Category Archives: Medicare

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.

Seniors Aging In Place Turn To Devices And Helpers, But Unmet Needs Are Common

March 27, 2019

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Bathroom with accessories to help with washing and using the toilet. Bathroom in a care home in England; A new study examines how seniors with deteriorating strength and other physical functions deal with such challenges as taking a shower or getting dressed in the morning. (E+/Getty Images)

NAELA News:  About 25 million Americans who are aging in place rely on help from other people and devices such as canes, raised toilets or shower seats to perform essential daily activities, according to a new study documenting how older adults adapt to their changing physical abilities.

But a substantial number don’t get adequate assistance. Nearly 60 percent of seniors with seriously compromised mobility reported staying inside their homes or apartments instead of getting out of the house. Twenty-five percent said they often remained in bed. Of older adults who had significant difficulty putting on a shirt or pulling on undergarments or pants, 20 percent went without getting dressed. Of those who required assistance with toileting issues, 27.9 percent had an accident or soiled themselves.

The study, by researchers from Johns Hopkins University, focuses on how older adults respond to changes in physical function — a little-studied and poorly understood topic. It shows that about one-third of older adults who live in the community — nearly 13 million seniors — have a substantial need for assistance with daily activities such as bathing, eating, getting dressed, using the toilet, transferring in and out of bed or moving around their homes; about one-third have relatively few needs; and another third get along well on their own with no notable difficulty.

For older adults and their families, the report is a reminder of the need to plan ahead for changing capacities.

“The reality is that most of us, as we age, will require help at one point or another,” said Dr. Bruce Chernof, president of the SCAN Foundation and chair of the 2013 federal Commission on Long-Term Care. Citing Medicare’s failure to cover so-called long-term services and supports, which help seniors age in place, he said, “We need to lean in much harder if we want to help seniors thrive at home as long as possible.” (KHN’s coverage of aging and long-term care issues is supported in part by the SCAN Foundation.)

Previous reports have examined the need for paid or unpaid help in the older population and the extent to which those needs go unmet. Notably, in 2017, the same group of Johns Hopkins researchers found that 42 percent of older adults with probable dementia or difficulty performing daily activities didn’t get assistance from family, friends or paid caregivers — an eye-opening figure. Of seniors with at least three chronic conditions and high needs, 21 percent lacked any kind of assistance.

But personal care isn’t all that’s needed to help older adults remain at home when strength, flexibility, muscle coordination and other physical functions begin to deteriorate. Devices and home modifications can also help people adjust.
Until this new study, it hasn’t been clear how often older adults use “assistive devices”: canes, walkers, wheelchairs and scooters for people with difficulties walking; shower seats, tub seats and grab bars to help with bathing; button hooks, reachers, grabbers and specially designed clothes for people who have difficulty dressing; special utensils designed to make eating easier; and raised toilets or toilet seats, portable commodes and disposable pads or undergarments for individuals with toileting issues.

“What we haven’t known before is the extent of adjustments that older adults make to manage daily activities,” said Judith Kasper, a co-author of the study and professor at Johns Hopkins’ Bloomberg School of Public Health.

The data comes from a 2015 survey conducted by the National Health and Aging Trends Study, a leading source of information about functioning and disability among adults 65 and older. More than 7,000 seniors filled out surveys in their homes and results were extrapolated to 38.8 million older Americans who live in the community. (Those who live in nursing homes, assisted living centers, continuing care retirement communities and other institutions were excluded.)

Among key findings: Sixty percent of the seniors surveyed used at least one device, most commonly for bathing, toileting and moving around. (Twenty percent used two or more devices and 13 percent also received some kind of personal assistance.) Five percent had difficulty with daily tasks but didn’t have help and hadn’t made other adjustments yet. One percent received help only.

Needs multiplied as people grew older, with 63 percent of those 85 and older using multiple devices and getting personal assistance, compared with 23 percent of those between ages 65 and 74.

The problem, experts note, is that Medicare doesn’t pay for most of these non-medical services, with some exceptions. As a result, many seniors, especially those at or near the bottom of the income ladder, go without needed assistance, even when they’re enrolled in Medicaid. (Medicaid community-based services for low-income seniors vary by state and often fall short of actual needs.)

