Category: CMS

Your Doctor or Your Insurer? Little-Known Rules May Ease the Choice in Medicare Advantage

By Susan Jaffe, KFF Health News | March 29, 2024

Bart Klion (Hans Pennink for KFF Health News)

Bart Klion, 95, and his wife, Barbara, faced a tough choice in January: The upstate New York couple learned couple that this year they could keep either their private, Medicare Advantage insurance plan — or their doctors at Saratoga Hospital.

The Albany Medical Center system, which includes their hospital, is leaving the Klions’ Humana plan — or, depending on which side is talking, the other way around. The breakup threatened to cut the couple’s lifeline to cope with serious chronic health conditions.

Klion refused to pick the lesser of two bad options without a fight.

..With rare exceptions, Advantage members are locked into their plans for the rest of the year — while health providers may leave at any time. …But a few years ago, CMS created an escape hatch by expanding special enrollment periods, or SEPs, which allow for “exceptional circumstances.” Beneficiaries who qualify can request SEPs to change plans or return to original Medicare. [Continued on KFF Health News]…

Dodging the Medicare Enrollment Deadline Can Be Costly

By Susan Jaffe, KHN  | December 7, 2023 | This story also ran on  

Angela M. Du Bois, a retired software tester in Durham, North Carolina, wasn’t looking to replace her UnitedHealthcare Medicare Advantage plan. She wasn’t concerned as the Dec. 7 deadline approached for choosing another of the privately run health insurance alternatives to original Medicare.

But then something caught her attention: When she went to her doctor last month, she learned that the doctor and the hospital where she works will not accept her insurance next year.

Faced with either finding a new doctor or finding a new plan, Du Bois said the decision was easy. “I’m sticking with her because she knows everything about me,” she said of her doctor, whom she’s been seeing for more than a decade.

Du Bois isn’t the only one tuning out when commercials about the open enrollment deadline flood the airwaves each year — even though there could be good reasons to shop around. But sifting through the offerings has become such an ordeal that few people want to repeat it. Avoidance is so rampant that only 10% of beneficiaries switched Medicare Advantage plans in 2019.

Once open enrollment ends, there are limited options for a do-over….  [Continued on Kaiser Health News and NPR]…

Uncle Sam Wants You … to Help Stop Insurers’ Bogus Medicare Advantage Sales Tactics

By Susan Jaffe, KHN  | November 30, 2023 | This story also ran on  

People gathered at the U.S. Capitol in Washington, D.C. in July protested denials and delays in private Medicare Advantage plans. (Alex Wong/Getty Image)

After an unprecedented crackdown on misleading advertising claims by insurers selling private Medicare Advantage and drug plans, the Biden administration hopes to unleash a special weapon to make sure companies follow the new rules: you.

Officials at the Centers for Medicare & Medicaid Services are encouraging seniors and other members of the public to become fraud detectives by reporting misleading or deceptive sales tactics to 800-MEDICARE, the agency’s 24-hour information hotline. Suspects include postcards designed to look like they’re from the government and TV ads with celebrities promising benefits and low fees that are available only to some people in certain counties.

The new rules, which took effect Sept. 30, close some loopholes in existing requirements by describing what insurers can say in ads and other promotional materials as well as during the enrollment process. [Continued on Kaiser Health News and NPR]…

Feds Rein In Use of Predictive Software That Limits Care for Medicare Advantage Patients

By Susan Jaffe, KFF Health News | October 5, 2023

This article also ran in The Washington Post.

Judith Sullivan was recovering from major surgery at a Connecticut nursing home in March when she got surprising news from h when she got surprising news from her Medicare Advantage plan: It would no longer pay for her care because she was well enough to go home.

At the time, she could not walk more than a few feet, even with assistance — let alone manage the stairs to her front door, she said. She still needed help using a colostomy bag following major surgery.

“How could they make a decision like that without ever coming and seeing me?” said Sullivan, 76. “I still couldn’t walk without one physical therapist behind me and another next to me. Were they all coming home with me?”

UnitedHealthcare — the nation’s largest health insurance company, which provides Sullivan’s Medicare Advantage plan — doesn’t have a crystal ball. It does have naviHealth, a care management company bought by UHC’s sister company, Optum, in 2020. NaviHealth’s proprietary “nH Predict” tool sifts through millions of medical records to match patients with similar diagnoses and characteristics, including age, preexisting health conditions, and other factors. Based on these comparisons, an algorithm anticipates what kind of care a specific patient will need and for how long. 

