November 17

States will be allowed to impose Medicaid work requirements, top federal official says

By Paige Winfield Cunningham in The Washington Post

The government will give states broader leeway in running their Medicaid programs and allow them to impose work requirements on enrollees, a top federal health official said Tuesday in outlining how the Trump administration plans to put its mark on the insurance program for low-income Americans.

Seema Verma, who heads the Health and Human Services Department’s Centers for Medicare and Medicaid Services, did not spare criticisms of the Obama administration and called its opposition to work requirements “soft bigotry.”

“Believing that community engagement requirements do not support the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” Verma said in a sweeping address to the National Association of Medicaid Directors. “Those days are over.”

The speech was Verma’s most detailed public explanation of how she plans to approach Medicaid in a highly politicized era in which Republicans still hope to roll back its expansion under the Affordable Care Act as well as enact future spending cuts through their various health-care bills.

The program’s chief problems, according to Verma, include the expansion to add able-bodied adults and overall costs, which now comprise 29 percent of total state spending. She also faulted the federal government for requiring too much reporting from states and for delaying approval of states’ waiver requests to run their programs in alternative ways.

Multiple times throughout her half-hour speech, she used the phrase “card without care” to make her point that simply enrolling people in Medicaid isn’t effective if they can’t find a doctor who will accept them — an ongoing problem with the program because its reimbursements are lower than for Medicare or private coverage.

“We fail to live up to that promise when Medicaid merely provides a card without care,” she said. “And that’s why we’re ushering in a new era for Medicaid at CMS.”

Verma stressed that she and President Trump are “deeply committed” to the program, while accusing the prior administration of quashing state innovation and undermining Medicaid’s traditional partnership between the federal and state governments.

She listed a number of ways that CMS will change its approach, by expediting state waiver requests that mirror past approvals, allowing some waivers for up to a decade and starting a “report card” that grades state programs.

Waivers are a major way the Trump administration can reshape Medicaid. A half-dozen states have applied or soon will apply to require program enrollees to get a job or do some kind of community volunteering as a condition of their coverage.

Verma has long supported such requirements, which the Obama administration uniformly rejected, but Tuesday was the first time she explicitly promised that her agency would approve this type of waiver request.

“The thought that a program designed for our most vulnerable citizens should be used as a vehicle to serve working-age, able-bodied adults does not make sense,” she said.

Some officials from states currently asking to implement work or community engagement requirements were pleased at Verma’s declaration of support, including Kentucky Medicaid commissioner Stephen Miller.

“You heard what was said today, and we’re right in sync with that,” Miller said. He said he’s expecting notification “soon” from CMS that Kentucky’s waiver request has been approved. The state is hoping to set its new requirements in motion starting the middle of 2018.

But New York Medicaid director Jason Helgerson said it was “completely reprehensible” for Verma to use the phrase “soft bigotry” to describe Medicaid programs that don’t impose extra requirements on low-income people seeking coverage.

“Where should I start? Helgerson said, when asked to respond to Verma’s address. “Shocked, appalled would be the two primary reactions I have.”

November 16

Consider $2M: The Cost of Long Term Care For One Aging Parent

By Carolyn Rosenblatt courtesy of

Every year since 2004, private long term care insurer, Genworth has conducted a national survey to determine the average costs of care at home, and in facilities. The data is broken down by states and one can find the 2017 results here. The bottom line: the cost of care is rising significantly in all the four general areas studied. They include home care, adult day health, assisted living and nursing homes. There is a lot more to consider than what the Genworth study shows. Long term care is not limited to the things this insurer pays for when you buy a product from them.

What does it mean for you or your aging loved ones? It’s expensive no matter how you look at it. Your odds of escaping the cost of long term care are not good.

In a book we wrote for financial planners, Hidden Truths About Retirement & Long Term Care (, 2017), we detail how about 70% of us are going to need some kind of long term care in our lives. And we discuss how most of us live in The Great American Fantasy that it won’t happen to us, that we will be fine and die quietly in our sleep at age 100 in full control of our faculties. In the book, we urge financial advisors to help clients get out of fantasy and into the reality that dollars need to be set aside to pay for what Medicare does not cover; so called “custodial care” that is not medical in nature. That includes things like home care workers, home modification to accommodate disabilities, assisted living and other things many people eventually need. We discuss the advantages and disadvantages of all the choices.

We examine some real cases in our book. One of them looks at a man who lived to be 95 and never wanted to be in a facility. His wife hired caregivers. Long term care insurance defrayed some of the cost but most came out of pocket. The bill for the 24/7 care he received over four years of increasing dependency: $2M. There was nothing unusual about his needs. He just got more frail and had more care issues over time. That’s typical of how some of us are going to age. At the end, he had four caregivers in shifts, a specially fitted van with special wheelchair, a home stair chair, a lift to get him into the bath, numerous other kinds of devices to help and huge increases in the cost of maintaining the home.