The precariousness of their lives is illustrated in a companion report on financial strain experienced by older adults who require long-term services and supports. Slightly more than 10 percent of seniors with high needs experienced at least one type of hardship, such as being unable to pay expenses like medical bills or prescriptions (5.9 percent), utilities (4.8 percent) or rent (3.4 percent), or skipping meals (1.8 percent). (Some people had multiple difficulties, reflected in these numbers.)

These kinds of adverse events put older adults’ health at risk, while contributing to avoidable hospitalizations and nursing home placements. Given a growing population of seniors who will need assistance, “I think there’s a need for Medicare to rethink how to better support beneficiaries,” said Amber Willink, co-author of both studies and an assistant scientist at Johns Hopkins’ Bloomberg School of Public Health.

That’s begun to happen, with the passage last year of the CHRONIC Care Act, which allows Medicare Advantage plans to offer supplemental benefits such as wheelchair ramps, bathroom grab bars, transportation and personal care to chronically ill members. But it’s unclear how robust these benefits will be going forward; this year, plans, which cover 21 million people, aren’t offering much. Meanwhile, 39 million people enrolled in traditional Medicare are left out altogether.

“We’ve had discussions with the [insurance] industry over the last couple of months to explore what’s going to happen and it’s a big question mark,” said Susan Reinhard, director of AARP Public Policy Institute, which publishes a scorecard on the adequacy of state long-term services and supports with several other organizations.

So far, she said, the response seems to be, “Let’s wait and see, and is this going to be affordable?”

There’s Still Time to Go Back to Traditional Medicare or Change MA Plans

February 27, 2019

Annual Enrollment has ended, but the Medicare Advantage Open Enrollment Period, allowing plan changes or a return to traditional Medicare continues through March 31 – Make sure you are fully informed about the Medicare that is right for you.

When?

  • January 1–March 31

What Can I Do?

  • If you’re in a Medicare Advantage Plan (with or without drug coverage), you can switch to another Medicare Advantage Plan (with or without drug coverage).
  • You can disenroll from your Medicare Advantage Plan and return to Original Medicare. If you choose to do so, you’ll be able to join a Medicare Prescription Drug Plan.
  • If you enrolled in a Medicare Advantage Plan during your Initial Enrollment Period, you can change to another Medicare Advantage Plan (with or without drug coverage) or go back to Original Medicare (with or without drug coverage) within the first 3 months you have Medicare.

What Can’t I Do?

  • Switch from Original Medicare to a Medicare Advantage Plan.
  • Join a Medicare Prescription Drug Plan if you’re in Original Medicare.
  • Switch from one Medicare Prescription Drug Plan to another if you’re in Original Medicare.

Get Medicare’s New, And First Official, “What’s Covered” App!

February 27, 2019

Is your medical item or service covered by Medicare Part A and/or Part B? Now there’s a quick way to check!

Medicare’s free “What’s Covered” app delivers accurate cost and coverage information right on your smartphone. Now you can quickly see whether Medicare covers your service in the doctor’s office, the hospital, or anywhere else you use your phone. The “What’s Covered” app is the only official U.S. government Medicare app.

The app delivers general cost, coverage and eligibility details for items and services covered by Medicare Part A and Part B.  Search or browse to learn what’s covered and not covered; how and when to get covered benefits; and basic cost information. You can also get a list of covered preventive services.

The “What’s Covered” app helps you understand the health care coverage offered by Original Medicare Part A (Hospital Insurance) and Part B (Medical Insurance).

Use this federal government app to:

  • Get answers to your Medicare coverage questions
  • See how much you’ll pay
  • Learn about the covered items and services
  • See helpful notes and where to get more information
  • Browse free preventive services

Original Medicare Items & Services: Find out exactly what your Medicare coverage has to offer by getting answers to questions like:

  • When are mammograms covered?
  • Are specialists or home health care covered?
  • Will Medicare pay for crutches, walkers, or diabetes testing supplies?

Preventive Health Coverage: Medicare coverage includes many common preventive services at no cost to you. Preventive services can help keep you healthy by finding health problems early, when treatment works best, and can keep you from getting certain diseases.

