The Center for Medicare Advocacy (the “Center”) works toward providing better Medicare coverage and health care, especially for older people and people with disabilities. In a transition memo to the Biden administration, the Center suggested several administrative actions intended to fix problems in the current Medicare system. The Department of Health and Human Services (DHHS) and the Centers for Medicare and Medicaid Services (CMS) already have the authority to make these improvements without additional legislation. In fact, simply enforcing laws and regulations on the books could prevent and solve some of the problems that plague many nursing facilities.
Improve Nursing Home Resident Protections
Even before the COVID-19 public health emergency, skilled nursing facilities struggled with staffing shortages, stringent infection controls, and shifting regulations.
Suggested actions include:
- Enforcing current quality of care requirements,
- Putting comprehensive staffing ratios in place, and
- Increasing training requirements.
Clarify Regulations Regarding Hospital Patient Status
Hospitals sometimes classify Medicare beneficiaries as outpatients instead of inpatients. This misclassification may bar or at least limit the beneficiary’s access to certain Medicare benefits.
DHHS and CMS could improve quality of care by:
- Revising policies and regulations,
- Redefining inpatient and outpatient status,
- Rescinding the Outpatient Prospective Payment Surgical System Final Rule.
Improve Access to Medicare-covered Home Health Care Benefits
Some patients who need medical care are reluctant to leave home, especially since the pandemic started. In fact, home healthcare is often safer since elderly people or people with comorbidities are more vulnerable to COVID-19. However, people also may find it challenging to find the home-based services they need.
The following administrative actions could improve availability:
- Ensure that services are available for everyone that qualifies,
- Monitor staffing for home health providers,
- Revise the Medicare home health payment model.
Address Inequities Between Traditional Medicare and Medicare Advantage
Medicare Advantage programs have been extensively promoted, sometimes to the detriment of traditional Medicare programs.
The following suggestions could help regain balance between the two programs:
- Address Medicare overpayments,
- Focus on oversight and enforcement of Medicare Advantage,
- Distinguish between marketing and education.
Ensure Beneficiaries Are Not Denied Coverage Based on an Improvement Standard
In the past, Medicare denied coverage to beneficiaries whose condition was unlikely to improve. The 2013 settlement agreement in Jimmo v. Sebelius attempted to overcome this erroneous belief. However, further action is needed. As suggested by the Center, the Biden administration could:
- Ensure implementation of the Jimmo settlement,
- Require additional training,
- Inform providers of the Jimmo settlement, and
- Ensure that CMS recognizes that improvement is not required for treatment to be covered.
Cover Medically Necessary Oral Health Care
Medicare does not cover routine dental care. However, some dental services are necessary and critical to a patient’s health.
Administrative actions could ensure Medicare coverage is available when dental problems are a serious health risk for the patient.
Additional Areas of Concern
We could cover only the highpoints of the Center’s suggestions for the Biden administration. For more information, check out the full transition memorandum.
Attorney Robert Slutsky was one of the first lawyers in Pennsylvania to focus on elder law issues. Since 1992, he has helped countless people plan for their future, set up proper estate plans, plan to protect assets and care for loved ones, and successfully apply for Medicaid.
For a listing of skilled nursing and rehabilitation facilities, please check out our Chester County PA Elder Law Directory and Senior Guide online at: