Chasing Life

With more than 750,000 Americans being diagnosed with Covid-19 every day, the need for clear guidance on isolation and quarantine is critically important. Sadly, the CDC’s guidance is continuously changing, confusing and at times contradictory.

 

Dr. Gerald Harmon, president of the American Medical Association, said in a statement last week that the agency's latest guidance threatens to allow the virus to spread further, putting patients and the health care system at risk.

 

The most recent CDC recommendations also highlight a persistent problem throughout the pandemic: a lack of available testing and a fundamental misunderstanding of how these tests are designed to work.

 

So what should you do? In a new essay for CNN.com, I suggest a simple and effective strategy that relies on both testing and clinical symptoms, distinguishes between those who are vaccinated and those who are not, and still allows for a rapid return to normal life if you're well.

 

The bottom line: If you have Covid-19, it's worth decreasing the risk of spreading it by really thinking about how you're going to come out of isolation. I support a strategy that considers your symptoms, your vaccination status, testing and the best data on your contagiousness at any given time.

 

I am confident that 2022 will be a year of promise and renewal and that we will get through this together. While Covid-19 is likely here to stay, these simple strategies can help accelerate the end of the pandemic.

There's more!

“Mild” Covid-19 doesn’t always feel that way 5 ways adults can boost kids’ well-being – and their own – as schools return from break amid a Covid-19 surge How to manage mindless snacking in your pandemic home office 6 creative ways to transform your workouts How our ancestors used to sleep can help the sleep-deprived today

Mediterranean diet named best diet for 2022

Mediterranean diet named best diet for 2022   It's a winning streak that just won't quit. For the fifth year in a row, the Mediterranean diet was first across the finish line in the annual race for best diet, according to ratings announced by U.S. News & World Report.   Coming in a close second, in a tie: the DASH diet, which stands for Dietary Approaches to Stop Hypertension and emphasizes reducing salt intake; and the flexitarian diet, which encourages being a vegetarian most of the time – but is flexible enough to allow a burger once in a while.   All three of these diets reduce or eliminate processed foods, and stress packing your plate with fruits, vegetables, beans, lentils, whole grains, nuts and seeds.   "I think it's important to note that the top three diets – Mediterranean, DASH and flexitarian – all offer variety, flexibility and few, if any, rules," said Gretel Schueller, managing editor of health for U.S. News & World Report, which puts out an annual ranking of diets, in an email.   "All the diets that perform well are safe, sensible and backed by sound science. The diet winners also all provide adequate calories with a focus on vegetables, fruits and whole grains; a modest amount of lean protein, dairy; and an occasional treat," Schueller added.

Former Biden health advisers say the US needs to change its Covid-19 strategy to a face a “new normal

Former health advisers to President Joe Biden say the US strategy for the Covid-19 pandemic needs to be updated to face a "new normal" of living with the virus, rather than aiming to eliminate it.

 

In three pieces published in the medical journal JAMA, six former Biden advisers proposed a new plan and detailed strategies for testing, mitigation, vaccines and treatments.

 

"Without a strategic plan for the 'new normal' with endemic COVID-19, more people in the US will unnecessarily experience morbidity and mortality, health inequities will widen, and trillions will be lost from the US economy," wrote Dr. Ezekiel Emanuel, a former Obama health adviser now with the University of Pennsylvania; Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota; and Dr. Celine Gounder, an infectious disease expert at Bellevue Hospital Center and at Grossman School of Medicine at New York University.

 

All were appointed to Biden's Transition Covid-19 Advisory Board in 2020.

 

For this new strategy, "humility is essential," they wrote. There remain unknowns about the virus and its future, and "predictions are necessary but educated guesses, not mathematical certainty." Leaders will have to communicate specific goals and benchmarks, and national plans will need to be adapted for local use.

 

They push for modernized data infrastructure to provide real-time information, a bolstered public health work force, more and empowered school nurses, and moves to rebuild trust in public health institutions. Substantial resources will be needed to "build and sustain an effective public health infrastructure," they write.

CDC updates Covid-19 prevention guidance for schools

CDC updates Covid-19 prevention guidance for schools   The US Centers for Disease Control and Prevention updated its guidance for Covid-19 prevention in K-12 schools last week, aligning the recommendations with the agency's recently updated Covid-19 quarantine and isolation guidelines for the general public. It also expands its recommendations for screening testing and urges canceling or going virtual with some extracurricular and sports activities in order to preserve in-person learning. The CDC's new recommendations say children who have not been fully vaccinated and are exposed to the coronavirus should quarantine for at least five days after their last close contact with a person who has Covid-19. Adults who are not vaccinated against Covid-19 or who have not received a booster shot are advised to follow this recommendation, too.   Separate from the CDC's guidance, Children's Hospital of Philadelphia and PolicyLab released Covid-19 school guidance aimed at preserving in-person schooling, saying that "outweighs the risks of infection to children and school staff at this stage of the pandemic."   The guidance aligns with the CDC on several points, including emphasizing that people with symptoms stay home, but it also urges discontinuing required weekly testing for people without symptoms and supports "mask to stay"-style policies that allow people exposed to Covid-19 to remain in class. "With limited access to testing and schools overwhelmed with contact tracing and required testing solutions that are no longer feasible or sustainable, the time has come to pivot towards solutions that prioritize normalization of in-school education alongside practical safety measures that can manage the worst of this resurgence," Dr. Jeffrey Gerber, associate director for inpatient research activities for the Center for Pediatric Clinical Effectiveness at Children's Hospital of Philadelphia and co-author of the guidance, wrote in a blog post.   "Failure to pivot quickly risks closure of many under-resourced schools, which have been disproportionately impacted by staffing shortages, and whose communities have had more limited access to testing," Gerber said.   Answers to your some of your questions this week: If you caught Covid-19 over the holidays, what should you do now? What’s safe for kids to do, with Omicron spreading quickly? Is it OK to use throat swabs for home Covid-19 tests? Should you report the results of a positive at-home test? What is “flurona,” and how serious is it?