The Genworth study is a wake-up call that many people ignore, based on the difficulty of facing what no one likes to face: a lot of our body parts wear out over time and dementia can creep up and destroy our ability to manage our lives for good. This is not to suggest that everyone has to buy long term care insurance. That is a complex decision best made with competent professional advice (not from a sales person) and comparison of the numerous products available. But we need to set assets aside and ensure that they are accessible when needed to pay for the high cost of long term care whether we self insure or buy a product. No long term care insurance pays for everything Medicare doesn’t cover.

Here are the figures from the newest Genworth study for 2017, showing the monthly national median costs:

Homemaker services (help with cooking, cleaning, transportation, shopping, etc.) $3,994

Home Health Aide (personal care: eating, bathing, dressing, walking, bathroom, etc.)$4099

Adult Day Health Care (socialization and some nursing supervision)$1,517

Assisted Living (nursing care from licensed professionals not available)$3,750

Nursing Home Private Room (licensed nursing care available 24/7)$8,121

Because the Genworth study only addresses things its insurance products cover, it does not look at Continuing Care Retirement Communities, board and care homes, durable medical equipment Medicare may not cover, home modification, and other things people may need as they age. It never discusses what happens when one runs out of the insurance benefits, which have limits. However, it is a starting point for you to plan for your own future or for your aging loved ones’ futures. The prospect of needing to pay out of pocket for any of these things must be looked at if you don’t want to burden the people you love. Any Baby Boomer may be thinking about this only as it applies to any aging parent still with us, but we all should consider that they are ourselves a few years down the road.Home Health Aide (personal care: eating, bathing, dressing, walking, bathroom, etc.)$4099

Adult Day Health Care (socialization and some nursing supervision)$1,517

Assisted Living (nursing care from licensed professionals not available)$3,750

Nursing Home Private Room (licensed nursing care available 24/7)$8,121

Because the Genworth study only addresses things its insurance products cover, it does not look at Continuing Care Retirement Communities, board and care homes, durable medical equipment Medicare may not cover, home modification, and other things people may need as they age. It never discusses what happens when one runs out of the insurance benefits, which have limits. However, it is a starting point for you to plan for your own future or for your aging loved ones’ futures. The prospect of needing to pay out of pocket for any of these things must be looked at if you don’t want to burden the people you love. Any Baby Boomer may be thinking about this only as it applies to any aging parent still with us, but we all should consider that they are ourselves a few years down the road.

November 15

Federal Medicare Head Says Action Is Needed to Ensure Program’s Financial Future

By: Alex Smith

President Trump has pledged to not make cuts to Medicare, the federal insurance program for seniors, but Seema Verma, administrator of the Centers for Medicare and Medicaid, acknowledges that changes are needed.

One of the program’s main funds, the Hospital Insurance Trust Fund, is expected to be depleted in 11 years.

On Monday, Verma was in Olathe, Kansas to talk with seniors about Medicare and encourage them to take part in Medicare open enrollment, which runs from October 15 through December 7.

In a rare interview with KCUR 89.3, the administration is now looking at ways Medicare can save money.

I know that one issue that you’re particularly interested in is financial future of Medicare – that in eleven years, we’ll run out of funds in the [Medicare] trust fund for hospital care. How do we address that?

We want to make sure that we are protecting the program, and that seniors will have access to this program for many years to come. This is something that people have paid for their whole lives, and they want to make sure when they get to that age that the program is around for that. So we’re doing lots of things across the Medicare program, but everything we do – we want make sure that we’re focusing on outcomes – producing good healthcare outcomes and making sure we’re actually increasing access to beneficiaries, so we’re doing things like thinking about how we pay our doctors and our providers, and instead of paying them for every little procedure they do, we’re thinking about how can we pay them in a way that holds them accountable for delivering positive health outcomes. So we’re looking at different ways to hold providers accountable. So we feel like we can build some efficiencies into the program.

You’ve suggested that some of that might be creating incentives for consumers to be more cost conscious. And some people have heard that and thought that sounds like seniors needing to pay more in the form of deductibles, co-pays…is that something they should be concerned about?

No, not at all. We want to make sure that seniors always have choices. So, just for a today example, I talked to a senior, Fred, and he was shopping around for a plans, and because he had shopped around, he’s gonna save a thousand dollars this year on his drug coverage. And so when people have some skin in the game, when they have that incentive to save money, they are going to take those steps, so that’s all we’re taking about – opportunities for people to be more involved in their healthcare.

When you came on, you suggested to states that in their Medicaid programs, they might introduce copays, deductibles, those kinds of things – but that’s not an approach that you advocate for Medicare?

