Category: Medicare
Congress Considers Bill to Address Medicare Late Penalties, Coverage Gap
Current enrollment rules can leave late enrollees liable for doc visits Medicare usually covers
By Susan Jaffe | Contributing Writer | MedPageToday | January 20, 2020
Some 10,000 Americans turn 65 every day and become eligible for Medicare, but enrollment mistakes can subject them to a lifetime of late penalties, as well as a months-long coverage gap.
Legislation that would fix these problems was one of the bills discussed at a hearing held by the House Energy & Commerce Health Subcommittee…. Although the panel focused on how the bipartisan Beneficiary Enrollment Notification and Eligibility Simplification (BENES) Act impacts Medicare patients, it also affects their physicians. [Continued here and PDF here]
Website Errors Raise Calls For Medicare To Be Flexible With Seniors’ Enrollment
Seniors will be able to change plans any time next year if they discover their coverage doesn’t provide what the government’s Plan Finder promised.
By Susan Jaffe | Kaiser Health News | December 6, 2019 | This article also ran on 
Saturday is the deadline for most people with Medicare coverage to sign up for private drug and medical plans for next year. But members of Congress, heal
th care advocates and insurance agents worry that enrollment decisions based on bad information from the government’s revamped, error-prone Plan Finder website will bring unwelcome surprises.
Beneficiaries could be stuck in plans that cost too much and don’t meet their medical needs — with no way out until 2021.
On Wednesday, the Centers for Medicare & Medicaid Services told Kaiser Health News that beneficiaries would be able to change plans next year because of Plan Finder misinformation, although officials provided few details. [Continued at Kaiser Health News or NPR.] …
As Medicare Enrollment Nears, Popular Price Comparison Tool Is Missing
By Susan Jaffe | Kaiser Health News | October 8, 2019 | This article also ran in the
Millions of older adults can start signing up next week for private policies offering Medicare drug and medical coverage for 2020. But many risk wasting money and even jeopardizing their health ca
re due to changes in Medicare’s plan finder, its most popular website.
For more than a decade, beneficiaries used the plan finder to compare dozens of Medicare policies offered by competing insurance companies and get a list of their options. Yet after a website redesign six weeks ago, the search results are missing crucial details: How much will you pay out-of-pocket? And which plan offers the best value? [Continued at Kaiser Health News, San Francisco
Class-Action Lawsuit Seeks To Let Medicare Patients Appeal Gap in Nursing Home Coverage
By Susan Jaffe | Kaiser Health News | August 12, 2019 | This KHN story also ran on Salon and Next Avenue
Medicare paid for Betty Gordon’s knee replacement surgery in March, but the 72-year-old former high school teacher needed a nursing home stay and care at home to recover.
Yet Medicare wouldn’t pay for that. So Gordon is stuck with a $7,000 bill she can’t afford — and, as if that were not bad enough, she can’t appeal.
The reasons Medicare won’t pay have frustrated the Rhode Island woman and many others trapped in the maze of regulations surrounding something called “observation care.”
Patients, like Gordon, receive observation care in the hospital when their doctors think they are too sick to go home but not sick enough to be admitted. They stay overnight or longer, usually in regular hospital rooms, getting some of the same services and treatment (often for the same problems) as an admitted patient….
(Photo courtesy of Betty Gordon)
But observation care is considered an outpatient service under Medicare rules, like a doctor’s appointment or a lab test. Observation patients may have to pay a larger share of the hospital bill than if they were officially admitted to the hospital.Medicare’s nursing home benefit is available only to those admitted to the hospital for three consecutive days. Gordon spent three days in the hospital after her surgery, but because she was getting observation care, that time didn’t count.
There’s another twist: Patients might want to file an appeal, as they can with many other Medicare decisions. But that is not allowed if the dispute involves observation care.
