Monday, December 31, 2012


3.5 million to 4 million … new members are anticipated by UnitedHealth Group in 2013, driven by expected growth in Medicare Advantage, international and self-insured businesses, according to a recent report by Reuters.

Today's Datapoint

20% to 30% … lower utilization rates were experienced in Medicare Advantage, as opposed to traditional FFS Medicare, between 2003 and 2009 in some of the major cost categories, including emergency departments and ambulatory surgery or procedures, according to an analysis by academic and industry researchers that appeared in the December issue of Health Affairs.

Caregivers Hold Keys to the Car for Seniors

By Charles Bankhead, Staff Writer, MedPage Today
Published: December 28, 2012
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

Action Points
·         The impressions of caregivers overwhelmingly topped all other reasons for ending the driving privileges of older people with dementia.
·         Note that the study also showed that more than a third of patients with clinically diagnosed dementia continued to drive.
The impressions of caregivers overwhelmingly topped all other reasons for ending the driving privileges of older people with dementia, results of a cohort study showed.
Among patients who had stopped driving, 93.8% did so because caregivers considered the risk unacceptable. Car accidents and suspension of driver's license followed far behind.
However, the study, reported online in PLOS One, also showed that more than a third of patients with clinically diagnosed dementia continued to drive.
"In multivariate analysis, none of the currently proposed screening tools for assessment of fitness to drive in elderly subjects ... were significantly associated with driving cessation," Reinhold Schmidt, MD, of the Medical University of Graz in Austria, and co-authors noted in their summation of the results.
Studies have indicated that as many as 46% of patients with mild or moderate dementia continue to drive, and almost every previous study showed an increased risk of driving accidents among patients with dementia, according to the authors' background information. However, little is known about factors that influence driving cessation in patients with dementia.
License-renewal policies vary substantially by country and even by state in the U.S., they continued. Clinicians have little guidance for assessing patients' fitness to drive, most of which is based on consensus opinion.
Several medical organizations have suggested certain assessment tools and tests as potentially useful for evaluating patients' ability to drive, including assessment of cognition, function, and medical status; the clinical dementia rating (CDR); and the Mini-Mental State Examination (MMSE).
"The MMSE is of dubious value because recent data assessing the predictive role of this dementia screening test on simulated driving ability failed to demonstrate a significant association," Schmidt and colleagues noted.
In an effort to bring some clarity to the discussion, they studied 240 patients enrolled in a dementia registry in Austria, evaluating the potential usefulness of parameters traditionally used to assess the driving ability of older people.
The study population comprised patients who met diagnostic (DSM-IV) criteria for dementia, had ever driven a car, were not institutionalized, and had caregivers (current or former) willing to provide information about their condition. The patients had a mean age of 74.2.
The population consisted of 194 patients with Alzheimer's disease, 12 with vascular dementia, 16 with frontotemporal dementia, 11 with Lewy body dementia, and seven with other dementia diagnoses.
The investigators assessed each patient by the MMSE, CDR, Neuropsychiatric Inventory (behavior/symptoms of dementia), Consortium to Establish a Registry for Alzheimer's Disease (CERAD)-Plus test battery, and tests evaluating cognition, function, and medical status. If a patient had stopped driving, information about the reasons was obtained from caregivers and categorized as unacceptable risk, involvement in a car accident, or revocation of driver's license.
Overall, 145 of the 240 patients had stopped driving, including 58.2% of patients with Alzheimer's disease, 66.7% of those with vascular dementia, 56.3% of those with frontotemporal dementia, and 90.9% of those with Lewy body disease.
In 136 of 145 cases (93.8%), the patient stopped driving because of a caregiver's risk assessment, followed by eight cases related to auto accidents, and one patient whose driver's license was revoked.
Patients who had stopped driving were older, more likely to be retired women, more often had at-home assistance, and had more severe dementia and greater disability. They also had lower MMSE and CERAD scores.
By logistic regression analysis, factors significantly associated with driving cessation were female sex (OR 5.1, P=0.002), impaired constructional abilities by CERAD (OR 0.611, P=0.02), and impaired activities of daily living (OR 0.941, P<0.001).
Acknowledging limitations of the study, the authors noted that they included only patients who attended memory clinics and who had caregivers willing to participate. They could not rule out the possibility that factors influencing driving cessation might differ between patients who had caregivers and those who did not.
The study was supported by the Austrian Alzheimer Society and the Austrian National Bank.
The authors had no relevant disclosures.