CMS Reports Record Enrollment in 2022 Affordable Care Act Health Plans

By mid-December, with a month left in the open enrollment period, enrollment for health coverage through Healthcare.gov and state-based marketplaces had already reached a record high. According to the Centers for Medicare & Medicaid Services (CMS), 13.6 million people enrolled in Affordable Care Act (ACA) health insurance coverage for 2022 by mid-December.

According to CMS, the 2022 plan year has the most participating issuers, with 213 issuers offering coverage through HealthCare.gov, an increase of 32 issuers compared to the 2021 plan year. CMS reports that the average consumer now has between six and seven issuers to choose from, up from four to five issuers in 2021.

Open enrollment has been extended by a month this year, lasting until January 15, 2022, for coverage starting on February 1, 2022.

In December, the Kaiser Family Foundation also released a useful issue brief on how the premiums for plans purchased through marketplaces are changing for 2022.

Reminder: Limited Opportunity to Make Certain Medicare Plan Changes Through the End of March

People who began 2022 enrolled in a Medicare Advantage (MA) plan have an additional opportunity to switch MA plans or disenroll from an MA plan and enroll in traditional Medicare with a Part D plan during the first 3 months of the calendar year, ending on March 31^st.  Note that this enrollment opportunity, called the Medicare Advantage Open Enrollment Period (MA-OEP), is not available to individuals who are in traditional Medicare and enrolled in a stand-alone Part D plan. 

In addition, there are certain rights to use a Special Enrollment Period (SEP) to change or get out of a private Medicare plan in certain circumstances. There are a number of SEPs, including when someone receives inaccurate or misleading information from the Medicare Plan Finder, customer service representatives at 1-800-MEDICARE, or an MA or Part D plan (or its agents). For a full list of available SEPs, see, e.g., for MA SEPs: Medicare Managed Care Manual, Chapter 2 (2021 update available here) and Title 42, Code of Federal Regulations §422.62(b); for Part D SEPs see Medicare Prescription Drug Manual, Chapter 3 (2021 update available here) and Title 42, Code of Federal Regulations §423.38.

As discussed in a previous CMA Alert and an October 2021 Special Report on the Medicare annual enrollment period, there is unequal access to different coverage options in Medicare and Medicare Advantage, and there are flaws in several means of comparing such options (including the MA quality star ratings, discussed elsewhere in this weekly CMA Alert).

Study Published in Health Affairs Finds that Medicare Advantage Quality Bonus Program Has Not Improved Quality

Health Affairs recently published a research article titled “The Medicare Advantage Quality Bonus Program Has Not Improved Plan Quality” by Adam A. Markovitz, John Z. Ayanian, Devraj Sukul, and Andrew M. Ryan (December 2021). As noted in the abstract of the report, “[i]n 2012 Medicare introduced the quality bonus program, linking financial bonuses to commercial insurers’ quality performance in Medicare Advantage (MA). Despite large investments in the program, evidence of its effectiveness is limited.”

As noted in an Inside Health Policy article by Bridget Early (Jan. 4, 2022) discussing the report, “[w]hile higher star ratings have been found to correlate with increased beneficiary enrollment, the study found that they did not improve quality of care.”

This report joins the growing evidence demonstrating that the MA quality bonus program is fundamentally flawed. As previously noted by the Center for Medicare Advocacy, including in an October 2021 Special Report on the Medicare annual enrollment period, the Medicare Payment Advisory Commission (MedPAC) has “in recent years ‘discussed the flaws in the 5-star system and the [quality bonus program] and the continuing erosion of the reliability of data on the quality of MA plans’ as noted in their March 2021 report to Congress. As a result, the Commission notes, ‘[t]he current state of quality reporting is such that the Commission’s yearly updates can no longer provide an accurate description of the quality of care in MA.’”  

In addition, as discussed in a previous CMA Alert, a September 2021 Health Affairs report titled “Medicare Advantage Plan Double Bonuses Drive Racial Disparity In Payments, Yield No Quality Or Enrollment Improvements” found that double bonuses for MA plans are not an efficient mechanism to improve the program, and are not equitable in allocation of those dollars, disproportionally benefiting White beneficiaries relative to Black beneficiaries, without improving quality or enrollment.

