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NOTICE Act Could Do More for Patients


Starting August 6th, the Notice of Observation Treatment and Implication for Care Eligibility Act, or NOTICE Act, will go into effect. This new law requires hospitals to give written and verbal notice to Medicare beneficiaries who have been on observation status for more than 24 hours.

What is observation status? 

In a nutshell, observation status is a term hospitals use to bill Medicare. Observation status is based on a doctor’s medical determination. Doctors place patients on observation status if their condition is not serious enough for inpatient admission status, but still requires monitoring in case health worsens.

The NOTICE Act is a step in the right direction because patients are often unaware of their observation status or its potential consequences. Prior to the NOTICE Act, the only way to know your status was to ask. Part of the reasoning behind the law is that beneficiaries get hit with serious financial consequences including higher than expected hospital bills and that Medicare won’t cover skilled nursing care needed after discharge from the hospital. However, the law could do better to prevent those consequences.

The issue for many patients is that being on observation status also means they are classified as an outpatient, not an inpatient. That means that rules for Medicare Part B (outpatient services) and D (prescription medication coverage) apply to their hospitalization rather than part A (inpatient).

To understand this better, here is a chart comparing estimated costs. Let’s say a patient stays at the hospital for 4 days, and the care provided ends up costing $10,000. Keep in mind that costs can vary greatly depending on the type of care provided during that time.


Oftentimes, Medicare beneficiaries learn about their observation status when arranging for the skilled nursing facility care they need after discharge. These patients make the very valid assumption that because they are wearing hospital gowns, in a hospital bed, eating hospital food, meeting with nurses and taking tests administered by doctors that they are an inpatient. They learn their actual status, and its consequences, too late and have little recourse.

How could the law be improved?

An appeal process is needed.
The NOTICE Act ensures people know about their observation status and the financial consequences of this determination. And that’s it. They don’t know the medical reasons a doctor made the decision and they aren’t given any avenues to appeal this determination. Patients will be informed of their observation status and the possibility of higher medical costs, but have no recourse to fight the decision.

Use plain-language in the notice to ensure comprehension. 
The Medicare Outpatient Observation Notice, or MOON, used to inform patients about their observation status is not written using easy-to-understand language. In its current form, the MOON is written for a 12-grade reading level, a break from the common practice of writing consumer materials for no more than an 8th grade reading level.

Do you agree Medicare patients deserve more?

Tell the federal government. They are asking for your comments right now in response to the proposed rules. You can use this comment template or submit comments on your own. Submit your comments with these simple steps:

  • Go to the website where comments are submitted. Enter the phrase "Medicare Program: Hospital Inpatient Prospective Payment Systems" in the search box. The first hit will be the rule you want to comment on. Click the "Comment Now!" blue box. 
  • Use our comment template to show how people you know have been hurt by observation status and why changes need to be made by including personal information where indicated with yellow highlights. Adding specific examples of real people makes your case more compelling.
  • You can also write your own feedback directly in the comment box.

Go ahead, make your voice heard! The greater number of people that speak up, the more likely changes will be made.

How can you get ready? 

While the law could be improved, it will be implemented August 6th. Prepare for the changes by getting informed:
Going to the hospital is already stressful. Deciphering complex notices, understanding jargon and dealing with unexpected medical bills increases the strain. Armed with knowledge, you can act as a more effective advocate for yourself, your clients or patients, and loved ones so they can focus on their health and recovery.

Bryce Marable
Health Policy Analyst
Health & Disability Advocates

An Observation on the “Observation Status” Law: It Doesn’t Work

The law, called the NOTICE Act, requires hospitals to notify patients hospitalized for more than 24 hours if they are on observation status. The law won’t go into effect until next August, which is great, because it could be better.

The way the law is written right now, it’s almost like asking a patient under anesthesia to sign a consent form. Within the first 24 hours of being admitted to the hospital for a medical event, many people—especially older people—aren’t able to focus on complicated issues of their status and its consequences.

Being on observation status has significant financial consequences. Observation status is considered outpatient service by Medicare. All care, supplies and procedures are covered under Part B, not Part A, and therefore are subject to Part B's higher deductible and co-pays. On top of that, most hospital pharmacies do not contract for Part D drug payments. Patients who have to take their normal medicines while under observation status will have to submit reimbursement requests to Medicare.