I think the idea is empowering patients. We want to empower patients to make choices that are going to work best for them and giving them opportunities to figure out what’s gonna work best for them. So copays and deductibles or incentives – again, that might work for some seniors. It might not work for others. But I think that if we’re looking at sustaining this program over the long term, we’re all gonna have to work together, right? It can’t just be the doctors and the pharmaceutical companies and insurance companies. We as individuals all need to work together to make sure that we’re getting value.

One of the things I think our seniors on the program can be very helpful [with] is helping us with fraud and abuse. You know, a lot of times we have our seniors that are looking over their statements and saying, “Hey, I didn’t get this service.” So I think when people are engaged and when they have some skin in the game, then they are working with us as a partner is identify how dollars can be used in the most appropriate way.

Something that came up in the discussion here was Medicare negotiating directly on drug prices – not the companies that administer Medicare, but the agency itself. The president has said he supported that. Is that something this administration will pursue?

I think the President is most focused on making sure that Americans are getting the best deal. He’s concerned about the increase that people are feeling when they go to the pharmacy, and they’re actually having to pay more for prescription drugs. And it’s a tough balancing act cause at the same time, our pharmaceutical companies have delivered some of the most innovative treatments and therapies coming out on the market – different types of therapies that are saving lives and are curing people from illnesses. And so we want to encourage that innovation that’s going on, but at the same time we want to make sure that drugs are affordable for people when they go to the pharmacy.

We do know that drug companies spend a lot on advertising. That’s something that we end up paying for indirectly when we pay drug companies. That seems like something we don’t necessarily want to fund through Medicare payment.

The goal is that seniors are paying the lowest possible costs, so we want to make sure we are looking at everything across the board. The president has many parts of the entire administration working on this. We’ve got our folks at FDA that are working on making sure that there is competition in the marketplace and having generics and other alternatives go through a lot quicker. So we’re looking at this from many different angles, and everything’s on the table, because we’re committed to making sure that people can afford their medications.

Alex Smith is a health reporter for KCUR

November 14

Medicare Home Health Coverage is Not a Short-Term, Acute Care Benefit ─ Congress Acted in 1980 to Provide for Longer-Term Coverage

Medicare home health coverage is often erroneously described as a short-term, acute care benefit. Though often implemented in this way, this is not true. Under the law, people who meet the threshold qualifying criteria (legally homebound and needing skilled care), are eligible for Medicare home health coverage so long as they need skilled care.[1] In fact, Congress actually acted affirmatively to authorize long-term Medicare home health coverage in 1980 – removing the annual cap on visits and rescinding the prior hospital stay requirement.

Congressional Action and Legislative History

The Omnibus Reconciliation Act of 1980 (OBRA 1980)[2], expanded the Medicare home health benefit. Prior to this, beneficiaries only enrolled in Part A were eligible for up to 100 home health visits annually, following a three day hospital stay. Coverage was also available under Part B, also limited to 100 visits per calendar year, but this coverage was not dependent on a prior hospitalization. OBRA 1980 eliminated the annual visit cap and the Part A prior hospitalization requirement, thus affirmatively expanding coverage for beneficiaries.

In the OBRA 1980 legislative history, Congress expressed a desire to further liberalize home care coverage, noting there were many “meritorious and deserving alternatives” proposed, and that agreement was reached on these particular improvements.[3] Thus, it is reasonable to infer that these changes – which made it clear that Medicare home care coverage is not short term or linked to acute care – were decisions Congress carefully considered and agreed upon.

Elimination of the Annual Cap on the Number of Covered Home Health Visits

Prior to 1980, coverage was capped under both Medicare Parts A and B at 100 home health visits per year. In the legislative history of OBRA 1980, Congress expressly stated that “unlimited visits would be available”[4] and that the “bill provides Medicare coverage for unlimited home health visits.”[5] The Congressional intent is clear: By removing the annual visit cap, Congress meant to authorize home health coverage for the long term – when appropriate and when other coverage criteria are met.

Elimination of the Three-Day Prior Hospital Stay

Previously, beneficiaries only enrolled in Medicare Part A could not access home health coverage without a prior three-day hospital stay. This requirement did not apply to beneficiaries who also had Part B, as coverage under Part B was not predicated on a prior hospital stay. OBRA 1980 repealed the Part A prior hospital requirement. The Subcommittee on Health of the Committee on Ways and Means stated “Part A was designed to encourage early discharge of hospital and skilled nursing facility (SNF) patients who continue to need skilled care but not at the intensive level provided for in a hospital or SNF. The Part B benefit – no prior hospitalization required – offers those who require skilled care as an alternative to or postponement of hospitalization.”[6]

Congress eliminated the three day requirement under Part A, aligning it with Part B. (Thus allowing coverage under both Parts A and B “to postpone or avoid hospitalization.”) At the time, more than 1.1 million beneficiaries had Part A only and would benefit from the repeal of the prior hospital requirement.[7] Now, all beneficiaries can qualify for Medicare home health coverage whether they were recently hospitalized or not. Medicare home health coverage is available for homebound beneficiaries who need skilled nursing or therapy, whether they are recovering from an acute illness or injury and are expected to improve, or have a longer-term problem and need home care to maintain or slow decline of their condition. As Congress intended in 1980, Medicare-covered home care can often help beneficiaries forego avoidable hospitalizations.