The Inside Health Policy article analyzing the December 2021 report quotes the Center: “‘The fact 9 out of 10 MA enrollees are in plans that receive 4 or 5 stars, combined with MedPAC’s finding that quality ratings are unreliable, means that the ratings, which are promoted as a tool for consumers to compare plans, is largely unusable for such purpose,” […] “This Health Affairs report highlights that billions of dollars in bonus payments – that could instead be used to expand Medicare benefits to all enrollees – have not improved quality in the MA program.’”

The authors of the report conclude that “[t]he MA quality bonus program poses a substantial and rising expense of $6 billion annually. Given the paucity of evidence for its effectiveness, our study supports calls from stakeholders […] for CMS to substantially revise the quality bonus program or eliminate it altogether.”

We concur.

CMS to Post Nursing Home Staff Turnover and Weekend Staffing Level Information on Care Compare

This month, the Centers for Medicare & Medicaid Services (CMS) will begin posting nursing staff turnover information and weekend staffing levels on the federal website Care Compare.[1]  Specifically, CMS will post:

Staff Turnover: “The percent of nursing staff and number of administrators that stopped working at the nursing home over a 12-month period.”  CMS will post:

• “The percent of [registered nurse] RN staff that left the facility over the last year.
• “The percent of total nurse staff that have left the facility over the last year.
• “The number of administrators that have left the facility over the last year.”

Weekend Staffing: “The level of total nurse and registered nurse RN staffing on weekends provided by each nursing home over a quarter.”

CMS will post the level of weekend RN and total nurse staff (RN, licensed practical nurse (LPN), certified nurse aide (CNA), “reported in terms of the average number of RN and total nurse hours worked per resident per day on weekends.”

Beginning in July 2022, CMS will use the staff turnover and weekend staffing information in its Nursing Home Five Star Quality Rating System.

CMS cites reports by the HHS Inspector General about staffing and Care Compare.  One report found that lower staffing levels on weekends are not reported on the federal website;[2] the other called for posting of information on staff turnover and tenure,[3] as explicitly required by the Affordable Care Act.[4] 

In its memorandum, CMS identifies a number of factors that may suggest why lower turnover rates are assoiated with higher quality of care for residents. For example, staff may be more familiar with residents and more able to identify changes in residents more quickly; staff may be more familiar with facility policies and procedures; and lower administrator turnover may reflect “greater leadership stability, direction, and operations, which may help staff provide care more consistently or effectively to residents.”

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[1] CMS, “Nursing Home Staff Turnover and Weekend Staffing Levels,” QSO-22-08-NH (Jan. 7, 2022), https://www.cms.gov/files/document/qso-22-08-nh.pdf 
[2] HHS Office of Inspector General, “Some Nursing Homes’ Reported Staffing Levels in 2018 Raise Concerns; Consumer Transparency Could Be Increased” (Data Brief), OEI-04-18-00450 (Aug. 20, 2020), https://oig.hhs.gov/oei/reports/OEI-04-18-00450.pdf 
[3] HHS Office of Inspector General, “CMS Use of Data on Nursing Home Staffing: Progress and Opportunities To Do More,” OEI-04-18-00451 (Mar. 2021), https://oig.hhs.gov/oei/reports/OEI-04-18-00451.pdf 
[4] 42 U.S.C. §§1395i-3(i)(1)(A)(i), 1396r(i)(1)(A)(i), Medicare and Medicaid, respectively

CMS Again Revises Visitation Guidance in Nursing Facilities

In March 2020, at the beginning of the coronavirus pandemic, the Centers for Medicare & Medicaid Services (CMS) barred visitors from nursing facilities.  Since then, it has issued multiple revisions to its guidance.  On November 12, 2021, CMS wrote, “Visitation is now allowed for all residents at all times.”[1]  CMS prohibited facilities from limiting “the frequency and length of visits for residents, [and] the number of visitors” or from requiring “advance scheduling of visits.”  Frequently Asked Questions (FAQs) issued on December 23, 2021 contradicted the November guidance and allowed nursing facilities, demonstrating “good faith efforts . . . to facilitate visitation,” to restructure their visitation policies, to ask visitors to stagger their visits, and to limit the number of visitors.[2]   On January 6, 2022, CMS revised the December FAQs again,[3] as discussed below.  The changing guidance on visitation reinforces the need for enactment of the Essential Caregivers Act of 2021, H.R. 3733,[4] to recognize a category of individuals – “essential caregivers” – who may be present in a facility, providing assistance and support, during any public health emergency, despite limitations otherwise imposed on visitors.

In the January 6 revisions to the FAQs, CMS reiterates that visitation can occur during the pandemic, but also stresses that “States may instruct nursing homes to take additional measures to make visitation safer.”  States have begun to impose requirements for visitors.  For example, on January 10, Rhode Island announced new regulations[5] requiring visitors “to either be vaccinated or provide proof of a negative COVID-19 test.”[6]

CMS also now encourages facilities “to consult with state and local health departments when outbreaks occur to determine when modifications to visitation policy would be appropriate.”  Facilities should document these discussions and “actions they took to attempt to control the transmission of COVID-19.”