If a patient requires skilled nursing care after being discharged, Medicare will only pay for it following three days of inpatient hospitalization. Being on observation status—an outpatient—doesn't count toward the three-day requirement.

One Woman’s $3,900 Surprise

Jean Arnau, an 84-year-old who spent five days in the hospital with a fractured spine is a perfect example of how observation status poses consequences after discharge. She was in a hospital bed, wore a hospital gown and ID bracelet, ate hospital food and received regular nursing care.

When she was discharged and needed to transfer to a skilled nursing facility for rehabilitation, her family learned that she had never been formally admitted as an inpatient to the hospital at all. Instead, she'd been classified as an outpatient under observation and the nursing facility would charge almost $4000.

What To Do Until There’s a Real Fix

It’s great that the NOTICE Act requires patients receive “accurate, real-time information with respect to their classification, the services and benefits available to them, and the respective cost-sharing requirements they are subject to." It’s just that doing it within 24 hours of admission is too often not fair.

Talk to your clients, and their loved ones, before the need arises. The Center for Medicare Advocacy has put together a thorough packet explaining what your clients can do to protect themselves.

You can help by discussing these things with them:

• Urge them to ask about their status each day they are in the hospital. It can change from day to day.
• Tell them to ask the hospital doctor to reconsider your case or refer it to the hospital committee that decides status.
• Tell them to ask their primary care physician to state whether observation status is justified. If not, ask him or her to call the hospital to explain the medical reasons why you should be admitted as an inpatient.
• If they need rehab or other continuing care but learn that Medicare won't cover a a skilled nursing facility, tell them to ask their doctor if they qualify for similar care at home through Medicare's home health care benefit, or for Medicare-covered care in a rehabilitation hospital.
• After the fact, let them know they can appeal a Medicare decision of non-coverage. All the avenues for appeal are spelled out in the Center for Medicare Advocacy’s packet.

Preparing loved-ones before they are hospitalized isn't a fix to law, but it will empower future patients with a plan and knowledge of their rights. After having these conversations, patients will be more enabled to fight for their rights while Washington hopefully gets around to making much needed improvements to the law.

Phillip Lanier
Health Policy Intern
Health & Disability Advocates


Stay the Course with SHIP


State budget cuts are not the only threat to seniors and people with disabilities. Federal reductions may be coming as well.

The US Senate is considering a 42% reduction in funding to the State Health Insurance Assistance Program, which counsels seniors and people with disabilities on their Medicare health plan options. SHIP funding would drop to a mere $20 million, diminishing the numbers and quality of the SHIP workforce.

SHIP is Necessary Now More than Ever

Every day, 10,000 Americans become eligible for a Medicare system that is increasingly more complex. Medicare beneficiaries pay the price for the confusion:
  • 700,000 Medicare are paying the Part B Late Enrollment Penalty because they missed the deadline to sign up,
  • Medicare Part D beneficiaries in Low-Income Subsidy are often unaware of lower priced options,
SHIP counselors are trained to sort through the mess of enrollment rules and multitude of health plan options. The Illinois program includes 600 SHIP counselors located across the State. These counselors provide free, unbiased counseling on Medicare, Medicare supplemental policies, Medicare managed care and long-term care insurance. Seniors can turn to SHIP counselors for assistance with fraud and abuse issues, billing problems and filing appeals. Annually, the Illinois SHIP creates a comparison guide for all Medicare supplemental policies, a vital resource to figure out the alphabet soup of options.

Poorer Trained, Less Helpful

The federal cuts would compromise SHIP's ability to adequately serve everyone who needs help. One and a half million fewer people would receive assistance. Moreover, most of the SHIP counselors are volunteers who donate almost two million hours of help. Cuts could also result in reduced or compromised volunteer training, which increases the risk of erroneous advice and reduces the quality of services beneficiaries receive.

No Substitute

Those in favor of the cuts claim there are less costly alternatives to SHIP. This is untrue. The materials suggested as substitutes, 1-800 Medicare, Medicare.gov and the Medicare Enrollment Handbook, all list SHIP as a resource for people to use with additional questions. A brochure is no substitute for one-on-one, expert advice.