 

…Next year, the Centers for Medicare & Medicaid Services will begin restricting how Medicare Advantage plans use predictive technology tools to make some coverage decisions.[Continued on Kaiser Health News and The Washington Post.]…

US pharmaceutical companies sue to halt cuts in drug prices

Volume 402, Issue 10399
29 July 2023 

 

WORLD REPORT  Medicare will soon be able to negotiate some drug prices to reduce costs for patients and taxpayers. Susan Jaffe reports from Washington, DC.

The first set of ten drugs subject to price negotiations by the US Medicare programme will be unveiled on Sept 1, 2023, but some pharmaceutical companies and their allies are not waiting to find out which products will be on the list. So far, four manufacturers and two trade associations are suing to stop the process before it begins. [Continued here.] 

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A Covid Test Medicare Scam May Be a Trial Run for Further Fraud

By Susan Jaffe, KHN  | May 18, 2023 | This story also ran on  

Medicare coverage for at-home covid-19 tests ended last week, but the scams spawned by the temporary pandemic benefit could have lingering consequences for seniors.

Medicare advocates around the country who track fraud noticed an eleventh-hour rise in complaints from beneficiaries who received tests — sometimes by the dozen — that they never requested. It’s a signal that someone may have been using, and could continue to use, seniors’ Medicare information to improperly bill the federal government. …One beneficiary in Indiana suspected something was amiss after receiving 32 unrequested tests over a 10-day period. [Continued on Kaiser Health News, NPR, Yahoo News, and St. Louis Post-Dispatch]…

US plan to shield science from “inappropriate influence”

Volume 401, Issue 10375
11 February 2023 

 

WORLD REPORT  The Biden administration is launching a new initiative on scientific integrity in federal agencies following multiple lapses. Susan Jaffe reports from Washington, DC.

Just a week after Joe Biden was sworn in as president in January, 2021, he created a multi-agency Task Force on Scientific Integrity to restore “trust in government through scientific integrity and evidence-based policy making”…Last month, the White House Office of Science and Technology Policy released A Framework for Federal Scientific Integrity and Practice, a follow-up to the task force’s 2022 recommendations that provides a blueprint for implementation. [Continued here.] …

Medicare Plan Finder Likely Won’t Note New $35 Cap on Out-of-Pocket Insulin Costs

By Susan Jaffe, KHN  | November 15, 2022 | This story also ran on

A big cut in prescription drug prices for some Medicare beneficiaries kicks in next year, but finding those savings isn’t easy.

Congress approved in August a $35 cap on what seniors will pay for insulin as part of the Inflation Reduction Act, along with free vaccines and other Medicare improvements. But the change came too late to add to the Medicare plan finder, the online tool that helps beneficiaries sort through dozens of drug and medical plans for the best bargain.

To fix anticipated enrollment mistakes, Medicare officials will give beneficiaries who use insulin a chance to switch plans next year. Typically, people are locked in for an entire year. [Continued on Kaiser Health News and US News & World Report]

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Medicare considers expanding dental benefits for certain medical conditions

By Susan Jaffe, KHN  | October 17, 2022 | This story also ran on

Proposed changes in Medicare rules could soon pave the way for a significant expansion in Medicare-covered dental services, while falling short of the comprehensive benefits that many Democratic lawmakers have advocated.

That’s because, under current law, Medicare can pay for limited dental care only if it is medically necessary to safely treat another covered medical condition. In July, officials proposed adding conditions that qualify and sought public comment. Any changes could be announced in November and take effect as soon as January. The review by the Centers for Medicare & Medicaid Services follows an unsuccessful effort by congressional Democrats to pass comprehensive Medicare dental coverage for all beneficiaries, a move that would require changes in federal law. As defeat appeared imminent, consumer and seniors’ advocacy groups along with dozens of lawmakers urged CMS to take independent action. [Continued on Kaiser Health News and CNN]

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Nursing Home Surprise: Advantage Plans May Shorten Stays to Less Time Than Medicare Covers

“The health plan can determine how long someone is in a nursing home typically without laying eyes on the person.”

By Susan Jaffe  | Kaiser Health News | October 4, 2022 | This KHN story also ran on Fortune logo

Amy Loomis (left) and Paula Christopherson (photo by Charles Christopherson)

After 11 days in a St. Paul, Minnesota, skilled nursing facility recuperating from a fall, Paula Christopherson, 97, was told by her insurer that she should return home.

“This seems unethical,” said daughter Amy Loomis, who feared what would happen if the Medicare Advantage plan, run by UnitedHealthcare, ended coverage for her mother’s nursing home care.  The facility gave Christopherson a choice: pay several thousand dollars to stay, appeal the company’s decision, or go home.