The January revisions to the FAQs add three entirely new questions and answers, at the end of the FAQs.  (Note: all revisions are in red italics.)  Question 10 confirms that facilities should “continue to permit visitation,” despite the spikes in infections caused by the Omicron variant: 

While CMS is concerned about the rise of COVID-19 cases due to the Omicron variant, we’re also concerned about the effects of isolation and separation of residents from their loved ones. Earlier in the pandemic we issued guidance for certain limits to visitation, but we’ve learned a few key things since then. Isolation and limited visitation can be traumatic for residents, resulting in physical and psychosocial decline. So, we know it can lead to worse outcomes for people in nursing homes. Furthermore, we know visitation can occur in a manner that doesn’t place other residents at increased risk for COVID-19 by adhering to the practices for infection prevention, such as physical distancing, masking, and frequent hand hygiene. There are also a variety of ways that visitation can be structured to reduce the risk of COVID-19 spreading. So, CMS believes it is critical for residents to receive visits from their friends, family, and loved ones in a manner that does not impose on the rights of another resident. Lastly, as indicated above, facilities should consult with their state or local public health officials, and questions about

visitation should be addressed on a case by case basis.

Question 11 reiterates federal regulations, 42 C.F.R. §483.10(f)(2) and (4), as “explicitly” stating that residents “have the right to make choices about significant aspects of their life in the facility and the right to receive visitors as long as it doesn’t infringe on the rights of other residents.”

Question 12 confirms that “visitation can occur regardless of the visitor’s vaccination status.”  It also suggests “extra precautions” that facilities “can and should take,” such as outdoor visits; “creating dedicated visitation space indoors;” permitting visitors in resident rooms when the roommate is not present; encouraging the use of a well-fitting mask, “preferably those with better protection, such as surgical masks or KN95;” offering surgical masks or KN95 masks; “increasing air-flow and ventilation,” and more.

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[1] CMS, “Nursing Home Visitation – COVID-19 (REVISED),” QSO-20-39-NH (revised 11/12/2021), https://www.cms.gov/files/docuent/qso-20-39-nh-revised.pdf, discussed in CMA, “CMS Revises Visitation Rules for Nursing Facilities” (CMA Alert, Nov. 18, 2021), https://medicareadvocacy.org/cms-revises-visitation-rules-for-nursing-facilities/.  See also CMA, “Updated Factsheet/CMS Nursing Home Visitation Guidance” (Dec. 2, 2021), https://medicareadvocacy.org/new-factsheet-cms-nursing-home-visitation-guidance/ 
[2] CMS, “Nursing Home Visitation Frequently Asked Questions (FAQs)” (Dec. 23, 2021), https://www.cms.gov/files/document/nursing-home-visitation-faq-1223.pdf, discussed in CMA, “CMS Revises November Visitation Guidance after Nursing Home Industry Calls on CMS to Allow Facilities to ‘Limit, Restrict, or Prohibit Visitors’” (CMA Alert, Dec. 23, 2021), https://medicareadvocacy.org/cms-revises-november-visitation-guidance-after-nursing-home-industry-calls-on-cms-to-allow-facilities-to-limit-restrict-or-prohibit-visitors/ 
[3] CMS, “Nursing Home Visitation, Frequently Asked Questions (FAQs)” (Jan. 6, 2022), https://www.cms.gov/files/document/nursing-home-visitation-faq-1223.pdf 
[4] https://www.congress.gov/bill/117th-congress/house-bill/3733?s=1&r=81 
[5] 216-RICR-40-10-27.5, link to regulation provided in News Release, note 6, infra 
[6] Rhode Island Governor Dan McKee, “Governor McKee Announces New Visitation Measures to Protect Vulnerable Residents in Nursing Homes, Assisted Living Facilities” (News Release, Jan. 10, 2022), https://governor.ri.gov/press-releases/governor-mckee-announces-new-visitation-measures-protect-vulnerable-residents

Skyrocketing COVID-19 Cases Lead to Hospital Struggles Across the Nation

The United States is facing the biggest surge of COVID-19 cases to date. According to the Centers for Disease Control and Prevention (CDC), on Tuesday, January 11, there were 797,216 new cases of the disease.[1] To put this into context, during the summer of 2020, the peak number of new COVID cases per day was 77,000 – a more than tenfold increase since that time.[2] Cases are also geographically widespread, with 99.13 percent of the counties in the U.S. experiencing “high” levels of community transmission of COVID-19.[3] The CDC measures transmission level by examining the total new cases of COVID-19 infections reported over the past 7 days and the percent of positive COVID tests for the county over the past 7 days.[4] The higher number of new cases and higher percent positivity correspond to higher levels of community transmission.

