility that cannot be provided at home or on an outpatient basis. In order to be considered “skilled,” nursing care must be ordered by a physician and delivered by, or under the supervision of, a professional such as a physical therapist, registered nurse or licensed practical nurse. Moreover, such care must be delivered on a daily basis. (Few nursing home residents receive this level of care.)

A new spell of illness can begin if the patient has not received skilled care, either in an SNF or in a hospital, for a period of 60 consecutive days. The patient can remain in the SNF and still qualify as long as he or she does not receive a skilled level of care during that 60 days.

Keep in mind that some or all of Medicare’s deductibles and co-payments for both IRF and SNF care may be covered by Medicare supplemental insurance, also called Medigap coverage.

Medicare Beneficiaries Need to Know the Difference Between a Wellness Visit and a Physical

June 4, 2019

ELA News:

Medicare covers preventative care services, including an annual wellness visit. But confusing a wellness visit with a physical could be very costly.

As part of the Affordable Care Act, Medicare beneficiaries receive a free annual wellness visit. At this visit, your doctor, nurse practitioner or physician assistant will generally do the following:

  • Ask you to fill out a health risk assessment questionnaire
  • Update your medical history and current prescriptions
  • Measure your height, weight, blood pressure and body mass index
  • Provide personalized health advice
  • Create a screening schedule for the next 5 to 10 years
  • Screen for cognitive issues

You do not have to pay a deductible for this visit. You may also receive other free preventative services, such as a flu shot.

The confusion arises when a Medicare beneficiary requests an “annual physical” instead of an “annual wellness visit.” During a physical, a doctor may do other tests that are outside of an annual wellness visit, such as check vital signs, perform lung or abdominal exams, test your reflexes, or order urine and blood samples. These services are not offered for free and Medicare beneficiaries will have to pay co-pays and deductibles when they receive a physical. Kaiser Health News recently related the story of a Medicare recipient who had what she assumed was a free physical only to get a $400 bill from her doctor’s office.

Adding to the confusion is that when you first enroll, Medicare covers a “welcome to Medicare” visit with your doctor. To avoid co-pays and deductibles, you need to schedule it within the first 12 months of enrolling in Medicare Part B. The visit covers the same things as the annual wellness visit, but it also covers screenings and flu shots, a vision test, review of risk for depression, the option of creating advance directives, and a written plan, letting you know which screenings, shots, and other preventative services you should get.

To avoid receiving a bill for an annual visit, when you contact your doctor’s office to schedule the appointment, be sure to request an “annual wellness visit” instead of asking for a “physical.” The difference in wording can save you hundreds of dollars. In addition, some Medicare Advantage plans offer a free annual physical, so check with your plan if you are enrolled in one before scheduling.

How To Find And Use New Federal Ratings For Rehab Services At Nursing Homes

June 4, 2019

NAELA News:

For the first time, the federal government is shining a spotlight on the quality of rehabilitation care at nursing homes — services used by nearly 2 million older adults each year.

Medicare’s Nursing Home Compare website now includes a “star rating” (a composite measure of quality) for rehab services — skilled nursing care and physical, occupational or speech therapy for people recovering from a hospitalization. The site also breaks out 13 measures of the quality of rehab care, offering a more robust view of facilities’ performance.

Independent experts and industry representatives welcomed the changes, saying they could help seniors make better decisions about where to seek care after a hospital stay. This matters because high-quality care can help older adults regain the ability to live independently, while low-quality care can compromise seniors’ recovery.

“It’s a very positive move,” said David Grabowski, a professor of health care policy at Harvard Medical School. He noted that previous ratings haven’t distinguished between two groups in nursing homes with different characteristics and needs — temporary residents getting short-term rehabilitation and permanent residents too ill or frail to live independently.

Temporary residents are trying to regain the ability to care for themselves and return home as soon as possible, he noted. By contrast, permanent residents aren’t expecting improvements: Their goal is to maintain the best quality of life.

Three separate ratings for the quality of residents’ care now appear on the Nursing Home Compare website: one for overall quality (a composite measure); another one for “short-stay” patients (people who reside in facilities for 100 days or less, getting skilled nursing services and physical, occupational or speech therapy) and a third for “long-stay” patients (people who reside in facilities for more than 100 days).