What’s covered will help you answer questions like:

  • Will my Medicare benefits cover a service to help me stop smoking?
  • Can I get a regular cervical cancer screening?
  • How often will my Medicare coverage allow me to get a bone mass measurement?
  • Ask your doctor or other health care provider which preventive services (like screenings, shots, and tests) you need to get.

Part A & Part B Costs: Medicare Part A and Part B cover certain medical services and supplies in hospitals, doctors’ offices, and other health care settings.

Part A hospital insurance coverage helps pay for inpatient care in a hospital, inpatient care in a skilled nursing facility, hospice care, home health care, or inpatient care in a religious non-medical health care institution. Copayments, coinsurance, or deductibles may apply for each service covered by Part A.

Part B medical insurance coverage supports medically necessary doctors’ services, outpatient care, home health services, durable medical equipment, mental health services, preventive services, and other medical services. Under Original Medicare, if the Part B deductible applies, you must pay all health care costs (up to the Medicare-approved amount) until you meet the yearly Part B deductible. After your deductible is met, Medicare begins to pay its share and you typically pay 20% of the Medicare-approved amount of the service, if the doctor or other health care provider accepts assignment. There’s no yearly limit for what you pay out-of-pocket.

For some items and services, you must meet eligibility criteria or you may be responsible for paying all costs. Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. Ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.

Use the “What’s Covered” app to answer questions like:

  • How much will I pay for prescription drugs included in Medicare Part B coverage?
  • Does the Part B deductible apply for cardiac rehabilitation?
  • What percentage of the Medicare-approved amount will I need to pay for colorectal cancer screenings?

Medicare Advantage Plans: If you have a Medicare Advantage Plan or other Medicare health plan, you have the same basic health care coverage as people who have Original Medicare, but the rules vary by plan. Some Medicare Advantage Plans offer extra benefits that Original Medicare doesn’t cover – like vision, hearing, or dental. Check with the plan or search in the App Store to see if the plan has a similar mobile application.

Download Medicare’s official “What’s Covered” app — available for free in both the Apple App Store and Google Play.    The “What’s Covered” is part of the agency’s eMedicareinitiative—launched in 2018—which is aimed at empowering beneficiaries with cost and quality information.

Key Elder Law Numbers for 2019: Our Annual Roundup

February 4, 2019

Below are figures for 2019 that are frequently used in the elder law practice or are of interest to clients.

Medicaid Spousal Impoverishment Figures for 2019

The new minimum community spouse resource allowance (CSRA) is $25,284 and the maximum CSRA is $126,420. The maximum monthly maintenance needs allowance is $3,160.50. The minimum monthly maintenance needs allowance remains $2,057.50 ($2,572.50 for Alaska and $2,366.25 for Hawaii) until July 1, 2019.

Medicaid Home Equity Limits

Minimum: $585,000

Maximum: $878,000

For CMS’s complete chart of the 2019 SSI and Spousal Impoverishment Standards, click here.

Income Cap

The income cap for 2019 applicable in “income cap” states is $2,313 a month.

Gift and estate tax figures

Federal estate tax exemption: $11.4 million for individuals, $22.8 million for married couples

Lifetime tax exclusion for gifts: $11.4 million

Generation-skipping transfer tax exemption: $11.4 million

Annual gift tax exclusion: $15,000 (unchanged)

Long-Term Care Premium Deductibility Limits for 2019

The Internal Revenue Service has announced the 2019 limitations on the deductibility of long-term care insurance premiums from income. Any premium amounts above these limits are not considered to be a medical expense.

Attained age before the close of the taxable year Maximum deduction
40 or less $420
More than 40 but not more than 50 $790
More than 50 but not more than 60 $1,580
More than 60 but not more than 70 $4,220
More than 70 $5,270

Benefits from per diem or indemnity policies, which pay a predetermined amount each day, are not included in income except amounts that exceed the beneficiary’s total qualified long-term care expenses or $370 per day (for 2019), whichever is greater.

For these and other inflation adjustments from the IRS, click here.