In Connecticut, for example, every county is rated with a high transmission level. While 79.4 percent of the state’s population of five-year-olds and over are vaccinated, Connecticut’s Department of Public Health is reporting a 24 percent positivity rate.[5] Furthermore, 82 percent of hospitals beds in the state are filled, and over a quarter of them are being used for COVID-19 patients. Connecticut’s utilization statistics are slightly higher than the national average of 79.15 percent of beds being filled, and just over one-fifth being used for those with COVID-19.[6]

The Center for Medicare Advocacy analyzed state-aggregated data for hospital utilization provided by the Department of Health & Human Services (HHS).[7] We highlight the top 25 states with the highest percent of inpatient population with suspected or confirmed COVID-19. Maryland ranked highest, with 42 percent of hospital patients having or suspected to have COVID and inpatient utilization at 87 percent. Connecticut ranks 7^th, with 32 percent of hospital patients having or suspected to have COVID-19.

Exacerbating this strain is the fact that hospitals are facing critical staff shortages. All but five states, along with Puerto Rico, the Virgin Islands, and American Samoa, reported hospitals with critical staff shortages.[8]

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[1] CDC. Trends in Number of COVID-19 Cases and Deaths in the US Reported to CDC, by State/Territory. Centers for Disease Control and Prevention. (Updated January 12, 2022). Available at: https://covid.cdc.gov/covid-data-tracker/#trends_dailycases 
[2] CDC. Trends in Number of COVID-19 Cases and Deaths in the US Reported to CDC, by State/Territory. Centers for Disease Control and Prevention. (Updated January 12, 2022). Available at: https://covid.cdc.gov/covid-data-tracker/#trends_dailycases 
[3] CDC. Covid-19 County Check Tool. Centers for Disease Control and Prevention. (September 30, 2021). Available at: https://www.cdc.gov/coronavirus/2019-ncov/more/aboutcovidcountycheck/index.html 
[4] CDC. Covid-19 County Check Tool. Centers for Disease Control and Prevention. (September 30, 2021). Available at: https://www.cdc.gov/coronavirus/2019-ncov/more/aboutcovidcountycheck/index.html 
[5] CT.gov. Connecticut COVID-19 data tracker. CT.gov. (Updated January 11, 2022).  Available at: https://portal.ct.gov/Coronavirus/COVID-19-Data-Tracker 
[6] HHS. Hospital Utilization. HHS Protect Public Data Hub. (Updated January 12, 2022). Available at: https://protect-public.hhs.gov/pages/hospital-utilization 
[7] U.S. Department of Health & Human Services. Covid-19 reported patient impact and hospital capacity by State. HealthData.gov. (Updated January 12, 2022). Available at: https://healthdata.gov/dataset/COVID-19-Reported-Patient-Impact-and-Hospital-Capa/6xf2-c3ie 
[8] HHS. Hospital Utilization. HHS Protect Public Data Hub. (Updated January 12, 2022). Available at: https://protect-public.hhs.gov/pages/hospital-utilization

Jimmo Update: CMS Reminds Providers and Contractors of Medicare Coverage to Maintain or Slow Decline

Skilled nursing care and skilled therapy services for beneficiaries who need skilled care to maintain function or to prevent or slow decline is covered by Medicare. That is the message of reminders issued by the Centers for Medicare & Medicaid Services (CMS) to Medicare providers as well as to Medicare Administrative Contractors.[1] CMS disseminated the information in its December 2, 2021 MLN Connects Newsletter.[2] Furthermore, CMS directed providers and contractors to visit the Jimmo Settlement Agreement webpage for further details.

The CMS statement follows:

The Center for Medicare Advocacy and Vermont Legal Aid brought the Jimmo v. Sebelius class action lawsuit on behalf of beneficiaries who were being denied Medicare coverage for skilled care on the basis that they were not improving or did not demonstrate potential for improvement. In 2013, the federal district court approved a settlement agreement that confirmed Medicare coverage should be determined by a beneficiary’s need for skilled care, not the individual’s potential for improvement; Medicare covers skilled care to maintain an individual’s condition or slow decline.[3] Essentially, improvement or progress is not necessary as long as skilled care is required. The Jimmo standards apply to home health care, nursing home care, outpatient therapies, and, to a certain extent, for care in Inpatient Rehabilitation Facilities/Hospitals.[4]

Check out a collection of Jimmo resources from the Center for Medicare Advocacy here .

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[1] CMS. MLN Connects® Newsletter (2021-12-02-MLNC). CMS. (December 2, 2021). Available at: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2021-12-02-mlnc#_Toc89267937 
[2] CMS. MLN Connects® Newsletter. CMS. (n.d.). Available at: https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive 
[3] CMA. Jimmo v. Sebelius Factsheet: Medicare Skilled Nursing Facility Coverage Does Not Require Improvement. Center for Medicare Advocacy. (May 20, 2021). Available at: https://medicareadvocacy.org/jimmo-v-sebelius-factsheet-medicare-skilled-nursing-facility-coverage-does-not-require-improvement/ 
[4] CMA. Improvement Standard and Jimmo News. Center for Medicare Advocacy. (May 15, 2020). Available at: https://medicareadvocacy.org/medicare-info/improvement-standard/

CMS Releases Proposed 2023 Rule for Medicare Advantage and Part D Plans

On January 6, 2022, CMS released CY 2023 Medicare Advantage and Part D Proposed Rule (CMS-4192-P) and an accompanying Press Release describing the overall rule, and a separate Press Release focusing on Part D prescription drug costs.  The proposed rule was published in the Federal Register on January 12, 2022, available here (87 Fed Reg 1842, CMS-4192-P). Comments are due March 7, 2022.

