December 28

Medicare’s Coverage Of Therapy Services Again Is In Center Of Court Dispute

Four years after Medicare officials agreed in a landmark court settlement that seniors cannot be denied coverage for physical therapy and other skilled care simply because their condition is not improving, patients are still being turned away.

So federal officials and Medicare advocates have renewed their court battle, acknowledging that they cannot agree on a way to fix the problem. Earlier this month, each submitted ideas to the judge, who will decide — possibly within the next few months — what measures should be taken.

Several organizations report that the government’s initial education campaign following the settlement has failed. Many seniors have only been able to get coverage once their condition worsened. But once it improved, treatment would stop — until they got worse and were eligible again for coverage.

Every year thousands of Medicare patients receive physical therapy and other treatment to recover from a fall or medical procedure, as well as to help cope with disabilities or chronic conditions including multiple sclerosis, Alzheimer’s or Parkinson’s diseases, stroke, and spinal cord or brain injuries. Although it removes the necessity to show an improving health condition, the settlement does not affect other criteria and limitations on Medicare coverage.

“We still regularly get calls from people who are told they are being denied coverage,” said Peter Schmidt at the National Parkinson Foundation, based in Miami. Denials sometimes occur because physical therapy providers use a billing code that still requires the patient to show improvement. Although Parkinson’s is a degenerative brain disease, Schmidt said physical therapy and exercise can help slow its progress.

The agreement, approved in 2013, settled a class action lawsuit against the Centers for Medicare & Medicaid Services filed by the Center for Medicare Advocacy and Vermont Legal Aid on behalf of five Medicare beneficiaries, including the late Glenda Jimmo, and six nationwide patient organizations. Coverage, the Jimmo settlement said, does not depend on the “potential for improvement from the therapy but rather on the beneficiary’s need for skilled care.”

In August, U.S. District Court Chief Judge Christina Reiss in Vermont ordered the government to work with the beneficiaries’ attorneys to strengthen its education campaign about the policy aimed at bill-processing contractors, claims reviewers, providers, appeals judges, people who staff the 800-MEDICARE help line and others. (Beneficiaries, however, were not included.) After working during the fall, both sides acknowledged this month they could not reach a compromise on the best way to make revisions to the education campaign.

“There was a long-standing kind of mythical policy that Medicare contractors put into place that said Medicare only pays for services if the patient could progress,” said Roshunda Drummond-Dye, director of regulatory affairs for the American Physical Therapy Association. “It takes extensive effort to erase that.”

Medicare’s proposals include educational efforts such as a special webpage with “frequently asked questions” spelling out the proper procedures for handling claims. The government would also issue a clear statement confirming that Medicare covers physical, speech and occupational therapy along with skilled care at home, and in other settings, even if the patient has “reached a plateau” — a term seniors still hear — and is not improving.

Attorneys for the seniors want to monitor how Medicare officials implement these new measures and have offered to write the policy statement disavowing what’s known as the “improvement standard.” They also want the government to repeat its 2013 conference call with providers, contractors and others involved in the process in order to correct mistakes, according to papers filed with the court Jan. 13.

“The major problem for us is that they do not want the plaintiff’s counsel to have any say or involvement in what they do,” said Gill DeFord, litigation director at the Center for Medicare Advocacy in Connecticut. “We think that’s exactly the reason the educational campaign was so riddled with inaccuracies in the first place.”

But in its filing, the government said, “The Plaintiffs’ plan seeks to address perceived deficiencies that were specifically not guaranteed under the [settlement] Agreement.” It added accepting the advocates’ plan “would also grant their counsel undue control in developing CMS educational materials and an outsize role in CMS’ corrective action efforts.”

The settlement affects care provided by a trained professional in a patient’s home, nursing home or the provider’s private office that is medically necessary to maintain the patient’s condition and prevent deterioration.

A Medicare spokesman declined to comment under agency protocol because the case is still pending.

KHN’s coverage of aging and long-term care issues is supported by The SCAN Foundation.

Susan Jaffe:, @SusanJaffe

December 28

Medicare Vs. Medicare Advantage: How To Choose

As health insurers struggle with shifting government policies and considerable uncertainty, one market remains remarkably stable: Medicare Advantage plans.

That’s good news for seniors as they select coverage for the year ahead during Medicare’s annual open enrollment period (this year running from Oct. 15 to Dec. 7).

For 2018, 2,317 Medicare Advantage plans will be available across the country, “the most we’ve seen since 2009,” said Gretchen Jacobson, associate director of the Kaiser Family Foundation’s program on Medicare policy. (Kaiser Health News is an editorially independent program of the foundation.)