Medicare Premiums, Deductibles and Copayments for 2019

  • Part B premium: $135.50/month (was $134)
  • Part B deductible: $185 (was $183)
  • Part A deductible: $1,364 (was $1,340)
  • Co-payment for hospital stay days 61-90: $341/day (was $335)
  • Co-payment for hospital stay days 91 and beyond: $682/day (was $670)
  • Skilled nursing facility co-payment, days 21-100: $170.50/day (was $167.50)

Part B premiums for higher-income beneficiaries:

  • Individuals with annual incomes between $85,000 and $107,000 and married couples with annual incomes between $170,000 and $214,000 will pay a monthly premium of $189.60.
  • Individuals with annual incomes between $107,000 and $133,500 and married couples with annual incomes between $214,000 and $267,000 will pay a monthly premium of $270.90.
  • Individuals with annual incomes between $133,500 and $160,000 and married couples with annual incomes between $267,000 and $320,000 will pay a monthly premium of $352.20.
  • Individuals with annual incomes between above $160,000 and married couples with annual incomes above $320,000 will pay a monthly premium of $433.40.
  • Individuals with annual incomes above $500,000 and married couples with annual incomes above $750,000 will pay a monthly premium of $460.50

High-earner premiums differ for beneficiaries who are married but file a separate tax return from their spouse. Those with incomes greater than $85,000 and less than $415,000 will pay a monthly premium of $433.40. Those with incomes greater than $415,000 will pay a monthly premium of $460.50.

For Medicare’s “Medicare 2019 costs at a glance,” click here.

Social Security Benefits for 2019

The new monthly federal Supplemental Security Income (SSI) payment standard is $771 for an individual and $1,157 for a couple.

Estimated average monthly Social Security retirement payment: $1,461 a month for individuals and $2,448 for couples

Maximum amount of earnings subject to Social Security taxation: $132,900 (was $128,400)

For a complete list of the 2019 Social Security figures, go to: https://www.ssa.gov/news/press/factsheets/colafacts2019.pdf

Understanding Medicare’s Hospice Benefit

February 4, 2019

Medicare’s hospice benefit covers any care that is reasonable and necessary for easing the course of a terminal illness. It is one of Medicare’s most comprehensive benefits and can be extremely helpful to both the terminally ill individual and his or her family, but it is little understood and underutilized. Understanding what is offered ahead of time may help Medicare beneficiaries and their families make the difficult decision to choose hospice if the time comes.

The focus of hospice is palliative care, which means helping people who are terminally ill and their families maintain their quality of life. Palliative care addresses physical, intellectual, emotional, social, and spiritual needs while also supporting the terminally ill individual’s independence, access to information, and ability to make choices about health care.

To qualify for Medicare’s hospice benefit, a beneficiary must be entitled to Medicare Part A, and a doctor must certify that the beneficiary has a life expectancy of six months or less. If the beneficiary lives longer than six months, the doctor can continue to certify the patient for hospice care indefinitely. The beneficiary must also agree to give up any treatment to cure his or her illness and elect to receive only palliative care. This can seem overwhelming, but beneficiaries can also change their minds at any time. It’s possible to revoke the benefit and reelect it later, and to do this as often as needed.

Medicare will cover any care that is reasonable and necessary for easing the course of a terminal illness. Hospice nurses and doctors are on-call 24 hours a day, 7 days a week, to give beneficiaries support and care when needed. Services are usually provided in the home. The Medicare hospice benefit provides for:

  • Physician and nurse practitioner services
  • Nursing care
  • Medical appliances and supplies
  • Drugs for symptom management and pain relief
  • Short-term inpatient and respite care
  • Homemaker and home health aide services
  • Counseling
  • Social work service
  • Spiritual care
  • Volunteer participation
  • Bereavement services

Services are considered appropriate if they are aimed at improving the beneficiary’s life and making him or her more comfortable.