Ratings for short-stay patients — available for 13,799 nursing homes — vary considerably, according to a Kaiser Health News analysis of data published by the government in late April. Nationally, 30% of nursing homes with a rating received five stars, the highest possible. Another 21% got a four-star rating, signifying above-average care. Twenty percent got three stars, an average performance. Seventeen percent got two stars, a worse-than-average score. And 13% got one star, a bottom-of-the-barrel score. (Altogether, 1,764 nursing homes did not receive ratings for short-stay patients.)

Here’s information about how to find and use the new Nursing Home Compare data, as well as insights from Kaiser Health News’ analysis:

Finding data about rehabilitation. Enter your geographic location on Nursing Home Compare’s home page, and a list of facilities will come up. You can select three at a time to review. Once you’ve done so, hit the “compare now” button at the top of the list. (To see more facilities, you’ll need to repeat the process.)

A new page will appear with several tabs. Click on the one marked “quality of resident care.” The three overall star ratings described above will appear for the facilities you’ve selected.

Below this information, two options are listed on the left side: “short-stay residents” and “long-stay residents.” Click on “short-stay residents.” Now you’ll see 13 measures with actual numbers included (most but not all of the time), as well as state and national averages.

Understanding the star rating. Six measures are used to calculate star ratings for the quality of rehab care for short-stay patients. Two of them concern emergency room visits and rehospitalizations, potential indicators of problematic care. Another two examine how well pain was controlled and bedsores were managed. One measure looks at how many patients became better able to move around on their own, an important element of recovery. Yet another examines the rate at which antipsychotic medications were newly prescribed. (These drugs can have significant side effects and are not recommended for older adults with dementia.)

One measure of great interest to seniors is the percentage of residents who return successfully home after a short nursing home stay. But actual numbers aren’t available on the Nursing Home Compare website this time around: Instead, facilities are listed as below average, average or above average. The national average, reported in April, was 48.6%, indicating room for improvement.Tracking variations in performance. Some facilities outperform others by large margins on measures of quality of care for short-stay residents. And some facilities have high scores in some areas, but not in others.

Tracking variations in performance. Some facilities outperform others by large margins on measures of quality of care for short-stay residents. And some facilities have high scores in some areas, but not in others.

For instance, the nursing home at Westminster Village, a high-end continuing care retirement community in Scottsdale, Ariz., had the highest score for rehospitalizations — 39.9% — out of 68 facilities in and around Phoenix. (By contrast, the lowest score in the Phoenix area was 15.4% and the state average was 23.5%.) It also had the highest rate of helping residents improve their ability to move around on their own — 88.6%. (The lowest score was 37.6% and the state average was 63.6%.)

In an email, Lesley Midkiff, marketing director at Westminster Village, said that the facility’s staff is vigilant about sending residents back to the hospital if health issues arise. At the same time, she said, staffers “push the residents just enough to regain independence and recover quickly from their short term stays.” Both priorities have the “residents’ best interest” in mind, she said.

If a facility has an average or low quality score, Dr. David Gifford, a senior vice president at the American Health Care Association, a nursing home industry group, recommended that people look closely at various measures and try to figure out where the institution fell short. Call the facility and ask them to explain, he said. Also, review Nursing Home Compare’s information about staffing and health inspections, Gifford suggested, and visit the facility if possible.

Variations within nursing homes. The newly published Nursing Home Compare data also shows that institutions aren’t always equally adept at caring for short-stay and long-stay residents.

Disparities in facilities’ ratings for short- and long-stay patients are common. Of 13,351 nursing homes that received both ratings, 32% received the same star ratings for the quality of care received by short-stay and long-stay residents. Another 32% of facilities received higher star ratings for short-stay residents, while 36% got higher ratings for long-stay residents. About one-third of the time, these rating categories were one star apart, but in another third of cases, they varied by two or more stars — a significant discrepancy. (This analysis does not include 2,212 nursing homes for which data was missing.)

In Phoenix, Desert Terrace Healthcare Center, which bills itself on its website as the city’s “premier location for short-term rehabilitation and long-term care,” is one such facility. Its quality-of-care rating for short-term residents was two stars, while its rating for long-term residents was five stars. Notably, hospital admissions and ER visits for short-stay patients were higher than the state average, while the portion of short-stay residents whose mobility improved was lower than average.

In an email, Jeremy Bowen, the facility’s administrator, wrote that the facility had a good record of managing pain and bedsores and limiting antipsychotic prescriptions for short-stay patients. Factors such as hospital readmissions depend on community resources and patients’ understanding of their health needs, which are difficult to control, he noted.