On the whole, this proposed rule signals a renewed dedication to providing needed oversight of Medicare Advantage (MA) and Part D plans – a welcome development.  As discussed below, there are a number of provisions that will considerably help consumers, but, in other ways, the proposed rule falls short of providing needed consumer protections.  This CMA Alert provides brief summaries of some of the provisions in the proposed rule.  The Center will be submitting more detailed comments to CMS, and encourages others to do so as well. We will post our comments on our website prior to the deadline.

Provisions of Proposed Rule

The following are short summaries of some, but not all, of the provisions of the proposed rule, with our added comments where relevant:

• Marketing and Communications – CMS proposes to strengthen oversight of marketing and communications re: MA and Part D plans based, in part, on an increase in beneficiary complaints concerned about (and an increase in TV and print ads related to) the marketing practices of third-party marketing organizations (TPMOs) who sell multiple MA and Part D products; in response, CMS proposes to:
• Make plan issuers responsible for the activities of TPMOs in the same way that they are now responsible for the activities of agents, brokers and other “first tier, downstream or related entities.”
• Require a TPMO to use the following standard disclaimer “prominently displayed on the TPMO’s website and marketing materials, including all print materials and television advertising that meet the definition of marketing [as well as] provided verbally, electronically, or in writing, depending on how the TPMO is interacting with the beneficiary.” (p. 1901):
• “We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.”
• CMS also proposes, among other things, to reinstate inclusion of multi-language inserts in top 15 languages used in the U.S. in specified materials re: availability of translation services (when beneficiaries are provided CMS-required materials, such as the Evidence of Coverage, enrollment form, Annual Notice of Change, and Summary of Benefits)
• Comment: we applaud CMS for this long-overdue enhancement of oversight of TPMOs; further, we appreciate that CMS reinstated the requirements concerning multi-language inserts.  We are disappointed, however, that CMS did not roll back other recent revisions to marketing guidelines that, among other things, weaken the distinction between education and marketing events (see, e.g., this CMA Alert discussing the January 2021 final rule)
• MA Network adequacy requirements for new or expanding plans – CMS proposes to require plan sponsor applicants to demonstrate (rather than just attest) that they meet network adequacy requirements for a pending service area at application “and to adopt a time-limited 10-percentage point credit toward meeting the applicable network adequacy standards for the application evaluation.”
• Comment: we support this proposal and agree that it will strengthen CMS’ “oversight of an organization’s ability to provide an adequate network of providers to deliver care to MA enrollees.” (p. 1844).  CMS does not, however, reverse recent policy changes that have generally weakened MA network adequacy requirements (for further discussion, see this CMA Alert discussing a June 2020 final rule)
• Past Performance Methodology to Better Hold Plans Accountable for Violating CMS Rules – CMS proposes to include additional criteria in their methodology to determine if it should permit an organization to enter into or expand an existing contract; specifically, CMS proposes to include Star Ratings, bankruptcy issues, and compliance actions
• Comment: We strongly support this enhanced oversight of plan sponsors, but note that MA plan Star Ratings are, by some accounts, unreliable (see, e.g., discussion in an October 2021 CMA Special Report)
• Greater Transparency re: MA Medical Loss Ratio – CMS proposes to reinstate previous requirements (and add some new ones) concerning greater transparency and reporting rules surrounding the medical loss ratio (MLR, or the “percentage, generally representing the percentage of revenue used for patient care rather than for such other items as administrative expenses or profit.” (p. 1902))
• Comment: we support this effort to enhance oversight and reporting of plans’ profit and spending  
• Special MA Requirements During a Disaster or Emergency – CMS proposes to clarify the period of time during which MA organizations must comply with special requirements to ensure access for enrollees to covered services
• Calculation of Star Ratings for Certain Measures for 2023 Given Impacts of Pandemic – [star ratings flawed]
• Dual-Eligible Special Needs Plans (D-SNPs):CMS proposes several changes to dual eligible special needs plans (D-SNPs), with the stated aim of improving integration of Medicare and Medicaid programs for those enrolled in the plans. The proposed changes include, among others, the following:
• a requirement that any MA organization offering a D-SNP must establish one or more enrollee advisory committees, which includes enrollees in the plans, in each state in order to solicit direct input on enrollee experiences, such as coordination of services, and health equity for underserved populations
• changes to definitions for fully integrated dual eligible special needs plan (FIDE SNP) and highly integrated dual eligible special needs plan (HIDE SNP)
• Establishing D-SNP-specific contracts
• a requirement that all SNPs include one or more standardized questions on the topics of housing stability, food security, and access to transportation as part of their Health Risk Assessments
• Attainment of Maximum Out-of-Pocket (MOOP) limit – CMS proposes to count accrual of all cost-sharing, regardless of whether it is paid by the beneficiary, Medicaid, other secondary insurance or is unpaid towards the MOOP; the current policy “results in increased State payments of Medicare cost-sharing and disadvantages providers serving dually eligible individuals in MA plans” (p. 1843-4)
• Comment: we support this provision, including for the reasons articulated by CMS that include the negative impact of current policy on access to Medicare providers for dually eligible enrollees
• Part D Price Concessions at the Point of Sale – According to a CMS press release, the agency is “proposing a policy that would require Part D plans to apply all price concessions they receive from network pharmacies to the point of sale, so that the beneficiary can also share in the savings. Specifically, CMS is proposing to redefine the negotiated price as the baseline, or lowest possible, payment to a pharmacy, effective January 1, 2023. This policy would reduce beneficiary out-of-pocket costs and improve price transparency and market competition in the Part D program”.