Monday, a trial begins in federal court in Hartford, Conn., where patients who were denied Medicare’s nursing home benefit are hoping to force the government to eliminate that exception. A victory would clear the way for appeals from hundreds of thousands of people. [Continued at Kaiser Health News, Next Avenue or Salon]
…Social Security Error Jeopardizes Medicare Coverage For 250,000 Seniors
By Susan Jaffe | Kaiser Health News | June 6, 2019 | This KHN story also ran on 
At least a quarter of a million Medicare beneficiaries may receive bills for as many as five months of premiums they thought they already paid.
But they shouldn’t toss the letter in the garbage. It’s not a scam or a mistake.
Because of what the Social Security Administration calls “a processing error” that occurred in January, it did not deduct premiums from some seniors’ Social Security checks and it didn’t pay the insurance plans.
[Continued at Kaiser Health News or NPR ]
…Home Health Care Providers Struggle With State Laws And Medicare Rules As Demand Rises
“We can send prescriptions to the pharmacy, including [for] narcotics,” says Marie Grosh, a geriatric advanced practice nurse practitioner and the owner of a medical house calls practice in a Cleveland suburb. “We can order lab work, x-rays, ultrasounds, EKGs [electrocardiagrams]; interpret them; and treat patients based on that. But we’re just not allowed to order home care—which is absurd.”
By SUSAN JAFFE | Health Affairs | June 2019 | Volume 38, Number 8
When Christine Williams began working as a nurse practitioner some forty years ago in Detroit, Michigan, older adults who couldn’t manage on their own and had no family nearby and no doctor willing to make house calls had few options besides winding up in a nursing home.
Not anymore.
Home check: Nurse practitioner Marie Grosh visits Leroy Zacharias at his home in a Cleveland suburb, He has Parkinson disease, and Grosh says he would be living in a nursing home if he couldn’t get medical care at home. (Photo by Lynn Ischay.)
“The move towards keeping seniors in their homes is a fast-galloping horse here,” says Williams, who settled in Cleveland, Ohio, more than a decade ago. “We don’t have space for them in long-term care [facilities], they don’t want to be in long-term care, and states don’t want to pay for long-term care. And everybody wants to live at home.”
But despite the growing desire for in-home medical care for older adults from nearly all quarters, seniors’ advocates and home health professionals claim that rules set by the Centers for Medicare and Medicaid Services (CMS) along with state regulations have created an obstacle course for the very providers best positioned—and sometimes the only option—to offer that care. [Continued here] …
Legal battles over abortion heat up in the USA
Volume 393 Number 10184 11 May 2019
WORLD REPORT Changes to Title X, several legal challenges, and a change to the Supreme Court composition could mean drastic changes for access to abortion in the USA. Susan Jaffe reports.
“We are the department of life…from conception until natural death, through all of our programmes”, US Department of Health and Human Services (HHS) secretary Alex Azar said earlier this year…. The government’s anti-abortion efforts have ignited lawsuits from Maine to California. Eventually, one or more of these cases are expected to reach the Supreme Court. With its newest arrival—Justice Brett Kavanaugh, whose nomination by Trump was championed by abortion opponents—the Supreme Court’s ideological balance has now shifted towards a conservative majority [raising] opponents’ hopes that a sympathetic court will diminish, if not overturn, Roe v. Wade...
Late last week, lawyers for the HHS appealed decisions by two federal court judges in Oregon and Washington state to temporarily halt new administration rules that would limit the information about abortion services that federally funded health-care providers can tell their patients.
“We are fighting back in the courts, we are fighting back in Congress and in state legislatures all across the country”, said Planned Parenthood president Leana Wen, noting that one in four women in the USA will have an abortion in their lifetime. “The public is with us when it comes to defending access to safe legal abortion, which people understand is part of the full spectrum of reproductive health care, which is health care.” [Continued here.]…
House Drug Price Hearing Takes Aim at Industry
By Susan Jaffe | Contributing Writer | MedPageToday | January 30, 2019
WASHINGTON — Pharmaceutical companies were pummeled during Tuesday’s hearing of the House Committee on Oversight and Reform. The panel’s first hearing of the 116th Congress examined the reasons for rising drug prices and follows committee chairman Elijah Cummings’ (D-Md.) launch of an aggressive investigation into pharmaceutical pricing issues.