Because the beneficiary is electing palliative care over treatment, there are things the hospice benefit will not cover:

  • Treatment to cure the beneficiary’s illness.
  • Prescription drugs other than for symptom control or pain relief.
  • Care from a provider that wasn’t set up by the hospice team, although the beneficiary can choose to have his or her regular doctor be the attending medical professional.
  • Room and board. If the beneficiary is in a nursing home, hospice will not pay for room and board costs. However, if the hospice team determines that the beneficiary needs short-term inpatient care or respite care services, Medicare will cover a stay in a facility.
  • Care from a hospital, either inpatient or outpatient, or ambulance transportation unless it arranged by the hospice team. The beneficiary can use regular Medicare to pay for any treatment not related to the beneficiary’s terminal illness.

To download Medicare’s booklet on the hospice benefit, click here.

Jason Frank Presses Maryland Senate for “Aging in Place”

January 28, 2019

by Federico Salas, J.D.

On January 17, 2019, the Maryland Senate Finance Committee held a briefing that, among other topics, addressed the Home and Community Based Options Waiver (HCBOW). Jason A. Frank, Esq. specifically discussed the problems with the HCBOW that he expects will be fixed by current proposed legislation that:

  • Ensures that those people who lose Community First Choice services because of aging into Medicare can access the HCBOW and continue to receive services in the community; and
  • Eliminates the 22,000-person HCBOW Registry (waiting list) and serves eligible people who want services directly in the community without first entering a nursing home.

Resources from the Briefing

View the recording of the Senate Finance Committee briefing (presentations on the HCBOW begin at 1:23:00).

Download Mr. Frank’s presentation on Aging in Place (PDF, 24 pages).

Senate Bill 699

This is a summary of SB 699 regarding Maryland’s Community First Choice program:

The Problem

Marylanders who have community Medicaid, including Medicaid Expansion, and get long-term care services through the Community First Choice (CFC) program for as little help as having someone to assist in bathing and dressing at home, will lose all access to services if both: (1) they get Medicare and (2) they have too much income or assets. For individuals in 2019, CFC-Medicaid Expansion enrollees who have a monthly income between $791–$1,396 per month or assets greater than $2,000 are at risk of losing services. The Home & Community Based Options Waiver (HCBOW) program can provide the needed services to Marylanders with disabilities at home, but it has an 8-year, 22,000-person waiting list (“the Registry”).

Currently, there is no way for Marylanders living at home to bypass the 8-year, 22,000-person waiting list and stay at home, except by unnecessarily entering a nursing home. This means that the people who lose CFC when they get Medicare must choose between having to enter a nursing home or go without help for 8 years in order to continue getting the help that they need.

The Solution

Permit certain individuals who are affected, or will be affected, by “the CFC problem” to bypass the 8-year, 22,000-person waiting list in order maintain CFC services WITHOUT having to wait out the 8-year Registry or go through unnecessary and extremely costly nursing home admission just to transfer back out into the community.

Senate Bill 700

This is a summary of SB 700 regarding Maryland’s HCBOW:

The Problem

Most Marylanders who need as little help as having someone to assist them in bathing and dressing—but lack the money to pay for it—must choose between entering a nursing home or going without help for 8 years. The Maryland Medicaid Home & Community Based Services Options Waiver (HCBOW) program can provide the needed services to Marylanders with disabilities at home, but it has an 8-year, 22,000-person waiting list (“the Registry”). The HCBOW has an 8-year-long waiting list because the HCBOW is not required to meet the demand for services.

This year, the HCBOW can serve 5,659 individuals. When the Maryland Department of Health (MDH) readjusts HCBOW program availability every few years, it does not count eligible people on the 8-year, 22,000-person waiting list. In 2016, the MDH actually reduced program availability DESPITE the size of the 8-year, 22,000-person waiting list.

There is no way for Marylanders living at home to bypass the 8-year, 22,000-person waiting list and stay at home, except by unnecessarily entering a nursing home. While on the Registry, registrants are also in the dark for 8 years regarding where they are on the waiting list.

The Solution

  • Require registrants to come off the Registry at a rate that would eliminate the 8-year waiting list within 12 months;
  • Require the HCBOW to meet the projected “demand” for services;
  • Require services to HCBOW-eligible individuals within 30 days; and
  • Provide information for registrants about their exact place on the Registry or when they might expect to receive services.