Medicare can be a source of coverage for long-term home health care for people who qualify.

The relevant legislative history for OBRA 1980 makes it clear that Congress intended to “liberalize” the Medicare home health benefit, and that the changes were seen as “benefit increases” which would be “important to beneficiaries.”[8]

Congress’ 1980 action to reframe and expand Medicare home health coverage appears to be all but forgotten today. Home health care is often mistakenly referred to as a short-term, acute care benefit. This is in conflict with Congressional intent and long-standing Medicare law. The Center for Medicare Advocacy will continue to refute this fiction and advocate for beneficiaries who need and are eligible for long-term Medicare home health coverage and care.

November 13

Nursing Home Illegally Dumps Elderly Resident They Don’t Want

By Carolyn Rosenblatt, RN

If you have an aging loved one who ever has to go to a nursing home, beware of a nasty practice in which some of these facilities engage. Some elders among us are low income and receive Medicaid. Some live in nursing homes, as they need full time care. It may not affect your own family, but certainly could affect an elder you know. Medicaid recipients are vulnerable and can be subject to terrible treatment, including being kicked out of a home just because they have to get temporary treatment at a hospital. It is disgusting to think that a nursing home will not only violate the law in refusing to allow its own resident back into the home after going to a hospital, but it will callously separate spouses by doing so. Neither has the luxury of choice. One spouse can stay while the other gets the boot?

Nursing Home evicted Ms. Single

That’s what happened to eighty-two year old Gloria Single who lived at Pioneer House, a nursing home that accepts Medicaid residents. She and her husband lived there together until she went to a hospital, expecting to return to Pioneer after she was released from the hospital. Instead, after she was medically cleared to return, Pioneer House refused to let her come home, thereby cruelly separating her from her husband. She now is staying in another home, still hoping to be with her husband again.

Ms. Single would have been voiceless but for the advocacy of AARP Foundation, the affiliated charity of AARP. According to Foundation attorney Kelly Bagby who, with other lawyers, represents Ms. Single in a case against the nursing home, Ms. Singleton has a clear legal right to return to the place where she lived, and the nursing home’s practice of dumping her is a growing trend, according to attorney Bagby, who has repeatedly faced this issue. The law prohibits it and the law is ignored. The lawsuit alleges that she is a victim of a corporate policy of evicting low-income residents to make room for more lucrative Medicare or private pay residents. In other words, they dump Medicaid people so they can make more money on other residents who are paid by better sources than Medicaid.

Says another of Ms. Single’s attorneys, Matthew Borden of BraunHagey & Borden, “Everyone deserves to spend their last days with their loved ones”. In the Single case, the hypocrisy of Pioneer’s corporate website advertising is startling. It says that the owner, RHF Foundation’s “concern for the whole person includes residents, their families and staff and RHF strives to be fair in all relationships”. In their case, concern seems to be directed solely toward the bottom line, not the resident and her family. Pioneer claims to be part of a faith-based organization.

Just to be clear, the term “nursing home” refers to rehab facilities, long term care facilities where skilled care is available, and places where people are often sent for therapy of various kinds after the person has been treated in a hospital. If your own aging loved one is ever mistreated, threatened with being evicted or dumped from a nursing home, know that he or she has rights that can be enforced. The place to start is with the Office of the State Long Term Care Ombudsman. The ombudsman is assigned the task of being the liaison between the facility and the resident or resident’s family. The ombudsman individually does not have the power to enforce the law nor represent a resident but can communicate with those involved and work on solutions. Ms. Singleton’s eviction went from the ombudsman to California Advocates for Nursing Home Reform, a consumer advocacy nonprofit organization, to the attorneys who now represent her.

Our low income, most vulnerable aging loved ones can seek justice, though it will take family members, ombudsmen, and other advocates to get them to the capable attorneys willing to take up their causes. The attorneys at AARP Foundation work vigorously to enforce their rights. The plight of those who live in these homes long term is not always visible to the public. Mistreatment may be concealed unless someone steps in to speak for them and the right organizations lead to the right lawyers to demand accountability by these nursing homes. An impaired elder like Ms. Single cannot speak up and stand up for herself. Nursing homes get away with dumping residents like her.

Ms. Single was treated worse than some people treat their dogs and cats. Having worked in nursing homes myself, I was appalled to learn of this callous practice. It is our hope for her here at that justice will be done and she can be reunited with her husband before it is too late.

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