“For the past decade I’ve been trying to investigate the actions of drug companies for all sorts of drugs — old and new, generic and brand name,” Cummings said. “We have seen time after time drug companies make money hand over fist by raising the prices of their drugs often without justification…” [Continued at MedPageToday]
State exemptions to the Affordable Care Act expanded
Volume 392, Number 10164
15 December 2018
WORLD REPORT In its latest blow to the ACA, the Trump administration provides guidance on how states can circumvent the health law. Susan Jaffe, The Lancet‘s Washington correspondent, reports.
In its most far-reaching move yet, the Trump administration has reinterpreted a provision of the landmark Affordable Care Act so that states can apply for exemptions to some requirements of the health law for states. [Continued here.]
… Trumpeted New Medicare Advantage Benefits Will Be Hard For Seniors To Find
By Susan Jaffe | Kaiser Health News | November 9, 2018 | This KHN story also ran on
For some older adults, private Medicare Advantage plans next year will offer a host of new benefits, such as transportation to medical appointments, home-delivered meals, wheelchair ramps, bathroom grab bars or air conditioners for asthma sufferers.
But the new benefits will not be widely available, and they won’t be easy to find.
Of the 3,700 plans across the country next year, only 273 in 21 states will offer at least one. About 7 percent of Advantage members — 1.5 million people — will have access, Medicare officials estimate.
That means even for the savviest shoppers it will be a challenge to figure out which plans offer the new benefits and who qualifies for them.
Medicare officials have touted the expansion as historic and an innovative way to keep seniors healthy and independent. Despite that enthusiasm, a full listing of the new services is not available on the web-based “Medicare Plan Finder,” the government tool used by beneficiaries, counselors and insurance agents to sort through dozens of plan options. [Continued at Kaiser Health News, NPR and CNN]…
No More Secrets: Congress Bans Pharmacist ‘Gag Orders’ On Drug Prices
Update: After this article was posted Oct. 10th, the President signed the legislation into law later that day.
By Susan Jaffe | Kaiser Health News | October 10, 2018 | This KHN story also ran on 
For years, most pharmacists couldn’t give customers even a clue about an easy way to save money on prescription drugs. But the restraints are coming off.
When the cash price for a prescription is less than what you would pay using your insurance plan, pharmacists will no longer have to keep that a secret.
…But there’s a catch: Under the new legislation, pharmacists will not be required to tell patients about the lower cost option. If they don’t, it’s up to the customer to ask. [Continued at Kaiser Health News and at NBC News]
…New Medicare Advantage Tool To Lower Drug Prices Puts Crimp In Patients’ Choices
Some physicians and patient advocates are concerned that the pursuit of lower Part B drug prices could endanger very sick Medicare Advantage patients if they can’t be treated promptly with the medicine that was their doctor’s first choice.
By Susan Jaffe | Kaiser Health News | September 17, 2018 | This KHN story also ran on
Starting next year, Medicare Advantage plans will be able to add restrictions on expensive, injectable drugs administered by doctors to treat cancer, rheumatoid arthritis, macular degeneration and other serious diseases.
Under the new rules from Medicare, these private Medicare insurance plans could require patients to try cheaper drugs first. If those are not 
effective, then the patients could receive the more expensive medication prescribed by their doctors.
Insurers use such “step therapy” to control drug costs in the employer-based insurance market as well as in Medicare’s stand-alone Part D prescription drug benefit, which generally covers medicine purchased at retail pharmacies or through the mail. The new option allows the private Medicare plans — an alternative to traditional, government-run Medicare — to extend that cost-control strategy to these physician-administered drugs.
…Critics of the new policy, part of the administration’s efforts to fulfill President Donald Trump’s promise to cut drug prices, say it lacks some crucial details, including how to determine when a less expensive drug isn’t effective. [Continued at Kaiser Health News and NPR]
…
Prospects for US single-payer national health care
Volume 392, Number 10149
1 September 2018
WORLD REPORT The single-payer national health-care bill, so-called Medicare for All, is gaining momentum with the public but is stalling in Congress. Susan Jaffe, The Lancet‘s Washington correspondent, reports.