n Up
Charles Bankhead Staff Writer
Working from Houston, home to one of the world's largest medical complexes, Charles Bankhead has more than 20 years of experience as a medical writer and editor. His career began as a science and medical writer at an academic medical center. He later spent almost a decade as a writer and editor for Medical World News, one of the leading medical trade magazines of its era. His byline has appeared in medical publications that have included Cardio, Cosmetic Surgery Times, Dermatology Times, Diagnostic Imaging, Family Practice, Journal of the National Cancer Institute, Medscape, Oncology News International, Oncology Times, Ophthalmology Times, Patient Care, Renal and Urology News, The Medical Post, Urology Times, and the International Medical News Group newspapers. He has a BA in journalism and MA in mass communications, both from Texas Tech University.

Today's Datapoint

$9,942 … more will be paid for family insurance coverage between 2014 and 2023 as a result of the tax on insurers mandated by the ACA, according to an AHIP study prepared by the consulting firm of Oliver Wyman.

Medicaid Expansion in Flux

Year in Review
By David Pittman, Washington Correspondent, MedPage Today
Published: December 23, 2012

As part of the Year in Review series, MedPage Today reporters are revisiting major news stories and following up with an analysis of the impact of the original report, as well as subsequent news on the topic. Here's what's happened with the states' option to expand Medicaid under the Affordable Care Act since we published the first 2012 piece on the effect of the June Supreme Court ruling.
When the Supreme Court upheld the constitutionality of the Affordable Care Act's (ACA) individual insurance mandate in its landmark June ruling, it also invalidated another provision of the law. The justices said the federal government couldn't withhold federal matching funds for states that didn't expand their Medicaid programs.
The law sought to cover 11 million low-income people by upping the Medicaid eligibility limit to 133% of the federal poverty level (FPL). Since eligibility requirements exclude the first 5% of income when making the calculation, the new threshold for coverage effectively becomes 138% of the FPL, which in 2012 amounted to $15,415 for an individual or $26,344 for a family of three.
But the Supreme Court decision gave states the option to opt out of the expansion with no penalty. In the nearly 6 months since the ruling, some states have made their decisions clear while others remain undecided. Meanwhile, the federal government answered states' questions about their options, and the healthcare provider community geared up for a possible increase in coverage.
To date, 10 states from mostly Republican-leaning regions -- including Texas, Florida, Louisiana, South Carolina, and others -- have said they won't expand their programs. Another 23 states remain undecided, while 17 states -- including California, Illinois, and Massachusetts -- as well as the District of Columbia have already opted for expansion.
"I think at this point the federal government has answered the majority of the pertinent questions," said Caroline Pearson, a director at the Washington consulting firm Avalere Health. "It's just a matter of waiting to see how the states respond."
Under the expansion, the federal government will pay 100% of the cost of those newly eligible enrollees for the first 3 years starting Jan. 1, 2014. Federal support will gradually drop to 90% by 2020, where it will remain.
Medicaid expansion was a key piece of the healthcare law's attempt to provide coverage to those with low incomes. Many low-income people who are not eligible for Medicaid will be able to purchase insurance through the ACA's health insurance exchanges, with the help of federal government subsidies.
Covering those low-income individuals could reduce their mortality and improve health, researchers have found.
The new Medicaid enrollees are different from the traditional Medicaid population and more like those with employer-based coverage, Sandra Hunt, principal in PwC's Health Industries Advisory practice, told MedPage Today.
"What you have is childless adults or families with an income that's too high to be Medicaid-eligible," Hunt said. "You're not going to have maternity services."
However, an analysis by PwC found the enrollees are less likely to be English speakers, and they need help navigating the healthcare market.
Not All Good
The expansion is not entirely a win for states, despite the federal government paying at least 90% of the costs for those newly eligible.
An analysis by the state of Georgia -- which has publicly stated it won't opt for the expansion -- found it would have cost that state $4.5 billion to pay for the extra 650,000 people added to its Medicaid rolls in the first decade alone.
Already facing a $700 million budget shortfall in the next 2 years, Brian Robinson, spokesman for Georgia Gov. Nathan Deal (R), said expanding Medicaid would cause Georgia's budget to "explode."