What’s Missing

For many years, the Center for Medicare Advocacy has pushed for legislative and administrative efforts to address the growing inequities between Medicare Advantage (MA) and traditional Medicare that favor MA, and thus the growing privatization of the Medicare program. These inequities include payment/spending, coverage of services, enrollment opportunities, and education/promotion of MA over other coverage options.

As discussed in our September 2021 CMA Special Report concerning the 2022 Medicare & You handbook,  we appreciate the steps that the current administration has taken to reverse the bias in favor of MA plans in recent additions, and we outlined where further work is necessary. As noted above, we also recognize that the proposed 2023 Part C and D rule is a welcome departure from recent de-regulatory efforts and hands-off oversight of the MA program, and strongly support many of the provisions proposed.

Through this propose rule, however, CMS does not make every effort within their authority to address the imbalance between MA and traditional Medicare, nor does it impose the greater level of oversight of private Medicare plans that is required to ensure both adequate consumer protections and safeguarding of program spending.

In December 2020, the Center issued a Transition Memorandum for the incoming administration outlining a range of proposed administrative actions that would improve access to coverage and quality of care for all people who rely on Medicare. This included a number of MA and Part D related proposals.  Many of these suggestions, which were developed in response to our and others’ experience assisting Medicare beneficiaries, remain unaddressed in this proposed rule. In addition to issues of payment equity (which may be addressed in other pending rules), we urge CMS to take further action in these areas (addressed in the Transition Memo), including the following:

• Oversight of MA Coverage and Care Denials, including restricting rampant use of prior authorization (PA) (the proposed rule only contains a request for information concerning PA for hospital transfers to post-acute care settings during a public health emergency – we assert that the problems created by PA are much more widespread and must be addressed more broadly)
• Revising MA flexibilities re: uniformity standards, meaningful differences that make it more difficult for beneficiaries to make informed decisions
• MA network adequacy – as noted above, the proposal re: tighter restrictions for new entrants is welcome, but the overall thresholds were weakened in recent years
• No new rights for beneficiaries re: Special Enrollment Periods (e.g. for mid-year provider terminations by plans)
• No rescission of allowance of MA plans to apply step-therapy to Part B drugs
• No reinstating of reporting requirements re: appeals
• No expansion of services that limit cost-sharing to traditional Medicare levels
• Marketing Communications Guidelines – while the proposed changes noted above are both welcome and necessary, CMS should reverse the significant changes to the guidelines that have weakened protections in recent years, and add new requirements; for example, as noted above, CMS should:
• Rescind rules weakening marketing v. educational events
• Impose requirements re: MA descriptions of supplemental benefits for the chronically-ill (SSBCI)

Conclusion

As a whole, this proposed rule is an important step in the right direction with respect to imposing greater oversight of Medicare Advantage plans.  More is needed, however, in order to adequately protect plan enrollees and the Medicare program.  

Social Media Checklist

https://www.pushbusinessonline.com/SocialMediaChecklist 

11 Example Social Media Posts For Insurance Agents To Try Right Now

https://learn.everquote.com/social-media-posts-for-insurance-agents 

How Much Does a Small Business Website Cost?

Whether you have a new business and you’re building a website from scratch or you’re just due for an update, you’ve landed here because you’re wondering how much it costs to build a small business website. You want answers! And we’ve got them! Well, kind of—there are a lot of factors in determining how much a small business website costs, so while we can’t give you an exact price to expect, we can help you understand what you’ll need to consider.