But instead of being relieved, Christopherson and her daughter were worried because her medical team said she wasn’t well enough to leave.

Health care providers, nursing home representatives, and advocates for residents say Medicare Advantage plans are increasingly ending members’ coverage for nursing home and rehabilitation services before patients are healthy enough to go home.  [Full story in and Fortune, Kaiser Health News, The Philadelphia Inquirer, and Yahoo News]

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US Congress lets Medicare negotiate lower drug prices

Volume 400, Issue 10352
20 August 2022 

 

WORLD REPORT  A new law also targets climate change in a major victory for Democrats and President Joe Biden. Susan Jaffe reports from Washington, DC.

Shattering decades of opposition from the pharmaceutical industry and its allies, slim Democratic majorities in the US House of Representatives and Senate have passed landmark legislation to begin to control runaway drug prices for almost 50 million older Americans with Medicare’s pharmaceutical benefit. The bill also provides the largest federal investment in US history—US$370 billion—to slash greenhouse gases by 40% below 2005 emissions and respond to the devastating effects of climate change…. The legislation also ensures that no Medicare beneficiary pays more than $2000 a year for drugs. “That means you will have more money in your pocket”, said Tatiana Fassieux, education and training specialist at California Health Advocates. [Continued here.]
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Medicaid Weighs Attaching Strings to Nursing Home Payments to Improve Patient Care

By Susan Jaffe  | Kaiser Health News | June 10, 2022 | This KHN story also ran on Fortune logo

The Biden administration is considering a requirement that the nation’s 15,500 nursing homes spend most of their payments from Medicaid on direct care for residents and limit the amount that is used for operations, maintenance, and capital improvements or diverted to profits.

If adopted, it would be the first time the federal government insists that nursing homes devote the majority of Medicaid dollars to caring for residents.

“The absolutely critical ingredient” for good care is sufficient staffing, Dan Tsai, a deputy administrator at the Centers for Medicare & Medicaid Services and Medicaid director, told KHN. [Full story in Kaiser Health News, Fortune, Yahoo News and St. Louis Post-Dispatch]  

 

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Medicare Surprise: Drug Plan Prices Touted During Open Enrollment Can Rise Within a Month

By Susan Jaffe  | Kaiser Health News | May 3, 2022 | This KHN story also ran on

Something strange happened between the time Linda Griffith signed up for a new Medicare prescription drug plan during last fall’s enrollment period and when she tried to fill her first prescription in January.

She picked a Humana drug plan for its low prices, with help from her longtime insurance agent and Medicare’s Plan Finder, an online pricing tool for comparing a dizzying array of options. But instead of the $70.09 she expected to pay for her dextroamphetamine, used to treat attention-deficit/hyperactivity disorder, her pharmacist told her she owed $275.90.

“I didn’t pick it up because I thought something as wrong,” said Griffith, 73, a retired construction company accountant who lives in the Northern California town of Weaverville.  “To me, when you purchase a plan, you have an implied contract,” she said. “I say I will pay the premium on time for this plan. And they’re going to make sure I get the drug for a certain amount.”

But it often doesn’t work that way.  [Full story in Kaiser Health News, NPR  and Tampa Bay Times]  

 

 

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Medicare covers new Alzheimer’s drug, but there is a catch

Volume 399, Issue 10335
23 April 2022 

 

WORLD REPORT  The federal health plan for older Americans will pay for the controversial new drug aducanumab only for patients participating in clinical trials.  Susan Jaffe reports.  

The Biden administration’s long-awaited decision to pay for a controversial new Alzheimer’s disease treatment, aducanumab, will not make it easier for many older Americans with Medicare health insurance to get it. [Continued here.] 

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Seeking to Shift Costs to Medicare, More Employers Move Retirees to Advantage Plans

By Susan Jaffe  | Kaiser Health News | March 3, 2022 | This KHN story also ran in Fortune and The Dallas Morning News.

As a parting gesture to a pandemic-ravaged city, former New York Mayor Bill de Blasio hoped to provide the city with a gift that would keep on giving: new health insurance for 250,000 city retirees partly funded by the federal government. Although he promised better benefits and no change in health care providers, he said the city would save $600 million a year.