"We can't pay for what we have now," Robinson told MedPage Today. "[Expansion] would make an unsustainable problem even more unsustainable."
The Department of Health and Human Services (HHS) clarified Dec. 10 that states need to fully cover those up to 133% of the FPL to receive full federal coverage of those newly eligible. While states are free to expand below that magic threshold, they won't receive the full amount of generous federal support, but would instead receive their current Medicaid match for each new enrollee, HHS said in a question-and-answer document.
The move upset Republican governors for HHS' lack of flexibility. They had hoped to be allowed to expand below the 133% and still receive the enhanced amount.
The decision also calls into question what will happen to those making less than 100% of the FPL and not in current Medicaid programs in states that opt against expansion. Only those making more than 100% are allowed in the ACA's health insurance exchanges with federal assistance, leaving those who fall below 100% in a lurch -- and likely uninsured.
However, HHS Secretary Kathleen Sebelius has said the federal government won't pursue fines against low-income people who are unable to obtain health coverage.
Washington's Budget Impasse a Hindrance
Another limiting factor for states in making a decision on the Medicaid expansion is the ongoing federal budget talks. State policymakers are uncertain how or if Medicaid will be impacted as those in Washington look to reduce federal spending.
States see the large price tag the expansion comes at for the federal government and are unsure it will survive the figurative ax in ongoing budget negotiations. Lawmakers could reduce the share the federal government pays from 90% to less than that.
"They're really concerned that, in the long term, there's no certainty about the federal funding commitment, and they don't want to extend the benefit to a population that they ultimately can't pay for," Pearson said.
If all states expand, federal spending on Medicaid will increase by $1 trillion in the first decade.
"Nationwide, the new federal costs will be $100 billion a year," Robinson said. "Where's that coming from? Why should we trust that the feds will keep their end of the bargain?"
Also at risk in the current budget talks are efforts to pay Medicaid primary care providers at Medicare rates in 2013 and 2014; Medicare rates are, on average, 66% higher.
The policy intends to expand the pool of Medicaid providers and increase access. "Whether providers at that point decide they're going to back off of that engagement we don't know," Hunt said.
The point becomes moot if lawmakers shelve the program to save the federal government money.
Pressure from Provider Groups
Hospital groups, medical societies, and patient advocates are expected to push states hard to expand their programs. Most groups have been fairly quiet on the issue up to now.
Providers -- particularly hospital groups -- stand to lose billions if their states decide against expansion. Disproportionate share payments to hospitals -- issued to compensate those hospitals that serve a large share of low-income, uninsured patients -- are getting cut on the assumption that more people have access to insurance.
"The drum beat from providers is going to grow over the next 12 months," Pearson said.
Advocates of expansion have more ammunition as they approach state leaders in their decision to expand. A report released in late November by the Urban Institute found states would save a combined $10 billion in the first 10 years of expansion.
While spending would increase a modest $8 billion or 0.3% if all opted into the expansion, the states would save $18 billion in uncompensated care, the analysis and state-by-state breakdown found.
But the report did find that in about half the states costs would increase by less than 5%, and rise by 5% to 11% in about a third of states. Not only do states have administrative costs, they stand to see increased enrollment among currently eligible people (mostly children) with the federal government paying only a regular Medicaid match for those.
It's difficult to find prognosticators to wager how many states -- and which ones -- will ultimately opt for expansion.
Expect those undecided states to slowly make decisions throughout 2014 as legislatures meet and states iron out their budgets. There is no deadline for a decision.
States can opt in or out at any time, but as Pearson noted, it may be tough for a state to pull out once it starts offering the health coverage to those with low incomes.
"I think it's going to be a very fluid environment between now and 2014 on this issue because the states have a lot of political and economic variables that they're weighing when making this decision," Pearson said. "Come 2014 we probably aren't likely to have 100% participation but I do think that most states will come into the program."