Medicare Advantage is an alternative to traditional Medicare. Run by private insurance companies, the plans — mostly health maintenance organizations (HMOs) and preferred provider organizations (PPOs) — are expected to serve a record 20.4 million people next year, or slightly more than one-third of Medicare’s 59 million members.

On average, seniors will have a choice of 21 plans, though in some counties and large metropolitan areas at least 40 plans will be accessible, Jacobson said. Availability tends to be far more restricted in rural locations.

While a few insurers are entering or exiting the Medicare Advantage market, most established players are remaining in place. Eight insurers dominate the market: UnitedHealthcare, Humana, Anthem, plans affiliated with Blue Cross and Blue Shield, Kaiser Permanente, Aetna, Cigna and WellCare. (Kaiser Health News is unaffiliated with Kaiser Permanente.)

Despite Medicare Advantage plans’ increasing popularity, several features — notably, the costs that older adults face in these plans and the extent to which members’ choice of doctors and hospitals is restricted — remain poorly understood.

Here are some essential facts to consider:

The Basics

Medicare Advantage plans must provide the same benefits offered through traditional Medicare (services from hospitals, physicians, home health care agencies, laboratories, medical equipment companies and rehabilitation facilities, among others). Nearly 90 percent of plans also supply drug coverage.

In 2018, 68 percent of plans offered will be HMOs, while 27 percent will be PPOs, Jacobson said. The remainder are small, specialized plans that are expected to have relatively few members. In general, HMOs require members to seek care from a specific network of hospital and doctors while PPOs allow members to obtain care from providers outside the network, at a significantly higher cost.

Pros And Cons

The Center for Medicare Advocacy recently summarized the pros and cons of Medicare Advantage plans. On the plus side, it cited:

Little paperwork. (Plan members don’t have to submit claims, in most cases.)
An emphasis on preventive care.
Extra benefits, such as vision care, dental care and hearing exams, that aren’t offered under traditional Medicare.
An all-in-one approach to coverage. (Notably, members typically don’t have to purchase supplemental Medigap coverage or a standalone drug plan.)
Cost controls, including a cap on out-of-pocket costs for physician and hospital services (Medicare Part A and B benefits).

On the negative side, it cited:

Access is limited to hospitals and doctors within plan networks. (Traditional Medicare allows seniors to go to whichever doctor or hospital they want.)
Techniques to manage medical care that can erect barriers to accessing care (for example, getting prior approval from a primary care doctor before seeing a specialist).
Financial incentives to limit services. (Medicare Advantage plans receive a set per-member-per-month fee from the government and risk losing money if medical expenses exceed payments.)
Limits on care members can get when traveling. (Generally, only emergency care and urgent care is covered.)
The potential for higher costs for specific services in some circumstances. (Some plans charge more than traditional Medicare for a short hospital stay, home health care or medical equipment such as oxygen, for instance.)
Lack of flexibility. Once someone enrolls in Medicare Advantage, they’re locked in for the year. There are two exceptions: a special disenrollment period from Jan. 1 to Feb. 14 (anyone who leaves during this time must go back to traditional Medicare) and a chance to make changes during open enrollment (shifting to a different plan or going back to traditional Medicare are options at this point).

Medigap Implications

Choosing a Medicare Advantage plan has implications for the future as well as the present. Notably, if someone enrolls in a Medicare Advantage plan when she first joins Medicare and stays with a plan for at least a year, she may not qualify for supplemental Medigap coverage if she wants to join traditional Medicare at a later date.

Medigap policies cover charges such as deductibles, coinsurance and copayments that seniors with Medicare coverage are expected to pay out-of-pocket. People who join Medicare for the first time are guaranteed access to Medigap policies, no matter what their health status is, only for a limited time. Afterward, they can be denied coverage based on their health in most states.

Parsing Costs

There’s a widespread perception that Medicare Advantage plans cost less than traditional Medicare. But actual costs depend on an individual’s circumstances and aren’t always easy to calculate.

Seniors often first consider what they’ll pay in monthly premiums. This year, the average monthly premium for Medicare Advantage plans is $30, almost $2 below last year’s. But nearly half of Medicare Advantage members are enrolled in plans that don’t charge a monthly premium — so-called zero premium plans. (Seniors also need to pay Medicare Part B premiums, although some Medicare Advantage plans cover some or all of that charge.)

