CHA Blog

Medicare’s General Enrollment Period (GEP) for Parts A and B is from January 1st – March 31. This is a particularly important time for Californian’s with low-incomes who are eligible and not yet enrolled in Medicare Part A. During this time, these individuals can apply for Medicare Parts A and/or B and the Qualified Medicare Beneficiary (QMB) program. QMB pays one’s Medicare Part A premium (if they do not qualify for premium-free Part A – which is $443 per month in 2009), Part B premium ($96.40 per month in 2009), and one’s Medicare deductibles and coinsurance. In addition, qualifying for and applying for QMB will automatically trigger a beneficiary’s entitlement to the full Part D Low-Income Subsidy (LIS). 

California (along with Alabama, Arizona, Colorado, Illinois, Kansas, Kentucky,  Missouri, Nebraska, New Jersey, New Mexico, Oregon, South Carolina, Utah and Virginia) does not have a Medicare Part A Buy-In Agreement that allows individuals to enroll in Medicare Part A at any time during the year in order to become eligible for Medicare cost-sharing benefits under QMB. Therefore, beneficiaries who don’t currently have Medicare Part A, must enroll in Part A before March 31, 2009 in order to be entitled to QMB benefits in 2009.

For those applying for Medicare Part A and QMB who aren’t eligible for premium-free Part A, and, cannot afford the Part A premium if they don’t qualify for QMB, a ‘conditional application’ process is available – see our website section,  How to Apply.  This means that these beneficiaries will only be enrolled in Medicare Part A if they are also confirmed eligible  for QMB and the state then pays their Part A premiums.  

People who already have both Medicare Parts A and B can apply for QMB and other Medicare Savings Programs (MSPs) at any time of the year. Visit or contact your local Department of Health Care Services (DHCS) to apply for these  Medicare Savings Programs and/or for Medi-Cal.

The Centers for Medicare & Medicaid Services (CMS) now has quality ratings for each of the nation’s 15,800 nursing homes that participate in Medicare or Medicaid.  Facilities are assigned star ratings from a low of 1 star to a high of 5 stars based on health inspection surveys, staffing information, and quality of care measures. The ratings are publicly available on the agency’s Nursing Home Compare website at medicare.gov.

You can search for nursing homes by state, county, or city, or by a specific nursing home’s name. For example, in searching for nursing homes in Oakland, California, 20 results come up with the easy-to-view star ratings on each nursing home. It also lists whether the nursing home participates in Medicare and/or Medicaid, how many beds the facility has, and its type of ownership (i.e. whether it is for profit or non profit).

Of the 20 nursing homes that came up in Oakland’s search – 12 of 20 (or 60%) had an overall rating of 4-5 stars, 25% had a rating of only 1-2 stars. 

Such a quality rating system provides families with a relatively easy-to-navigate, straightforward assessment of nursing home quality. The website has suggested questions for beneficiaries and their family members to ask nursing homes, and also has additional information on paying for nursing home care and alternatives to nursing homes. 

Based on consultations with academic experts, patient advocacy and nursing home provider groups, CMS developed the rating system based on each nursing home’s performance in 3 critical areas:

• Health inspection surveys   Each year state and federal surveyors conduct about 15,800 on-site, comprehensive assessments of each nursing home’s health care services and compliance with federal/state rules.   These surveys are designed to help protect the health and safety of residents, including resident’s rights and general quality of life. Surveyors also conduct about 50,000 complaint investigations each year.  Information from the most recent three years of survey findings were used to develop the ratings. 
• Quality measures The quality rating system uses 10 key quality measures out of the 19 that can be found on the Nursing Home Compare website.  Areas examined include the percent of at-risk residents who have pressure ulcers (bed sores) after their first 90 days in the nursing home, the number of residents whose mobility worsened after admission, and whether residents received the proper medical care.
• Staffing information There is strong evidence that low staffing levels can comprise the level of patient care in a nursing home and is considered an important indicator of quality.  This measure reports the number of hours of nursing and other staff care per patient per day.  This measure is adjusted to account for the level of illness and services required by each facility’s residents.