David Pittman
David Pittman is MedPage Today’s Washington Correspondent, following the intersection of policy and healthcare. He covers Congress, FDA, and other health agencies in Washington, as well as major healthcare events. David holds bachelors’ degrees in journalism and chemistry from the University of Georgia and previously worked at the Amarillo Globe-News in Texas, Chemical & Engineering News and most recently FDAnews.

Aging Is Easier with Endurance Exercise

By Todd Neale, Senior Staff Writer, MedPage Today
Published: December 28, 2012
Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania

Action Points
·         This study was designed to determine whether the length of muscle telomeres -- potential markers of mitotic cellular age associated with the physical aging process -- was associated with endurance exercise training and maximal oxygen consumption.
·         The study found that older athletes who engaged in endurance training had longer telomere length compared with older people with medium activity levels, and that maximal oxygen consumption was positively associated with telomere length.
Endurance training such as that done for track competitions may protect against the effects of aging in older individuals, a study of telomeres -- the caps on chromosomes that include repetitive, noncoding DNA sequences -- suggested.
Among individuals ages 66 to 77, endurance athletes had significantly longer telomeres compared with their less active counterparts (P=0.04), a relationship that was not seen among individuals in their 20s, according to Javaid Nauman, PhD, of the Norwegian University of Science and Technology in Trondheim, and colleagues.
The results "suggest that endurance exercise training may regulate the telomeres in old age and results in slowing of [the] aging process by maintaining telomere length," the authors wrote in online in PLOS ONE.
They noted, however, that the findings, which were based on a small sample of just 20 individuals, should be considered preliminary and interpreted cautiously.
Telomeres shorten over time as cells continue to reproduce. Telomere length has been related to both cellular age and the physical aging process. Studies examining the association between telomere length and exercise training and capacity have yielded inconsistent results.
To explore the issue, the researchers recruited 20 men, half of whom were ages 22 to 27 (mean age about 24) and the other half ages 66 to 77 (mean age about 69). In each age group, half of the participants were endurance athletes who were taking part in a cross-country ski race or track competitions. The others were nonathletes who were active, but who had never competed at higher levels in any sports.
All of the participants were free from known cardiovascular disease, obesity, and a history of current or past smoking. None was taking regular medications.
After muscle biopsies, mean telomere length was assessed using the ratio of the telomere repeat copy number to the single-gene copy number (T/S ratio) as measured by quantitative real-time polymerase chain reaction. Maximal oxygen consumption (VO2max) was measured as the participants ran on a treadmill.
In the older age group, the endurance athletes had significantly longer telomeres (T/S ratio 1.12 versus 0.92, P=0.04), a difference that might have clinical significance in terms of longevity, according to the researchers.
"However," they added, "the design of the present study being cross-sectional in nature does not allow commenting about the causality of these results."
In the younger age group, telomere length was not significantly different between the endurance athletes and the nonathletes (T/S ratio 1.47 versus 1.33, P=0.12), possibly because of the small sample size or shorter exposure to physical activity.
Exercise capacity as measured by VO2max was higher for the endurance athletes both in the younger age group (67 versus 53.9 mL/kg/min) and the older age group (45.4 versus 39.4 mL/kg/min).
In the overall cohort, telomere length was positively associated with VO2max (r=0.70, P=0.001). The relationship was stronger among the endurance athletes (r=0.78, P=0.02) and fell short of statistical significance among the nonathletes (r=0.58, P=0.09).
Those findings "provide further support to the hypothesis that long-term exercise, higher aerobic fitness, and longer telomeres all are part of same phenotype expressed in some older adults," the authors wrote.
Besides the small sample size, they acknowledged other study limitations, including the inclusion of males only and the possibility of residual confounding by unknown or unmeasured factors.
The study was supported by grants from the K.G. Jebsen Foundation, the Faculty of Medicine, Norwegian University of Science and Technology.
The authors reported no conflicts of interest.
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Todd Neale
Senior Staff Writer
Todd Neale, MedPage Today Staff Writer, got his start in journalism at Audubon Magazine and made a stop in directory publishing before landing at MedPage Today. He received a B.S. in biology from the University of Massachusetts Amherst and an M.A. in journalism from the Science, Health, and Environmental Reporting program at New York University. He is based at MedPage Today headquarters in Little Falls, N.J.