Instead of fading away into legislative oblivion, some Democrats campaigning for congressional seats and candidates for state offices are supporting the Medicare for All bill—or some variation thereof—as the November election approaches. They are not alone: a Morning Consult/Politico national poll in June found that 63% of Americans support “a Medicare for All healthcare system, where all Americans would get their health insurance from the government”. [Continued here.]
…
Trump Administration’s Medicaid work rules hit a snag
Susan Jaffe | Washington Correspondent for The Lancet | 10th July 2018
After winning a federal court decision to stop Kentucky from requiring some Medicaid patients find paid or volunteer work to keep their coverage, beneficiary advocates are considering legal challenges to stop similar efforts in other states.
The victory may expose a major flaw in the Trump Administration’s effort to reshape the Medicaid program, advocates say. But others claim the flaw is in the court decision. [Continued here.]…
Looking For Lower Medicare Drug Costs? Ask Your Pharmacist For The Cash Price.
Sometimes a drug plan’s copay is higher than the cash, but insurers’ “gag orders” keep pharmacists from telling Medicare beneficiaries. A little-known Medicare rule requires pharmacists to divulge the lower cash price if patients ask.
By Susan Jaffe | Kaiser Health News | May 30, 2018 | This KHN story also ran on
As part of President Donald Trump’s blueprint to bring down prescription costs, Medicare officials have warned insurers that “gag orders”
Scott Olson/Getty Images
keeping pharmacists from alerting seniors that they could save money by paying cash — rather than using their insurance — are “unacceptable and contrary” to the government’s effort to promote price transparency.
But the agency stopped short of requiring insurers to lift such restrictions on pharmacists.
That doesn’t mean people with Medicare drug coverage are destined to overpay for prescriptions. Under a little-known Medicare rule, they can pay a lower cash price for prescriptions instead of using their insurance. But first, they must ask the pharmacist about that option…. [Continued at Kaiser Health News, NPR and CNN Money]…
Medicare Advantage Plans Cleared To Go Beyond Medical Coverage — Even Groceries
By Susan Jaffe | Kaiser Health News | April 3, 2018 | This KHN story also ran on 
Air conditioners for people with asthma, healthy groceries, rides to medical appointments and home-delivered meals may be among the new benefits added to Medicare Advantage [private insurance] coverage when new federal rules take effect next year.
The Institute for Aging in San Francisco helps seniors get to doctor appointments and social activities. (Photo/Susan Jaffe)
…But patient advocates including David Lipschutz. senior policy attorney at the Center for Medicare Advocacy, are concerned about those who may be left behind. “It’s great for the people in Medicare Advantage plans, but what about the majority of the people who are in traditional Medicare?” he asked. “As we tip the scales more in favor of Medicare Advantage, it’s to the detriment of people in traditional Medicare.” [Continued at Kaiser Health News, The Philadelphia Inquirer, The Washington Post and CNN Money]
…Lifting Therapy Caps Is A Load Off Medicare Patients’ Shoulders
Last month’s budget deal means Medicare beneficiaries are eligible for physical and occupational therapy indefinitely. Plus, prescription drug costs will fall for more seniors.
By Susan Jaffe | Kaiser Health News | March 14, 2018 | This KHN story also ran on
Physical therapy helps Leon Beers, 73, get out of bed in the morning and
Leon Beers gets help from caregiver Timothy Wehe. (Bert Johnson for KHN)
maneuver around his home using his walker. Other treatment strengthens his throat muscles so that he can communicate and swallow food, said his sister Karen Morse. But in mid-January, his home health care agency told Morse it could no longer provide these services because he had used all his therapy benefits allowed under Medicare for the year.
… Under a recent change in federal law, people who qualify for Medicare’s [physical, occupational and speech] therapy services will no longer lose them solely because they used too much.
