Recent Developments in the Medicare Program

Recent Developments in the Medicare Program

By Donald D. Vanarelli, Esq.


Outcomes Based Quality Improvement (OBQI) System for Home Health Agencies (HHAs)

The CMS is implementing this system, in which CMS contractors will provide training and technical assistance to Home Health Agencies in order to assist the HHAs in interpreting outcome reports, targeting, developing and implementing plans to improve outcomes for improvement.i

Revision to Clinical Nurse Specialist (CNS) Definition

The definition of a CNS has been revised to include persons certified as clinical nurse specialists by a national certifying body that has established CNS standards and approved by the Secretary. This may enable CNSs specializing in fields such as critical care or rehabilitation to qualify as a CNS for purposes of Medicare.ii

Medicare Savings Program Update

Through the Qualified Individual Programs (QI-1 and QI-2), Medicaid has provided assistance with Medicare Part B premiums to low-income Medicare beneficiaries. Program QI-1 was designed for people with income of 120% to 135% of the federal poverty line, and provides full payment of the Part B premiums; QI-2 was for those between 135% and 175% of the poverty line, and paid $3.91 toward the monthly Medicare premiums. The scheduled expiration date for both programs was December 31, 2002. In April 2001, Congress approved the extension of the QI-1 program for five additional years. The QI-2 program was not extended.iii

Medicare Home Health Coverage

In July 2002, changes were enacted for Medicare coverage of home health care for those with chronic disabilities who are homebound. These changes allow those individuals to occasionally leave their homes for special non-medical events, such as a family reunion, without running the risk of having Medicare contractors determine that they no longer qualify as “homebound.”iv

Changes in Appeals Process

Although CMS has delayed implementing some of the provisions of the 2000 Benefits Improvement and Protection Act, CMS implemented the following provisions. First, it implemented the provision increasing the deadline from requesting redetermination or review of a Part A and Part B claim from 60 to 120 days. Second, it implemented the reduced claim amount necessary to request an ALJ hearing from $500 to $100 for all Part A and Part B claims.v

Medicare Program Amount Changes From 2002 to 2003

The inpatient hospital deductible per “benefit period” rose from $812 to $840. The daily hospitalization coinsurance amount for day 61 through day 90 during any “benefit period” increased from $203 to $210. The coinsurance amount for each of the sixty “lifetime reserve” days increased from $406 to $420. For each “benefit period”, the coinsurance amount for each day between days 21 and 100 in a skilled nursing facility increased from $101.50 to $105. The Medicare Part B standard monthly premium increased from $54 to $

Informative Websites

The following informative websites may be worthy of inclusion in your “Favorites” folder:

Centers for Medicare & Medicaid Services (CMS)– The official website of the CMS, formerly the Health Care Financing Administration (HCFA), provides a variety of information on Medicare programs and issues. The website includes a “Laws and Regulations” section, with a chart of regulations published in the current and previous quarters and a summary of each regulation.

Website for the Center for Medicare Education (CME), a resource for public agencies and private organizations that provide consumer education about Medicare. CME is funded by the Robert Wood Johnson Foundation and is part of the Institute for the Future of Aging Services, a policy research institute of the American Association of Homes and Services for the Aging.

The Official U.S. Government Site for People with Medicare. The website includes a complete listing of all beneficiary publications, as well as the “Medicare & You” 2003 Handbook.End of article icon.

i 2003 Medicare Changes & Fact Sheet for Physicians and Other Providers: Key News from Medicare for 2003.
ii Id.
iii Center for Medicare Education,
iv Id.
v Id.
vi 2002-2003 New York Life Insurance Company website.


For additional information regarding New Jersey Elder Law, Probate, Estate and Special Needs Planning, Mediation and Collaborative Family Law, call us at 908-232-7400 or click here to contact us online.