To get a full picture of plan costs, which can vary annually, seniors should look beyond premiums to drug expenses (including which drugs are covered by their plan, at what level and with what restrictions); deductibles (plans can charge deductibles for both medical services and drugs); what plans charge for hospital care (some have daily copayments for the first week or so); and coinsurance rates for services such as home health care or skilled nursing care, experts said.

“It’s really critical that folks dig deep and find out about all possible costs they may incur in a plan before they sign up for it,” said Chris Reeg, director of Ohio’s Senior Health Insurance Information Program. (Every state has a program of this kind; find one near you at

“Part of the equation has to be what you’ll have to pay if you need lots of care,” said David Lipschutz, senior policy attorney at the Center for Medicare Advocacy “In our experience, that’s often more than people expected.”

Since 2011, Medicare Advantage plans have limited members’ annual out-of-pocket costs to no more than $6,700 — a form of financial protection. There is no similar limit in traditional Medicare. Yet, protection isn’t complete since out-of-pocket limits don’t apply to drug costs, which can be considerable. (In PPOs, a cap of $10,000 limits costs for services received from out-of-network providers as well.)

Plans have discretion in setting out-of-pocket limits. In 2018, 43 percent of plans will have out-of-pocket limits exceeding $6,000; 31 percent will set limits between $4,000 and $6,000; 20 percent will have limits between $3,000 and $4,000; and 6 percent will set limits beneath $3,000, according to a new Avalere Health analysis.

Information about Medicare Advantage plans’ deductibles, copayments and coinsurances rates for medical services as well as coverage details for the medications you’re taking can be found at Medicare’s plan finder.

Finding A Doctor

One way that Medicare Advantage plans try to control costs and coordinate care is by working with a limited group of physicians and hospitals. But reliable information about these networks is hard to find and published directories often contain mistaken or out-of-date information.

“It’s not easy to determine who’s in-network for a Medicare Advantage plan,” said Fred Riccardi, director of client services at the Medicare Rights Center. “This information isn’t on Medicare’s website and there’s no one, streamlined way to search for information about provider networks across plans.” His advice to consumers: Call all your doctors to ask if they’re participating in a plan you’re considering. (Make sure you have your plan number when you do, because a single company may offer multiple plans in your market.)

Making matters even more difficult: Plans can drop physicians or hospitals from their networks during the year, leaving members without access to trusted sources of care.

A new report discloses data about the size of Medicare Advantage plans’ physician networks for the first time. It finds that, on average, Medicare Advantage HMOs included 42 percent of physicians in a county in their networks while PPOs included 57 percent. Altogether, 35 percent of Medicare Advantage members are in plans with narrow physician networks, which tend to be the cheapest plans.

Although this data highlights the choices that seniors have with regard to physicians, it doesn’t speak to the wait time they may encounter in accessing care, Jacobson said, adding that, to her knowledge, this kind of information about Medicare Advantage plans is not publicly available.

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

December 28

The Right Way to Choose a Medicare Plan During Open Enrollment

These six moves will help you find a Medicare plan that fits your health care needs
By Mary C. Hickey

If you’re one of the 58 million Americans on Medicare and you’ve been happy with your coverage, you may be tempted to ignore this fall’s open enrollment period, which began in mid-October and runs through Dec. 7 for most beneficiaries. Do nothing and you’ll likely be automatically re-enrolled in your current plan for 2018.

A good idea? Not at all. Insurers are constantly altering their coverage from year to year, including the amount you pay in premiums, copays, and deductibles. Your health needs may change too.

“The plan that was right for you last year may not be the best one for next,” says Patricia Barry, author of “Medicare for Dummies” (Third Edition). “Shopping around to make sure you’re selecting the right plan can save you hundreds, even thousands of dollars.”

Yet most seniors don’t bother to make any changes. Only about 18 percent of Medicare Advantage members switched policies during recent open enrollment periods, according to a Kaiser Family Foundation report. A study by the National Bureau of Economic Research found that Medicare Part D enrollees who changed their drug coverage saved an average of $180 the following year.

These six guidelines can help you get the best coverage at the lowest cost:

1. Look for changes in your plan.

Fall open enrollment allows seniors with traditional Medicare (Parts A and B) to change their Part D prescription drug plan, and for those enrolled in Medicare Advantage to change to another version of the plan.

“If you’re in those plans, you should have received an ‘annual notice of change’ in the mail in late September,” says Samantha Morales, associate director of client services at the Medicare Rights Center, a nonprofit consumer service organization. (Call your insurance company or visit its website if you’ve misplaced that letter.)