Medicare Cuts Loom Large as 'Cliff' Nears

By David Pittman, Washington Correspondent, MedPage Today
Published: December 28, 2012

WASHINGTON -- It's looking less and less likely that Congress and the White House will strike a deal to keep the country from falling over the "fiscal cliff" next week, so physicians are preparing for a 28.5% cut in Medicare payments that will take effect on Jan. 1.
That figure includes a 26.5% cut under Medicare's sustainable growth rate (SGR) reimbursement formula and a 2% cut mandated by the Budget Control Act, the piece of legislation that outlined the tax increases and spending cuts that define the fiscal cliff.
"Given the current progress with the legislation, CMS [the Centers for Medicare and Medicaid Services] must take steps to implement the negative update," the agency said in a Dec. 19 notice on its website.
CMS will continue to pay claims for services rendered on or before Dec. 31 at current rates, and made it a point the remind doctors of the agency's payment schedule: clean electronically transmitted claims are paid no sooner than 14 days after submission and payment on clean paper claims takes at least 29 days.
"CMS will notify you on or before January 11, 2013, with more information about the status of Congressional action to avert the negative update and next steps," the notice stated. The message, some believe, is that physicians should take their time submitting claims.
As has been the case in previous years, the minimum two-week delay in claim processing allows CMS to pay for services at the normal rate if Congress retroactively repeals the SGR cuts while a broader budget deal is negotiated.
Any action on the SGR, however, may not have an effect on the 2% cut mandated in the Budget Control Act, which calls for a 9.4% cut in most parts of defense spending and an 8.2% cut for most nondefense agencies.
Medicaid, veterans health programs, and the Vaccines for Children program are all exempt from automatic spending cuts. Some -- but not all -- community health centers are limited to a 2% cut, like Medicare.
The National Institutes of Health is slated to lose a whopping $2.5 billion from its fiscal 2013 budget under the mandatory spending cuts, translating to 700 fewer grants per year.
The CDC stands to lose $464 million. The FDA would see its budget slashed by $318 million and the Substance Abuse and Mental Health Services Administration $275 million.
Although no one expects all the cuts to last in the long-term, neither the White House nor any federal agencies have spelled out what impact the cuts will have in the short term.
Federal health agencies contacted by MedPage Today declined to comment on how they were planning to handle the spending cuts and referred us to the White House's Office of Management and Budget (OMB). OMB didn't return a request for comment.
Although the OMB has outlined how much money each agency should cut, there are no publicly available details on what programs will be affected by the cuts.
"There is no fixed list of activities that the FDA will drop without this money, but significant programmatic and manpower reductions would be impossible to avoid," Steve Grossman, deputy executive director for the Alliance for a Stronger FDA, wrote on the advocacy group's blog. "Mission failure may not be an option for FDA, but it will be very hard to avoid."
There is also an option for President Obama to order the Treasury Department and OMB to delay implementing the sequestration if a deal is imminent.
David Pittman
David Pittman is MedPage Today’s Washington Correspondent, following the intersection of policy and healthcare. He covers Congress, FDA, and other health agencies in Washington, as well as major healthcare events. David holds bachelors’ degrees in journalism and chemistry from the University of Georgia and previously worked at the Amarillo Globe-News in Texas, Chemical & Engineering News and most recently FDAnews.

Putting a Donut Hole Back in Medicare: Proposals to Increase Medigap Costs Put Vulnerable Beneficiaries at Risk