Over the past decade, an increasing number of employers have taken a similar deal, using the government’s Medicare Advantage program as an alternative to their existing retiree health plan and traditional Medicare coverage. …Scores of private and public employers offer Medicare Advantage plans to their retirees. Yet the details — and the costs to taxpayers — are largely hidden. Because the federal Centers for Medicare & Medicaid Services is not a party to the negotiations among insurers and employers, the agency said it does not have details about how many or which employers are using this strategy or the cost to the government for each retiree group. [Full story in Kaiser Health News, Fortune and The Dallas Morning News]  

 

 

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Medicare Patients Win the Right to Appeal Gap in Nursing Home Coverage

By Susan Jaffe | KAISER HEALTH NEWS | January 28, 2022

A three-judge federal appeals court panel in Connecticut has likely ended an 11-year fight against a frustrating and confusing rule that left hundreds of thousands of Medicare beneficiaries without coverage for nursing home care, and no way to challenge a denial.

The Jan. 25 ruling, which came in response to a 2011 class-action lawsuit eventually joined by 14 beneficiaries against the Department of Health and Human Services, will guarantee patients the right to appeal to Medicare for nursing home coverage if they were admitted to a hospital as an inpatient but were switched to observation care, an outpatient service. [Full story in Kaiser Health News and Modern Healthcare.] 

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The next steps for US vaccine mandates

Volume 399, Issue 10323
28 January 2022 

 

WORLD REPORT   As the Supreme Court blocks one of the Biden Administration’s plans to raise COVID-19 vaccination rates but approves another, Susan Jaffe looks at the next steps.

President Joe Biden’s efforts to encourage the most reluctant Americans to get fully vaccinated against COVID-19 have hit one legal roadblock after another. About one in four adults have still not received either the two-dose or single regimen of the vaccine, according to the Centers for Disease Control and Prevention. However, the path to greater vaccination uptake is shrinking as federal courts muddy his Administration’s pro-vaccine message, cases of infection driven by the Omicron variant continue to rise in many parts of the country, and the president’s popularity ratings fall. …In the first of two rulings on Jan 13, the Supreme Court decided 6–3 to block the Biden Administration’s mandate for private companies with more than 100 employees to require weekly COVID-19 tests for employees who have not been fully vaccinated. ,,,Yet in a pair of lawsuits the court heard along with the employer mandate cases, the court came to the opposite conclusion. In a 5–4 decision, they upheld the Biden Administration’s requirement of vaccination for 10·4 million workers at 76 000 health-care facilities that treat patients covered by the government’s Medicare or Medicaid health insurance.[Continued here.] 

 

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Holmes verdicts prompt questions over justice for patients

Volume 399, Issue 10321
15 January 2022

 

WORLD REPORT   The founder of Theranos was found guilty of defrauding some investors, but cleared of charges that she misled patients. Susan Jaffe reports.

On Jan 3, a federal jury in California found Elizabeth Holmes, creator of the blood-testing startup Theranos, guilty of lying to some of her investors about a portable blood analyser that she claimed would transform health care. It could run dozens of tests from a fingerprick of blood, she said, and deliver dependable results quickly. However, government prosecutors’ account of Holmes’s empty promises and hype failed to convince the jury that she also deceived patients and their doctors who depended on her device’s inaccurate readings. [Continued here.]  
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Theranos founder counters fraud charges in federal trial

Volume 398, Issue 10315
27 November 2021

 

WORLD REPORT   Federal prosecutors charged Theranos’ founder Elizabeth Holmes and former Theranos president Ramesh Balwani with wire fraud and conspiracy to commit wire fraud, alleging that they deceived investors and patients and their doctors by claiming that Theranos’s machine could produce accurate test results from blood collected in its tiny “nanotainer” device instead of several vials. But witnesses for the prosecution testified that the devices did not operate as promised…. “When something is brought forward as the next new thing regardless of whether it’s a drug or device, it needs to go through the process of rigorous scientific and clinical testing, then presented to the scientific community for peer review and ultimately publication”, said Roy Silverstein a haematologist and chair of medicine at the Medical College of Wisconsin. “And I’m not aware of any single publication that ever came out of this Theranos technology.” [Full story here.]  

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Legal challenges threaten Biden’s COVID-19 vaccine rule

Volume 398, Issue 10314
20 November 2021

 

WORLD REPORT  Almost a year after the first COVID-19 vaccine was approved for emergency use in the USA, roughly a third of adults have still not received it. After urging Americans to get vaccinated, US President Joe Biden has taken a tougher approach: under his administration’s new workplace safety standard, people must get vaccinated or undergo weekly tests for the virus if they work for companies with at least 100 employees. “The rule will protect more than 84 million workers from the spread of the coronavirus on the job”, said Jim Frederick, Deputy Assistant Secretary of Labor for Occupational Safety and Health. …A day after OSHA’s announcement on Nov 4, 2021, multiple lawsuits to block the rule started rolling in to federal courts across the country.[Continued here.]  