Check that information for any changes to the plan’s “formulary,” which is the list of prescription drugs it covers. Insurers also assign drugs to one of five tiers, each with a different copay, which can also change.

A prescription drug with a $5 copay one year could have a $10 copay the next year, or a brand-name drug may be dropped from the formulary completely. So you’ll need to compare the next year’s drug line-up with the list of medications you are taking.

With Medicare Advantage, which typically provides health care through an HMO or PPO, you may see changes in the doctors and hospitals included in their networks. Some of these plans also include vision and perhaps dental coverage, so find out if those offerings will be the same next year as well.

2. Add up your total out-of-pocket costs.

Premium costs for most Medicare Advantage recipients will average $30 a month next year, which is two dollars less than in 2017, according to the Centers for Medicare & Medicaid Services, the federal agency that oversees these programs. The average premium for Part D will go down by $1.20 to about $33.50 a month, the first decline since 2012.

For those who are collecting Social Security, which automatically pays your Part B premium, your costs will be about $109 because of a federal law that prevents Medicare from lowering your Social Security payment.

If you’re not on Social Security, the average Medicare Part B premium will be about $134 a month, roughly the same as it was in 2017. But the premium costs for many high earners will rise—for individuals earning between $133,001 and $160,000 ($267,000 and $320,000 for married couples filing jointly), Part B premiums will jump by $80 a month.

Still, “consumers really need to look beyond the premiums to understand their total out-of-pocket costs,” says David Lipschutz, senior attorney at the Center for Medicare Advocacy, a national nonprofit organization.

To understand the true cost of your plan, add up what you will likely pay in deductibles and copays, which can offset any savings in premiums. Use your benefits statements and medical bills for the past year as a guide.

3. Assess your medical needs.

By this point, you will have gathered a list of your prescription medications and recent medical expenses. Now consider how those health care costs might change next year: Will you need a costly knee replacement surgery? Have you been prescribed an expensive specialty drug? If so, a different plan might be in order.

Think about convenience and your personal preferences, too. Some prescription plans will steer you toward a “preferred pharmacy” instead of your favorite local drug store or give you a better deal if you order prescriptions by mail. Others mandate “step therapy,” which means you have to try a generic before you can use a brand-name drug.

Medicare Advantage plans often require pre-authorization to see specialists, have strict rules about using out-of-network providers, and have varying levels of copays for hospital services. Check out all of a plan’s particulars before deciding what best works for you at a price you can afford.

4. Consider the consequences of switching.

During fall open enrollment, you have the option of changing from traditional Medicare to Medicare Advantage, and vice versa. But switching to traditional Medicare after being in Medicare Advantage can be difficult if you want to enroll in a Medigap plan, which is private insurance that helps defray costs not covered by Parts A and B.

Under federal law, insurers cannot deny you a Medigap policy when you initially enroll in Medicare—you have a seven-month window around your 65th birthday month to sign up. The law also requires that insurers renew your coverage each year as long as you continue to pay your premiums.

But if you try to buy a Medigap policy after the initial enrollment window, insurers might be able to turn you down based on your health, or charge higher prices, due to a pre-existing condition. (There are exceptions: Some states provide greater protections, so be sure to check.)

The fall open enrollment does not apply to Medigap policies, which aren’t part of the government Medicare program. If you want to make changes to your Medigap plan, contact insurance companies for information on what you can do and when you can do it.

5. Use these helpful resources.

Plan to spend a few hours doing your research. The best place to start is with the Medicare plan finder tool. After you enter your zip code and specific information about your medications, you can compare the overall costs of the various Part D options.

This same tool lets you compare Medicare Advantage plans, but you’ll need to perform two different searches: one to compare medical benefits, and the other to compare drug coverage. (If you’re not comfortable using an online tool, you can get the same information by calling Medicare at 800-633-4227.)

Another good resource is the State Health Insurance Assistance Program (SHIP) which provides free help over the phone. To find your state’s program, go to or call 877-839-2675.

Once you have the information, the Medicare Rights Center advises confirming everything by calling the insurance company you plan to use. “Make sure to write the date and time of your phone call, and get the name of the customer service representative you spoke with,” Morales says. For extra peace of mind, she suggests calling your doctors for confirmation, too.

Finally, low-income seniors should check out the Medicare Savings Program, which can help with out-of-pocket costs. Those who are eligible may also be automatically enrolled in Part D Low Income Subsidy or Extra Help program, which can reduce the cost of your prescription drugs. To find out your eligibility, go to, or call your state’s SHIP program.