CMS Reports High Rates of Inaccuracy in Medicare Advantage Provider Directories

December 26, 2018

NAELA News:

  1. Amidst Medicare Open Enrollment, CMS Reports High Rates of Inaccuracy in Medicare Advantage Provider Directories
  2. In Her Own Words: A Beneficiary’s Take On Medicare Advantage Steering
  3. Health Care Sabotage: Administration Doubles Down on States’ Ability to Undermine ACA

Amidst Medicare Open Enrollment, CMS Reports High Rates of Inaccuracy in Medicare Advantage Provider Directories

The Medicare Annual Coordinated Election Period (ACEP) is the most crucial time of year for Medicare beneficiaries to make decisions about how they wish to receive their Medicare coverage.  This year the Administration seems to be actively promoting Medicare Advantage plans. However, at the same time that this steering toward private plans is occurring, the Centers for Medicare & Medicaid Services (CMS) reported that Medicare Advantage  provider directories contain extremely inaccurate information, which could lead beneficiaries to sign up for plans that might not actually include their doctors.

This is CMS’ third round of provider directory review since initially being alerted by a beneficiary complaint. CMS Examined 5602 providers and their listed locations from 52 different Medicare Advantage organizations between November 2017 and July 2018.  Reviewers in the study called provider offices to verify the accuracy of the information in the provider directory. Information to be verified included names, address and phone numbers; whether the provider accepted the MA-PD in question at that location, and whether they accepted new patients with the MA-PD in question. CMS assigned each error a score, with incorrect locations, numbers and statements regarding accepting patients weighted highest.[1]

The CMS review found that:

  • Almost half (48.74%) had at least one inaccuracy.
  • Percentage of inaccuracies by MA organization ranged from 4.63% for the best network listing to 93.02% for the worst.
  • The majority of MA organizations had between 30% and 60% inaccuracies.
  • “Providers should not have been listed at 33.14% (3,481) of the locations…either because the provider did not work at the location or because the provider did not accept the plan at the location.”[2]
  • “85.64% of locations with deficiencies…had deficiencies of the highest weighted, most egregious errors.”[3]
  • 41.75% of all locations listed had inaccuracies “with the highest likelihood of preventing access to care.”[4]

Beneficiaries and caregivers rely on provider directories to make important choices about their care. In this era of overt steering toward Medicare Advantage by the Administration[5], accurate information has never been more crucial. Errors in provider listings “create a barrier to care and raise questions regarding the adequacy and validity of the MAO’s network as a whole.”[6] 

Despite these inaccuracies, according to the Washington Post, “[t]he Trump administration is holding off on punishing Medicare Advantage plans for error-ridden doctor directories — further evidence” that CMS “is showing special favor to the alternative program over traditional Medicare offerings.”[7]  The Post continues: “Last year, the agency threatened to impose fines on the plans if they didn’t clean up their act. While this year’s report shows no substantial improvement overlast year (or the year before that), CMS isn’t following through on the threat [emphasis in original].”


[1] Online Provider Directory Review Report (Centers for Medicare & Medicaid Services) (November 2018), available at: https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/Provider_Directory_Review_Industry_Report_Round_3_11-28-2018.pdf, p. 5, table 3.
[2] Id, p. 6
[3] Id, p. 8
[4] Id, p. 1
[5] In addition to previous Center Alerts, see, e.g. “Trump Administration Peppers Inboxes With Plugs for Private Medicare Plans” by Robert Pear, New York Times, (Dec. 1, 2018), available at: https://www.nytimes.com/2018/12/01/us/politics/trump-medicare-advantage-plans.html, and “The Health 202: Trump administration lets Medicare plans off the hook” by Paige Cunningham, (Dec. 4, 2018), Washington Post, available at:  https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2018/12/04/the-health-202-trump-administration-lets-medicare-plans-off-the-hook/5c058e4b1b326b60d12800f1/?utm_term=.072d2e85242c.
[6]Online Provider Directory Review Report , p. 1
[7] “The Health 202: Trump administration lets Medicare plans off the hook” by Paige Cunningham, (Dec. 4, 2018), Washington Post, available at:  https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2018/12/04/the-health-202-trump-administration-lets-medicare-plans-off-the-hook/5c058e4b1b326b60d12800f1/?utm_term=.072d2e85242c.