“It is a great idea,” said Beers. “It will help me get back to walking.” [Continued at Kaiser Health News, NPR and The Washington Post]
…
Home Care Agencies Often Wrongly Deny Medicare Help To The Chronically Ill
By Susan Jaffe | Kaiser Health News | January 18, 2018 | This KHN story also ran on
Colin Campbell (Heidi de Marco/KHN)
Colin Campbell needs help dressing, bathing and moving between his bed and his wheelchair. He has a feeding tube because his partially paralyzed tongue makes swallowing “almost impossible,”he said.
Campbell, 58, spends $4,000 a month on home health care services so he can continue to live in his home just outside Los Angeles. Eight years ago, he was diagnosed with amyotrophic lateral sclerosis, or “Lou Gehrig’s disease,” which relentlessly attacks the nerve cells in his brain and spinal cord and has no cure.
The former computer systems manager has Medicare coverage because of his disability, but no fewer than 14 home health care providers have told him he can’t use it to pay for their services. That’s an incorrect but common belief…. [Continued at Kaiser Health News and NPR]…
A Few Pointers To Help Save Money And Avoid The Strain Of Medicare Enrollment
By Susan Jaffe | Kaiser Health News | Oct. 17, 2017 | This article also ran in 
and 
Older or disabled Americans with Medicare coverage have probably 
noticed an uptick in mail solicitations from health insurance companies, which can mean only one thing: It’s time for the annual Medicare open enrollment.
Most beneficiaries have from Oct. 15 through Dec. 7 to decide which of dozens of private plans offer the best drug coverage for 2018 or whether it’s better to leave traditional Medicare and get a drug and medical combo policy called Medicare Advantage.
Some tips for the novice and reminders for those who have been here before can make the process a little easier. [Continued at Kaiser Health News, USA Today and The Washington Post]
…Money-Saving Offer For Medicare’s Late Enrollees Is Expiring. Can They Buy Time?
By Susan Jaffe | Kaiser Health News | September 22, 2017 | This KHN story also ran on
[UPDATE: Since this article was published, Medicare officials extended the deadline for applying for an exemption to the Part B late enrollment penalty to Sept. 30, 2018. The announcement came in a fact sheet posted on Oct. 12, 2017.]
Many older Americans who have Affordable Care Act insurance policies are going to miss a Sept. 30 deadline to enroll in Medicare, and they need more time to make the change, advocates say.
A lifetime of late enrollment penalties typically await people who don’t sign up for Medicare Part B — which covers doctor visits and other outpatient services — when they first become eligible. That includes people who mistakenly thought that because they had insurance through the ACA marketplaces, they didn’t need to enroll in Medicare.
Medicare officials are offering to waive those penalties under a temporary rule change that began earlier this year, but the deal ends Sept. 30.
On Wednesday, more than 40 groups, including consumer health advocacy organizations and insurers, asked Medicare chief Seema Verma to extend the waiver deadline through at least Dec. 31, because they are worried that many people who could be helped still don’t know about it. [Continued at Kaiser Health News and NPR]…
Feds To Waive Penalties For Some Who Signed Up Late For Medicare
By Susan Jaffe | Kaiser Health News | June 6, 2017 | This KHN story also ran on
[UPDATE: Since this article was published, Medicare officials extended the deadline for applying for an exemption to the Part B late enrollment penalty to Sept. 30, 2018. The announcement came in a fact sheet posted on Oct. 12, 2017.]
Each year, thousands of Americans miss their deadline to enroll in Medicare, and federal officials and consumer advocates worry that many of them mistakenly think they don’t need to sign up because they have purchased insurance on the health law’s marketplaces. That decision can leave them facing a lifetime of enrollment penalties.
Now Medicare has temporarily changed its rules to offer a reprieve from penalties for people who kept Affordable Care Act policies after becoming eligible for Medicare.