Sierra Winds, part of a continuing care community in Peoria, Ariz., has a similar split in quality ratings (two stars for short-stay residents, five stars for long-stay residents). On four of six measures used to calculate star ratings for short-stay residents, it performed worse than the state average.

“Sierra Winds remains committed to providing the highest quality care and services to its residents,” wrote Shannon Brown, the facility’s executive director, in an email. “We are proud of our 4-star rating with CMS [the Centers for Medicare & Medicaid Services].”

That’s the facility’s overall rating (this includes data about staffing and health inspections). But it doesn’t address the split in scores for short-stay and long-stay patients, which raises a red flag and should certainly cause seniors and their families to ask follow-up questions.

“If I’m a patient looking for a place for a short-term rehab stay, I really want to know how patients who look like me did,” said Dr. Rachel Werner, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania and a quality-measurement expert.

KHN senior correspondent Jordan Rau contributed to this report.

Doughnut Hole Closed, But Many Still Struggle With Medicare Drug Costs

June 3, 2019

NAELA  News:   Three times a week, Tod Gervich injects himself with Copaxone, a prescription drug that can reduce the frequency of relapses in people who have some forms of multiple   sclerosis. After more than 20 years with the disease, Gervich, 66, is accustomed to managing his condition. What he can’t get used to is how Medicare’s coinsurance charges drain his wallet.

Unlike commercial plans that cap members’ out-of-pocket drug spending annually, Medicare has no limit for prescription medications in Part D, its drug benefit. With the cost of specialty drugs increasing, some Medicare beneficiaries could owe thousands of dollars in out-of-pocket drug costs every year for a single drug.

Recent proposals by the Trump administration and Sen. Ron Wyden (D-Ore.) would address the long-standing problem by imposing a spending cap. But it’s unclear whether any of these proposals will gain a foothold.

The 2006 introduction of the Medicare prescription drug benefit was a boon for Americans 65 and older, but the coverage had weak spots. One was the so-called doughnut hole — the gap beneficiaries fell into after they accumulated a few thousand dollars in drug expenses and were on the hook for the full cost of their medications. Another was the lack of an annual cap on drug spending.

Legislative changes have gradually closed the doughnut hole so that, this year, beneficiaries no longer face a coverage gap. In a standard Medicare drug plan, beneficiaries pay 25% of the price of their brand-name drugs until they reach $5,100 in out-of-pocket costs. Once patients reach that threshold, the catastrophic portion of their coverage kicks in and their obligation drops to 5%. But it never disappears.

5% Responsibility Adds Up Fast

It’s that ongoing 5% that hits hard for people, like Gervich, who take expensive medications.

His 40-milligram dose of Copaxone costs about $75,000 annually, according to the National Multiple Sclerosis Society. In January, Gervich paid $1,800 for the drug and another $900 in February.

Discounts that drug manufacturers are required to provide to Part D enrollees also counted toward his out-of-pocket costs. By March, he hit the $5,100 threshold that pushed him into catastrophic coverage. For the rest of the year, he’ll owe $295 a month for this drug, until the cycle starts over again in January.

That $295 is a far cry from the approximately $6,250 monthly Copaxone price without insurance. But, combined with the $2,700 he already paid before his catastrophic coverage kicked in, the additional $2,950 he’ll owe this year is no small amount. And that assumes he needs no other medications.

“I feel like I’m being punished financially for having a chronic disease,” he said. He has considered discontinuing Copaxone to save money.

His drug bill is one reason Gervich has decided not to retire yet, he said.

An annual cap on his out-of-pocket costs “would definitely help,” said Gervich, a self-employed certified financial planner in Mashpee, Mass.

More Will Reach ‘Catastrophic Coverage’ Threshold

Drugs like Copaxone that can modify the effects of the disease have been on a steep upward price trajectory in recent years, said Bari Talente, executive vice president for advocacy at the National Multiple Sclerosis Society. Drugs that used to cost $60,000 annually five years ago cost $90,000 now, she said. With those totals, Medicare beneficiaries “are going to hit catastrophic coverage no matter what.”

Specialty-tier drugs for multiple sclerosis, cancer and other conditions — defined by Medicare as those that cost more than $670 a month — account for more than 20% of total spending in Part D plans, up from about 6% before 2010, according to a report by the Medicare Payment Advisory Commission, a nonpartisan agency that advises Congress about the program.

Just over 1 million Medicare beneficiaries in Part D plans who did not receive low-income subsidies had drug costs that pushed them into catastrophic coverage in 2015, more than twice as many as the 2007 total, an analysis by the Kaiser Family Foundation found. (KHN is an editorially independent program of the foundation.)