What You Can Do

Tell your Senator to fight cuts to the SHIP program, that your family, friends, even you personally, benefit from the free services that SHIP counselors provide. It's easy:
  • Send our Senators this model letter drafted by the National Council on Aging. Just copy and paste the text into their contact forms:  Sen. Kirk's form  Sen. Durbin's form (remember to sign your name!)
  • Tweet your advocacy with this graphic we created – and tag @SenatorKirk @SenatorDurbin
  • Feel free to personalize with your story, or the story of loved ones. Personal stories make a difference!
Go ahead, spread the word, fight the cuts. And as you do, share your efforts with Illinois Health Matters!


Bryce Marable MSW
Health Policy Analyst
Health & Disability Advocates

Patchwork of Short-Sighted Solutions Leave the State's Most Vulnerable at Risk

The following letter to the editor originally appeared in the Chicago Tribune.

The expectation that Medicaid-funded long-term care providers will continue to provide care to low-income and vulnerable citizens without payment for those services is short-sighted and doesn’t fully consider the strains that it places on them - and the direct care staff who provide the hands-on care to elders and people with disabilities.

For providers that can keep their doors open without Medicaid funding, it may mean cutting costs by laying-off staff, leaving the remaining nursing assistants to work longer shifts at the nursing home. Or, it may result in a consumer getting care from a new home care aide when her regular aide – who knew her schedule and needs – had to quit after losing her day care subsidy – another casualty of Gov. Rauner’s and the legislature’s inability to act and pass a budget.

For those providers that cannot keep their doors open without Medicaid payment, where are the people who relied on them for housing, for a meal, for a bath, or transportation to a medical appointment supposed to turn for care?  In many instances the home care aide is the professional who checks in to make sure that her client is well, taking her medication, and isn’t at risk for injury.  And for those receiving care in a nursing home, there is often not another option for them to receive 24-hour care.

These are realities that lawmakers are not taking into consideration as the budget impasse lingers on without a solution in sight. While ensuring that Medicaid providers in Cook County who serve children continue getting paid was a great solution, none seems to be in sight for the thousands statewide who rely on Medicaid services for care in nursing homes or to live safely and with dignity in their communities.

A patchwork of short-sighted solutions will only leave the state’s most vulnerable at risk.  It is time to pass a budget with sufficient revenue to fund the services that seniors and people with disabilities rely on and to stabilize the long-term care employers and workers who provide the services.

Tameshia Bridges Mansfield
Midwest Director
Paraprofessional Healthcare Institute

What Really Happens After Enrolling in Medicaid Managed Care?

Health & Disability Advocates (HDA) is monitoring the rollout of the Medicare-Medicaid Alignment Initiative (MMAI) and has heard from frustrated case managers working with consumers who are confused about the enrollment process and their rights. In response, HDA developed an enrollment timeline that explains what new enrollees can expect from Managed Care Organizations (MCOs) and plan representatives upon enrollment. To produce the timeline, HDA researched the MMAI demonstration contract developed by the State of Illinois and approved by the Center for Medicare and Medicaid Services (CMS)  HDA also solicited input from health plans on whether their on-the-ground practices were accurately reflected in the timeline.

The finished product outlines important points for case managers and their clients to consider.

One Day Changes Everything

Consumers who are enrolled in a managed care plan after the 12th day of the month will not see their coverage start until the month after next. This is relevant for consumers choosing a specific managed care plan in order to see a particular provider or specialist in that plan’s network. Submitting paperwork after the cut-off date means consumers would have to wait longer than expected for necessary treatment. Helping consumers submit required documents in a timely manner can guarantee they are connected to the medical treatment they need, which promotes continuity of care.

Stratification Sets Up Future Contact Standards

Once enrolled in a plan, all enrollees can expect to complete a Health Risk Screening within 60 days. The screen collects information on the enrollee’s physical and mental health conditions and identifies their current medical providers. This is what IlliniCare’s Health Screen looks like. Health plans use the screen to establish intensity of services and frequency of contact with Care Coordinators by stratifying the enrollee as low, moderate or high risk.

Enrollees stratified as low risk will receive annual follow-ups from their Care Coordinators while those stratified as moderate or high risk will have quarterly follow-ups. Moderate and high risk enrollees will also complete a Health Risk Assessment and create an Individualized Care Plan within 90 days. These enrollees will help form their own Interdisciplinary Care Team of healthcare providers that meets quarterly to review the Individualized Care Plan.