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Medicare’s Open Enrollment Is Open Season for Scammers

By Susan Jaffe  | Kaiser Health News | November 11, 2021 | This KHN story also ran in The Washington Post.

Finding the best private Medicare drug or medical insurance plan among dozens of choices is tough enough without throwing misleading sales tactics into the mix.  Yet federal officials say complaints are rising from seniors tricked into buying policies — without their consent or lured based on questionable information — that may not cover their drugs or include their doctors.

In response, the Centers for Medicare and Medicaid Services has threatened to penalize private insurance companies selling Medicare Advantage and drug plans if they or agents working on their behalf mislead consumers.  The agency has also revised rules making it easier for beneficiaries to escape plans they didn’t sign up for or enrolled in only to discover promised benefits didn’t exist or they couldn’t see their providers.

The problems are especially prevalent during Medicare’s open-enrollment period, which began Oct. 15 and runs through Dec. 7. A common trap begins with a phone call like the one Linda Heimer, an Iowa resident, received in October. [Full story in The Washington Post and Kaiser Health News.] 

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3 States Limit Nursing Home Profits in Bid to Improve Care

“If they choose to rely on public dollars to deliver care, they take on a greater responsibility,” says New York Assemblyman Ron Kim. “It’s not like running a hotel.” 
By Susan Jaffe | KAISER HEALTH NEWS | October 25, 2021 |  This story also ran on

Nursing homes receive billions of taxpayers’ dollars every year to care for chronically ill frail elders, but until now, there was no guarantee that’s how the money would be spent.

Massachusetts, New Jersey and New York are taking unprecedented steps to ensure they get what they pay for, after the devastating impact of covid-19 exposed problems with staffing and infection control in nursing homes. The states have set requirements for how much nursing homes must spend on residents’ direct care and imposed limits on what they can spend elsewhere, including administrative expenses, executive salaries and advertising and even how much they can pocket as profit. …With this strategy, advocates believe, residents won’t be shortchanged on care, and violations of federal quality standards should decrease because money will be required to be spent on residents’ needs. At least that’s the theory. [Continued on Kaiser Health News, Fortune, NBC News, Yahoo Finance, and Chicago Sun-Times]…

The Push For Nursing Home Reform In The Middle Of A Pandemic

Sept. 20, 2021 | Today on NPR‘s news program “1A,”  reporter Susan Jaffe discusses her Kaiser Health News story about new state laws protecting nursing home residents in response to the COVID-19 pandemic. Changes affect staffing, visitation rights, virtual communications, “essential support persons,” and more. A  resident of a Connecticut nursing home quoted in this KHN article is also a guest. …

After pandemic ravaged nursing homes, new state laws protect residents

So far, 23 states have passed more than 70 new pandemic-related provisions affecting nursing home operations. 

By Susan Jaffe | KAISER  HEALTH  NEWS | August 17, 2021 |  This story also ran in

When the coronavirus hit Martha Leland’s Connecticut nursing home last year, she and dozens of other residents contracted the disease while the facility was on lockdown. Twenty-eight residents died, including her roommate.

“The impact of not having friends and family come in and see us for a year was totally devastating,” she said. “And then, the staff all bound up with the masks and the shields on, that too was very difficult to accept.” She summed up the experience in one word: “scary.”

But under a law Connecticut enacted in June, nursing home residents will be able to designate an “essential support person” who can help

take care of a loved one even during a public health emergency. Connecticut legislators also approved laws this year giving nursing home residents free internet access and digital devices for virtual visits and allowing video cameras in their rooms so family or friends can monitor their care.

Similar benefits are not required by the Centers for Medicare & Medicaid Services, the federal agency that oversees nursing homes and pays for most of the care they provide. But states can impose additional requirements when those federal rules are insufficient or don’t exist.  And that’s exactly what many are doing, spurred by the virus that hit the frail elderly hardest. [Continued at Kaiser Health News and USA Today] 

 

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Chiquita Brooks-LaSure: innovative US federal health director

Volume 398, Issue 10300
14 August 2021

 

PROFILE  
Chiquita Brooks-LaSure, President Joe Biden’s choice to lead the Centers for Medicare and Medicaid Services, presides over an agency with a US$1 trillion budget that provides health insurance to more than 154 million people. Tackling health-care inequities is one of her top priorities. “These disparities have long existed, but COVID-19 has illuminated them in a way that is really unprecedented”, she said. [Full story here.]

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