“When the drug benefit was created, 5% probably didn’t seem like that big a deal,” said Juliette Cubanski, associate director of the Program on Medicare Policy at the Kaiser Family Foundation.

“Now we have such expensive medications, and many of them are covered under Part D — where, before, many expensive drugs were cancer drugs” that were administered in doctors’ offices and covered by other parts of Medicare.

The lack of a spending limit for the Medicare drug benefit sets it apart from other coverage. Under the Affordable Care Act, the maximum amount someone generally owes out-of-pocket for covered drugs and other medical care for this year is $7,900. Plans typically pay 100% of customers’ costs after that.

The Medicare program doesn’t have an out-of-pocket spending limit for Part A or Part B, which cover hospital and outpatient services, respectively. But beneficiaries can buy supplemental Medigap plans, some of which pay coinsurance amounts and set out-of-pocket spending limits. Medigap plans, however, don’t cover Part D prescription plans.

Plan for Spending Cap Still Leaves Problem

Counterbalancing the administration’s proposal to impose a spending cap on prescription drugs is another that could increase many beneficiaries’ out-of-pocket drug costs.

Currently, brand-name drugs that enrollees receive are discounted by 70% by manufacturers when Medicare beneficiaries have accumulated at least $3,820 in drug costs and until they reach $5,100 in out-of-pocket costs. Those discounts are applied toward beneficiaries’ total out-of-pocket costs, moving them more quickly toward catastrophic coverage. Under the administration’s proposal, manufacturer discounts would no longer be treated this way. The administration said this would help steer patients toward less expensive generic medications.

Still, beneficiaries would have to pay more out-of-pocket to reach the catastrophic spending threshold. Thus, fewer people would likely reach the catastrophic coverage level where they could benefit from a spending cap.

“Our concern is that some people will be paying more out-of-pocket to get to the $5,100 threshold and the drug cap,” said Keysha Brooks-Coley, vice president of federal affairs at the American Cancer Society Cancer Action Network.

“It’s kind of a mixed bag,” said Cubanski of the proposed calculation change. “There will be savings for some individuals” who reach the catastrophic phase of coverage. “But for many there will be higher costs.”

For some people, especially cancer patients taking chemotherapy pills, the lack of a drug-spending cap in Part D coverage seems especially unjust.

These cutting-edge targeted oral chemotherapy and other drugs tend to be expensive, and Medicare beneficiaries often hit the catastrophic threshold quickly, said Brooks-Coley.

By Michelle Andrews

Court Denies All Government Motions in Class Action Seeking Appeal Right for Medicare Beneficiaries on “Observation Status”

May 1, 2019


NAELA News: In a decision issued on March 27, 2019, a federal judge denied multiple attempts by the federal government to halt a lawsuit by Medicare patients seeking a right to appeal their placement on “outpatient observation status” in hospitals. Alexander v. Azar is a nationwide class action brought by individuals who were forced to pay up to $30,000 for post-hospital skilled nursing facility care because they had been classified as outpatients in observation status, rather than as inpatients.

Although care provided to patients on observation status is often indistinguishable from inpatient care, it does not count toward the three-day inpatient hospital stay requirement for Medicare coverage of nursing home care. This leaves beneficiaries with the burden of paying for – or forgoing – extremely costly nursing and rehabilitative care. The opportunity to appeal is critical because of the severe ramifications that can result from the observation status categorization. Class member Ervin Kanefsky of Pennsylvania, for example, a 93-year-old World War II veteran, had to pay approximately $10,000 for nursing home care after being hospitalized for a shoulder fracture for five days. He was initially admitted as an inpatient but later was told that the “powers that be” had changed his status to observation before he was discharged.

In a 50-page opinion, the court addressed the government’s motion for summary judgment, motion to “decertify” the class, and motion to dismiss the case. Each motion was denied. Judge Michael P. Shea concluded that the evidence plaintiffs submitted could reasonably establish that physician decisions about whether to classify patients as inpatients are “meaningfully constrained” by criteria set by Medicare. Class members may therefore possess a “property interest” in the Medicare coverage they seek, a necessary component of their constitutional due process claim. The court also concluded that the plaintiffs continue to have standing to bring the case, and that their claims are not moot. The court declined to take the drastic step of decertifying the class, but did modify the class definition to target individuals who have been harmed by observation status in specific ways, and requested further briefing from the parties on that issue. In concluding his opinion, Judge Shea emphasized that the action, now approaching its eighth year, must proceed to trial without delay.