 

 

How Much Does it Cost to Build a Website for a Small Business? We’re not going to bury the lede here: it can cost under $1K to build a website, or it can cost over $20K. That’s a sizable price range, and the cost you’ll end up paying depends on the size of your site, the features you want or need, the complexity of your needs, and whether you DIY it or hire a professional web design team. Factors That Determine Website Cost Let’s dig into the reasons for the large range of prices for website design. Here are the factors at play: Domain Name If you are lucky, you’ll type your business name into GoDaddy or Namecheap, add “.com” to the end, and purchase your domain name for a few bucks. Easy! Unfortunately, good domain names are getting harder and harder to come by. Sometimes it’s simply because someone else shares your business name. Other times, some squatters snatch up promising domains and lie in wait until someone like you needs one—and then they expect you to pay through the nose for it. If this happens to you, you’ll have a few potential options: You could use a different top-level domain. While your options were once .com, .net, or .org, today there are top-level domains (TLDs) for just about everything: .guitars! .biz! .bike! .ooo! The upside of this is that you can (probably) use your business name in the domain without any alterations, but the downsides are that people are less likely to remember your domain and that search engines favor traditional TLDs over these newer ones. You could tweak how you write your business name. Add a hyphen, put “the” in front of your business name, add your location after your name—there are some small changes you can make that could give you the ability to get that coveted .com even if your first choice is taken. You could pay up. It might be hundreds or even thousands of dollars to get the domain you want, but it can be worth it. Most people will type in yourbusinessname.com when looking for your website. If you have to explain that there’s a hyphen in there, or that it’s theyourname.com, or that it’s actually yourname.inc instead of .com, you’re going to kick yourself for not getting the domain you wanted. Website Hosting A lot of small businesses simply go with the cheapest host they can find—or the one they know from advertising. This works out just fine for many business owners! Still, there are reasons to invest in a better hosting service. Inexpensive hosts tend to have poorer performance and lackluster customer service. (You know what they say: you get what you pay for.) Most of the time, people have no problems with their hosting until they do, and then they want to pull their hair out trying to get the answers they need. Setting aside the different hosting providers, you have a few different hosting options to consider: Shared hosting is the least expensive option because you’ll be sharing a server with other websites. This is the best choice for a small website that doesn’t require a lot of resources. A virtual private server, or VPS, is an upgrade from shared hosting; you’ll still be sharing a server, but you’ll have dedicated space on it. Dedicated hosting, or your very own server. These are typically only needed for very high-traffic websites. Managed hosting, is a hosting option that has the host take care of your hardware, software, updates, and maintenance. We recommend this for small businesses that want to be more hands-off with the backend of their websites and would rather have their host resolve any unexpected problems that come up. We generally recommend managed hosting for businesses that are looking to rely on their website for leads or sales. It’s more reliable than shared hosting, but not as expensive as dedicated hosting. SSL Certificate SSL certificates have gone from being an option to a must. Short for secure sockets layer, SSL certificates protect sensitive data from your users. If you don’t have an SSL certificate, most browsers will issue a warning to users steering them away from your website. (Not having an SSL certificate isn’t good for your SEO either!) Some hosting companies include SSL certificates as part of their hosting packages (most good managed hosting companies include a free SSL certificate), but in other cases, you may need to purchase one. The average cost is around $60 per year. Design Everything we’ve discussed up until this point is small potatoes compared to design. This is what will make or break your budget. It’s also what can make or break your business. Poor design can leave visitors feeling skeptical about your business and can even impact your search rankings. In contrast, a well-designed website can help you soar above the competition, make Google rank you at the top of the SERPs, and convert visitors into customers. For most small businesses, coming in somewhere in the middle of the road is best. You don’t want to go with the lowest cost option, which will probably involve outsourcing all the work overseas and fitting your website into some premade theme with a poorly done logo, but you also don’t need to pay a fortune for the developer who custom codes everything and works with a graphic designer who draws your logo by hand. At a minimum, you’ll need your designer to create a homepage, templates for your product or service pages, and a contact page. From here, you may want to add more pages and options and naturally, your costs will go up, too. Remember that you can always add more later, so there’s no need to get in over your head—take care of the basics first, then add more as your budget allows. Number of Pages Related to the previous point, the number of pages will impact your costs as well. An e-commerce website that needs 200 pages will cost more than a site for an accountant who simply needs 4 different service pages. If, as mentioned above, you have a template built for your product and service pages rather than having them all built out by your developer, you can save yourself a lot of money. Functionality If you’re building your website on WordPress, you can add a lot of functionalities by using simple, free plugins. If you’re not on WordPress, or you want to do something that doesn’t have a free plugin (or that requires several different plugins working together), it will add to the cost of your website—and sometimes significantly. Things like subscriptions, secure online payments, or digital product sales all require more of an investment. Content Management System The most common content management system (CMS) for small businesses is WordPress. This is great news for you because WordPress is free. (Hooray!) But unless you use a free WordPress theme, or template, you’ll need to pay a licensing fee for it. And if you don’t use WordPress, or if you use a custom CMS, you can expect to pay a lot more. DIY vs. Professional Web Design You’ve heard the ads on your favorite podcast—it’s easy to create a small business website with [insert name of trendy website builder]. If your favorite wacky podcast host built his website without any help, surely you can too, right? Ads never exaggerate or lie, right? Here’s where we’re going to surprise you: you can definitely build a nice-looking website without professional help. (Can you believe we’re telling you this? We sell website design services!) And these options can be easy if you have some baseline knowledge about how the internet works. That said, DIY is a smaller financial investment, but it is a bigger time investment—time spent learning, building, and maintaining your website. If you have more money than time, then it makes sense to hire a professional web designer. If you’re short on both, then read on to help you make a decision. Click Here to Read the Full Article on Our Blog