A 5 star designation means the facility ranks “much above average,” 4 star indicates “above average,” 3 means “about average,” 2 is a “below average” ranking with a 1 indicating that a facility ranks “much below average.”  Rankings are dynamic and will be updated monthly. 

In this first round of quality ratings about 12% of the nation’s nursing homes received a full 5 star rating while 22% scored at the low end with one star.  The remaining 66% of facilities were distributed fairly evenly among the 2, 3 and 4 star rankings.

CMS also publishes a list of the nation’s nursing homes with consistently poor performance records.  Nursing homes selected as such “Special Focus Facilities (SFF)” are provided with increased oversight, including onsite inspections that occur twice as often as better performing homes.  Homes with the SFF designation are clearly marked on the Compare website.

CMS recently published an updated version of its Guide to Choosing a Nursing Home which can help families through the process. You can also find up-to-date information about hospitals at Hospital Compare and dialysis clinics at Dialysis Facility Compare, as well as information about Medicare health and prescription drug plans.

You can also see our website for more information on options long-term care, including some information on nursing homes.

We recently published an issue brief exploring how the new marketing rules for the sale of Medicare Part C and D plans have failed to cure the problems in Medicare’s marketplace. 

Even though, Congress and the Centers for Medicare and Medicaid Services (CMS) have made progress in their recognition of and efforts to address marketing misconduct in the Medicare marketplace, many problems persist. This year Congress passed the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) and CMS has issued implementing regulations and clarifying guidance. Many of the statutory and regulatory changes do improve beneficiary protections, but they also have some significant loopholes and/or exceptions, and it is yet unclear how some of the rules will be implemented. Some of these new rules are codifications of existing rules (e.g. a prohibition on unsolicited door-to-door marketing) that, in the view of those assisting Medicare beneficiaries, have been widely flaunted. Although the new rules will help, this issue brief points out how and why marketing misconduct continues. It discusses some ongoing systemic barriers to adequate oversight of the Medicare marketplace, such as the federal preemption that still plagues the regulation of Medicare Advantage and Part D plans by hindering or even preventing action at the state level, and the sporadic oversight and enforcement actions at the federal level.

This brief also reviews some of the changes in marketing rules implemented in 2008 by identifying strengths, weaknesses, and room for improvement. The brief is organized as follows:

• Part I provides a short overview of regulation changes to the Medicare marketplace in the last couple of years;
• Part II explores unresolved systemic issues that prevent adequate oversight of marketing in the Medicare marketplace;
• Part III analyzes selected new marketing rules, including their shortcomings;
• Part IV provides recommendations to better protect consumers from marketing abuses;
• Appendix 1: is an update on Medicare Advantage “Gap” Plans (following-up on an issue brief on the subject drafted by California Health Advocates in November 2007), along with a couple of examples of ongoing marketing of these products to agents; and
• Appendices 2 and 3 are examples of marketing documents referenced in the text.

View the full issue brief (pdf).

Also, learn more about Medicare Advantage plans and Medicare Part D plans.

CHA recently submitted comments drafted jointly with various advocacy organizations on the Center for Medicare and Medicaid Services’ (CMS) proposed rules. The comments reveal how proposed compensation rules actually encourage unsuitable Medicare Advantage enrollments. This is because, under the current rules, commissions are nearly double for enrolling beneficiaries new to Medicare Advantage versus commissions for people staying in their current plans or switching to a similar MA plan. The rules encourage agents to focus enrollment efforts on people new to Medicare, or those in Original fee-for-service Medicare who have a Medicare supplement plan (Medigap), Medi-Cal, or employer or retirement coverage. This poses a problem because it is precisely these beneficiaries—those who are accustomed to the wide provider access, protection against catastrophic expenses and predictable monthly expenses of a Medigap supplemental plan, who may have all Medicare cost-sharing and additional benefits paid by Medicaid, or who stand to lose supplemental coverage from a former employer —for whom a Medicare Advantage plan is often unsuitable. 

The comments include several recommended changes to these rules and agent compensation structures.

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