The Care Coordinators’ Role

Care Coordinators focus on enrollees’ healthcare needs by connecting them to necessary tests, doctors and treatment. They also facilitate information sharing among providers by leading the Interdisciplinary Care Team. Addressing enrollees’ medical needs is their priority. Care Coordinators direct less attention to linking enrollees to social supports, like housing and public benefits.

It’s also important for case managers to know that Care Coordinators must manage a substantial caseload of up to 600 enrollees. Caseloads include a blend of low, moderate and high risk enrollees, with each risk level weighted differently.

Understanding what a care coordinator can—and cannot—be expected to do is advantageous to case managers. When roles are clearly recognized, case managers know how care coordinators can be used as a resource. And in what instances an alternative referral would be more appropriate. This establishes a stronger professional relationship between case managers and care coordinators, which ultimately benefits the enrollee.

Case managers and Care Coordinators are on the front lines of healthcare reform and fostering solid working relationships between these two players will be a critical component of the success or failure of these efforts. Knowing what case managers and their clients can expect from managed care plans can lay the foundation for a strong relationship that supports the health of individuals while also furthering the goals of healthcare reform.

Bryce Marable MSW
Health Policy Analyst
Health & Disability Advocates


Redoing Redes: Strengthening Communication Procedures in the Illinois Medicaid Redetermination Project

The Illinois Medicaid Redetermination Project (IMRP) is erroneously suspending vital medical care for people who remain eligible. Since the rollout of the IMRP in early 2013, the program has been plagued by inadequate communication from the state that leaves consumers confused and ultimately without healthcare. Consumers report that they are not receiving the required notices by mail and when they call with questions, frontline state staff cannot provide answers. Because of the state’s ineffective communication protocols and inadequate employee training, rightful Medicaid beneficiaries are in the precarious situation of being unable to fill their prescriptions, go to the doctor or receive treatment. The purpose of the IMRP is to save state dollars by trimming the Medicaid program of those who are no longer eligible, not cut people who still deserve services.

Letters Lost in the Mail

Medicaid beneficiaries are cut simply because they never received their redetermination notices in the mail. For example, Health & Disability Advocates worked with a mother whose child had been dropped from Medicaid because IMRP sent the notice to a non-existent address. The fact that IRMP sent the letter to an incorrect address on the same street where the family lived suggests that it was a clerical error. In this situation, a young adult dealing with serious mental illness could not access medication and treatment, because the state, not the individual made an error. Sudden lapses in care can pose serious consequences for people who rely on these supports for their physical and mental health.

This is not an isolated instance. A survey of case managers working with older adults and people with disabilities found that the IMRP fails to adequately notify people of their redetermination responsibilities and inform them when they are bounced from the program. Many get the bad news when they attempt to fill prescription or go to the doctor and are told that they are no longer covered. People deserve clear communication from the state telling them they are no longer covered and the steps to get reinstated.

Confused and Not Covered

Even in cases where Medicaid recipients do receive notices, many consumers find the letters are hard to understand and filled with jargon. Given that the intended audience has never before been required to submit to annual redeterminations and may also have lower literacy levels, the letters must be crystal clear. Reports from case managers suggest the letters are confusing.  One case manager surveyed noted “clients do not understand what documents they need to submit with the form and whether they need to submit anything.” With the potential for people to lose their health coverage, the consequences of this confusion are severe.

IMRP’s own data reveal their communication shortcomings. According to May’s Medicaid redetermination numbers, 81% of cancellations are due to a lack of response. Being cancelled doesn’t mean a person is ineligible. In fact, a substantial portion of these clients should still be receiving services.  Of those dropped, 1/3 were reinstated within three months.  In FY 2015 alone, this translates into 238,025 people being incorrectly cut from Medicaid, and this number could be even higher. People who are less frequent healthcare users may learn of their cancellation when they attempt to schedule a doctor’s appointment. With people who deserve Medicaid cut from the program, the IMRP is not achieving its main objective of reducing state expenditures by eliminating those who no longer qualify. Cutting eligible people will actually result in higher costs. Without access to primary medical treatment, people will resort to more costly emergency room care for conditions that could have been managed or even prevented.