Plaintiffs’ lead attorney, Alice Bers of the Center for Medicare Advocacy, welcomed the decision: “People who have paid into Medicare their whole lives, and who risk having to pay thousands of dollars for necessary medical care, deserve a fair process to determine whether they will receive Medicare coverage.” Co-counsel Luke Liss of Wilson Sonsini Goodrich & Rosati, echoed Bers’s observations: “We look forward to showing at trial that these vulnerable patients have a right to appeal to Medicare as matter of constitutional due process.” Co-counsel Regan Bailey of Justice in Aging added, “Hospitals routinely appeal Medicare’s determination of whether a stay was inpatient or observation status. Older adults and people with disabilities should have the same right.”

U.S. government boosts 2020 Medicare payments to insurers by 2.53 percent

May 1, 2019

NEW YORK (Reuters) – The U.S. government on Monday said it would increase by 2.53 percent on average 2020 payments to the health insurers that manage Medicare Advantage insurance plans for seniors and the disabled, a reflection of a new estimate on medical cost growth.

The rate, which affects how much insurers charge for monthly healthcare premiums, plan benefits and, ultimately, how much they profit, represents an increase over the 1.59 percent increase proposed by the Centers for Medicare & Medicaid Services (CMS) in February.

The government raised the final payment rate from the proposed rate after revising its estimate for increases in medical services for next year. Its final estimate of that growth rate is 5.62 percent compared with 4.59 percent in its February proposal.

“Most of the puts-and-takes remained the same as proposed, but CMS upped the growth rate, which is definitely helpful in 2020,” said Ipsita Smolinski, managing director at healthcare research consulting firm Capitol Street.

Medicare Advantage plans serve more than 20 million people, most of them aged 65 and older.

Shares in insurers were unchanged in after hours trading. UnitedHealth Group Inc, Humana Inc, CVS Health Corp, through its acquisition of Aetna, and WellCare Health Plans Inc are the largest sellers of Medicare Advantage health insurance.

Under the program, they are paid a set rate by the government to cover member healthcare costs.

In addition to medical costs, the government’s 2020 payment rate also factors in other changes in policies, such as quality of care related payments that may result in declines or increases from year to year.

For instance, the 2020 rate reflected a decline in payments of 3.08 percent related to the Affordable Care Act requirement that Medicare Advantage and fee-for-service Medicare have the same payment structure.

Starting in 2020, Medicare Advantage plans will also be able to offer supplemental non-health related benefits to chronically ill enrollees that address their social needs, CMS Administrator Seema Verma said. Those can include needed structural changes to the home, such as adding ramps and widening doorways.

The plans can tailor these offerings to individuals, and the offerings could increase competition between plans, Verma said.

Previously, plans have only been allowed to offer health related benefits.

Medicare Advantage competes with the traditional Medicare fee-for-service program. Both have grown as the “Baby Boomer” generation ages into Medicare. Together, they cover more than 55 million people.

Reporting by Caroline Humer; Editing by Bill Berkrot

Universal long-term care coverage included in House Democrats’ new Medicare-for-all plan

March 29, 2019

House Democrats unveiled a plan this week that would offer all Americans a government insurance plan option that would provide coverage for long-term services at no cost.

The Washington Post first reported the ambitious effort late Tuesday, which is backed by more than 100 members of Congress. Spearheaded by Rep. Pramila Jayapal (D-WA), the proposal would move all Americans to one public payer in two years, providing them with coverage for medical, vision, dental and long-term care services.

Though the measure has 106 cosponsors, it has no shot at passing the House or in the Republican-controlled Senate, the Post reported.

“We have a real plan,” Jayapal told reporters this week. “Americans are literally dying because they cannot afford insulin and can’t get the cancer treatments they need … I think this Medicare-for-all bill makes it clear what we mean by healthcare for all. We mean a complete transformation of our healthcare system.”

Critics have said the plan would require a sharp increase in taxes, with one previous estimate projecting that Medicare for all would increase federal expenditures by $30 trillion. Jayapal’s bill is more ambitious than a 2017 single-payer pitch from Sen. Bernie Sanders. Her idea also includes a crackdown on the pharmaceutical industry, aimed at lowering drug prices, and the government-run long-term care option, which also could cover home health services.

Nursing homes, hospitals and other providers would be paid under a fixed annual budget, determined by several factors including historical volume of services, Jayapal told reporters.