6. Don’t miss your deadline.

For most beneficiaries, your enrollment decision must be made by December 7. But if you live in a place affected by recent hurricanes, you have until Dec. 31 to sign up—those areas include Florida, Georgia, Louisiana, South Carolina, Texas, Puerto Rico, and the U.S. Virgin Islands.

Once you’ve made your selection, you can enroll in a new plan by calling Medicare at 800-633-4227. Take detailed notes of your phone conversation with the Medicare representative in case of any problems down the line.

After all that work, if you conclude that your current plan is still your best option, do nothing and you’ll be automatically re-enrolled. Your new coverage starts Jan. 1.

December 27

Medical Expense Deduction Saved

On Friday, Republicans released their final tax bill. I am pleased to tell you that the legislation not only retains the medical expense deduction, but temporarily expands the deduction for two years.

NAELA played a critical role in lobbying to protect this deduction. When the House version of the tax bill was introduced last month, few organizations understood the potential devastating impact this would have on individuals with high medical and long-term care expenses.

NAELA took the lead in educating aging and disability groups about the medical expense deduction, bringing together the voices of many organizations to fight its removal. In addition, using the collective expertise of NAELA members to focus on the impact this would have on the chronically ill, NAELA was able to demonstrate how removal of the medical expense deduction would harm many Americans. This was critical because the average deduction understates its importance in protecting those with catastrophic health costs. Read more about the medical expense deduction.

NAELA educated a range of stakeholders from congressional staff and advocacy organizations to the media. Our advocacy raised into the public consciousness the terrible impact eliminating the deduction would have on individuals in nursing homes and families of children with disabilities. This recognition was a key factor in saving the deduction.

As practitioners, our ability to help our clients is only as good as the laws we have. That’s why advocating to protect good law and improve others is so critical to NAELA’s mission.

Thank you to all of the members who provided stories demonstrating how the medical expense deduction is critical to the lives of many Americans, informed others in the community, and called their member of Congress on this issue. Your continued support will be needed in the months and years to come.

Hyman G. Darling, CELA, CAP

December 27

Does Your Nursing Home Have Enough Care Staff?

New Federal Data Released on Staffing Levels in U.S. Nursing Home

Contact: Richard Mollot – 212-385-0356,

New York, NY, November 1, 2017—This week marks the official release by the U.S. Centers for Medicare and Medicaid Services (CMS) of new data on staffing levels in U.S. nursing homes. Staffing is key to the quality of care and safety provided by a nursing home. Though the critical need for sufficient staffing is widely acknowledged, too many nursing homes fail to have enough staff to ensure that residents receive decent care and are able to live with dignity. With over half of Americans who reach age 60 expected to need nursing home care at some point, accurate staffing information is important to the public and to state and federal policymakers (who are responsible for overseeing both public safety and the appropriate use of Medicaid and Medicare funds, which pay for the majority of nursing home services).

Following is information on the new data released by CMS.

What’s New?: CMS has released, for the first time, information on nursing home staffing that is based on payroll or other auditable data sources. Up until now, public information on nursing home staffing levels has been based on data that are self-reported by facilities. Also, up until now, there has been no mechanism in place to ensure that facilities are accurately reporting this vital information.

Why?: The new reporting system was developed because the self-reported data have long been considered by many to be suspect (i.e., that there is a strong potential for facilities to overstate their staffing levels with impunity). Under the new, payroll-based journal (PBJ) reporting system, facilities are required to report verifiable staffing data that distinguishes between staff who were assigned to resident care and those with administrative duties.

Where?: The new data are available in large files at To facilitate public access to the information which we have identified as most important to resident safety, LTCCC has published facility data on our website at

The data provided on include: resident census, RN, LPN and CNA care staffing for every facility (as reported on the CMS database). We used those data to compute hours per resident day (HPRD) for both all care staff and for RNs. To facilitate ease of use, we separated the data into individual state files and inserted sorting (arrow) icons at the top of each column so that the state files can be sorted by criteria such as RN HPRD.

How Is This Important To The Public?: Direct care staffing levels, especially those of Registered Nurses (RNs) are one of the most important indictors of a nursing home’s quality and safety. Thus, it is essential that the information on staffing levels is accurate and accessible.

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LTCCC is a non-profit organization dedicated to improving care and quality of life for residents in nursing homes and other residential care settings. Visit for more information about nursing home quality and compliance with minimum safety standards as well as our free resources for LTC consumers.