Matters get worse when consumers call state workers for clarification, because frontline staff members are often not fully informed themselves. In the above-mentioned case of the mother fighting for her son’s coverage to be reinstated, her interaction with the IMRP hotline was unhelpful and hurtful. The representative said there was nothing more she could do and blamed the family. Stateline workers should be fully trained to provide answers; anything less only increases confusion and frustration.

The Path Forward

The state must develop plain-language notices that explain redeterminations and their importance while outlining the specific steps to keeping coverage. This would not be a new undertaking. State officials have previously brainstormed ways to create simple, more consumer friendly forms. Unfortunately, the furor around budget deficits and service cut threats has drowned out the push for clear communication standards. Even worse, continuing to deemphasize this issue will leave many rightful Medicaid recipients suddenly without coverage. Communication protocols and state staff should support individuals in maintaining their vital connection to healthcare, not create hurdles that effectively jeopardize emotional and physical health. State officials must restart the discussions on clear notices and broaden the conversation to include improved training for frontline staff. These reforms will go a long way towards supporting the IMRP’s original objective of eliminating wasteful spending while also keeping those who still deserve coverage connected to care.


Bryce Marable MSW
Health Policy Analyst

Rauner's Budget is Bad Medicine for State's Health Services

The following post originally appeared on Crain's Chicago Business.

The much-anticipated “turnaround budget” from Illinois Gov. Bruce Rauner feels more like a “look back,” parading out failed ideas from past years. Rauner says this budget "preserves services to the state's most vulnerable residents”—but a quick review suggests this is far from true. Instead, we see a budget that:



• Further decimates a fragile community mental health system
• Reduces access to lifesaving drugs for people living with HIV and prevention services for those at risk of HIV
• De-funds critical substance-abuse treatments
• Drastically reduces cost-effective breast and cervical cancer screening services
• Makes it harder, and in some cases impossible, for people with disabilities and seniors to get support to live at home
• Reduces funding for evidence-based tobacco prevention and cessation services
• Eliminates Medicaid benefits for preventive health services, including adult dental care
• Eliminates health insurance for workers with disabilities, coverage unavailable in the private marketplace
• Slashes funding for hospitals serving Medicaid populations
• Eliminates funding for care coordination, originally designed to contain costs
• Secures Illinois' position near the bottom of states for per-enrollee Medicaid funding

It's ironic the governor calls these cuts “tough medicine,” when the proposed budget would deny any medicine and critical health care services to so many. We've been down this road before, and here's what we learned:

• Cuts of $113 million to mental health and addiction treatment services in fiscal years 2009-11 increased state costs by more than $18 million due to increased emergency room visits, hospitalizations and nursing home placements.
• Elimination of Medicaid coverage for adult dental services in 2012 caused spikes in emergency department visits for dental problems. In-patient ER treatment for dental problems averaged $6,498, nearly 10 times the cost of preventive care delivered in a dentist's office.
• Disinvesting in HIV prevention will lead to new infections, for which the Centers for Disease Control estimates lifetime treatment costs of $379,668 per case.
• For every dollar Illinois spends on providing tobacco cessation treatments, it has on average saved $1.29. Cutting funding for smoking cessation services will increase costs by up to $32.3 million annually in health care expenditures and workplace productivity losses.

As proposed, the Rauner budget is not only bad for our health, but it's bad for businesses, too, likely resulting in decreased productivity, loss of jobs and economic activity, and greater health care costs for employers. Some examples:

• The proposed child care “intake freeze” and increase in parent co-pays will lead to increased absenteeism as employees will take time off to care for children. Such absenteeism already is costing American businesses nearly $3 billion annually.
• Planned cuts to Illinois hospitals are expected to result not only in the loss of more than 12,500 jobs but $1.7 billion in economic activity.
• Cuts in funding for health care services, such as cancer screening, most certainly will increase the health care costs of Illinois businesses. One study of major employers found that patients with cancer cost five times as much to insure as patients without cancer ($16,000 versus $3,000 annually).

We urge the governor to listen to the critics of this budget and learn from Illinois' past experiences. We stand prepared to support him on this learning curve.

Barbara A. Otto
CEO
Health & Disability Advocates

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