“Many of these individuals did not receive the information necessary [when they became eligible for Medicare or when they initially enrolled] in coverage through the marketplace to make an informed decision regarding” Medicare enrollment, said a Medicare spokesman, explaining the policy change.
Those who qualify include people 65 and older who have a marketplace plan or had one they lost or canceled, as well as people who have qualified for Medicare due to a disability but chose to use marketplace plans. They have until Sept. 30 to request a waiver of the usual penalty Medicare assesses when people delay signing up for Medicare’s Part B, which covers visits to the doctor and other outpatient care…
“This has been a problem from the beginning of the Affordable Care Act, because the government didn’t understand that people would not know when they needed to sign up for Medicare,” said Bonnie Burns, a consultant for California Health Advocates, a consumer group. “Once they had insurance, that relieved all the stress of not having coverage and then when they became eligible for Medicare, nobody told them to make that change.”[Continued at Kaiser Health News and NPR]…
Volunteers Help Ombudsmen Give Nursing Home Residents ‘A Voice’ In Their Care
By Susan Jaffe | Kaiser Health News | May 2, 2017 | This KHN story also ran in 
Since retiring four years ago, Barbara Corprew has visited Paris, traveled to a North Carolina film festival and taken Pilates classes, focusing on — as she puts it — just “doing things for me.” Now the former Justice Department lawyer, who worked on white-collar crime cases, is devoting time to something completely different: She visits nursing homes every week.
Barbara Corprew, says her service as a volunteer ombudsman was sparked in part by her experience acting as an advocate for her parents when they became ill. (Courtesy of Barbara Corprew)
Corprew is a volunteer in the District of Columbia’s Long-Term Care Ombudsman’s Office, a government-funded advocacy agency for nursing home and assisted-living residents.
The ombudsmen’s offices, which operate under federal law in all 50 states and the District, investigated 200,000 complaints in 2015, according to the Administration on Aging, a part of the Department of Health and Human Services. Of those, almost 117,000 were reported to have been resolved in a way that satisfied the person who made the complaint, and about 30,000 were partially resolved. At the top of the list were problems concerning care, residents’ rights, physical environment, admissions and discharges, and abuse and neglect.
The volunteers have permission to enter any nursing home, assisted-living or other long-term-care facility anytime, unannounced, talk to any resident and go wherever they want. They respond to issues raised by residents and their families and can bring up problems they discover. All complaints are handled confidentially, even kept from family members, unless residents allow the ombudsman to reveal their identities.
… Medical or legal experience is not required. Volunteers come from all kinds of backgrounds and careers, but they seem to have one thing in common: an abundance of compassion.
Gwendolyn Devore, another District volunteer, remembers a forlorn woman sitting in a hallway at the nursing home where her aunt lived. When she asked a staff member about the woman, the only reply was an angry look that unmistakably said, “It’s none of your business,” Devore recalled as she explained her interest in becoming a volunteer. “Now no one will be able to say it’s none of my business.” [Continued at Kaiser Health News and in The Washington Post]…
Home-Care Workers
Susan Jaffe | Washington Correspondent for The Lancet | 28 August 2015
Home-care workers are excluded from the federal law requiring most employees to receive a minimum wage—currently $7·25 an hour—and 150% of that pay when they work overtime. After 40 years, the US Department of Labor (DOL) issued rules eliminating that exemption. The new rule was supposed to take effect last January but it was blocked by a lawsuit filed by associations representing companies that hire these workers. [Continued here.] [with video of Illinois Congresswoman Jan Schakowsky shadowing home-care worker Gilda Pipersburgh]…
Medicare Combats Fraud With Billing Statements That Beneficiaries Can Understand
Susan Jaffe | March 7, 2012 | KAISER HEALTH NEWS produced in collaboration with 
In the latest effort to enlist seniors in the fight against Medicare fraud, federal officials have overhauled Medicare billing statements to make it easier to find bogus charges without a magnifying glass. ….And for those who might need an incentive to scour their bills, the new statements promise a reward of up to $1,000 for a tip that leads to uncovering fraud.[Continued here.]…