Among proposals aimed at reducing federal spending for Medicare, some are suggesting that Medigap insurance be restructured to increase the cost-sharing burden on beneficiaries and/or add a surcharge for those that choose plans offering "first-dollar" or "near first-dollar" coverage.   These proposals operate under the assumption that charging beneficiaries more in up-front, out-of-pocket costs will deter them from using unnecessary care.  But this assumption ignores the fact that adding costs for Medigap insurance will deter many beneficiaries from seeking medically necessary care. While these proposals might yield limited federal savings in the short term, such savings would lead many to forego needed care until more acute, and costly, treatment is needed.[1]
Two thirds of people with Medigap coverage live on incomes below $40,000. In addition to monthly Part B and Part D premiums, beneficiaries pay Medigap premiums ranging from $178 - $220 per month.[2]  Beneficiaries turn to Medigap policies for greater financial stability and predictability in determining their health spending, especially if they require more health care services to manage chronic conditions.
Proposals that impose co-pays, deductibles, cost-sharing, or eliminate "first-dollar" Medigap coverage would particularly harm people with chronic conditions and people with limited incomes. This is akin to a "sick tax," forcing people who need care to pay more and get less.  For example, under some Medigap restructuring proposals, it is estimated that 37% of beneficiaries in fair or poor health would face higher costs, as would people with more hospitalizations.[3]
The Affordable Care Act closes the Part D Donut Hole, the built-in gap in prescription drug coverage that forces beneficiaries to pay out-of-pocket for all drug costs between an initial coverage limit and higher, catastrophic limit.  Imposing additional up-front Medigap costs for beneficiaries would create a new Donut Hole, just as we close the old one.  It would also encourage people to leave traditional Medicare and join private Medicare Advantage plans, which are more expensive for Medicare and taxpayers.
There are better ways to achieve savings in Medicare without shifting additional costs to beneficiaries; we urge policymakers to explore them.[4]  
For more information, contact policy analyst Xenia Ruiz ( or attorney David Lipschutz ( in our Washington, DC office at (202) 293-5760.

[1] See Medicare Supplement Insurance First Dollar Coverage and Cost Shares Discussion Paper, National Association of Insurance Commissioners (NAIC), Senior Issues Task Force, Medigap PPCA Subgroup, (October 2011), available at:  Also see, e.g., Leadership Council on Aging (LCAO) issue brief “Reforming Medigap Plans by Shifting Costs onto Beneficiaries: A Flawed Approach to Achieving Medicare Savings” (December 2012), available at:
[2] Medigap Reform: Setting the Context, Kaiser Family Foundation, (September 2011), available at
[3]Medigap Reform: Potential Effects of Benefit Restrictions on Medicare Spending and Beneficiary Costs, Kaiser Family Foundation, (July 2007), available at
[4] See, e.g., previous Weekly Alerts, including finding drug savings in Medicare (November 2011) ; Prescription Drug Rebates (July 2011) ; and additional options for achieving Medicare savings (June 2011)

You Can Leave the Nursing Home: Home for the Holidays (Winter 2012 Update)

December is a time for gatherings with family and friends.  Nursing home residents often want to participate in these gatherings but may be under the impression that they will lose Medicare coverage if they leave the facility to do so. This is not true.
The Medicare Benefit Policy Manual recognizes that although most beneficiaries are unable to leave their facility,
an outside pass or short leave of absence for the purpose of attending a special religious service, holiday meal, family occasion, going on a car ride, or for a trial visit home, is not, by itself evidence that the individual no longer needs to be in a SNF for the receipt of required skilled care.[1]
A facility should NOT notify patients that leaving the facility will lead to loss of Medicare coverage. The Medicare Benefit Policy Manual says that such a notice is "not appropriate."[2]
If the resident begins a leave of absence and returns to the facility by midnight, the facility can bill Medicare for the day's stay.[3]
If the resident is gone overnight (i.e., past midnight) and returns to the facility the next day, the day the resident leaves is considered a leave of absence day. Clarifying what seemed to be conflicting provisions in the Manuals, the Centers for Medicare & Medicaid Services confirms that the facility can bill a beneficiary for bed-hold days during a SNF absence.[4]
Chapter 6 of the Medicare Claims Processing Manual provides that the facility cannot bill a beneficiary during a leave of absence, "except as provided in Chapter 1 of the manual at §"[5] That section authorizes skilled nursing facilities (SNFs) to bill a beneficiary for bed-hold during a temporary "SNF Absence" if the SNF informs the resident in advance of the option to make bed-hold payments and of the amount of the charge and if the resident "affirmatively elect[s]" to make bed-hold payments prior to being billed.[6] Charges to hold a bed and maintain the resident’s "person effects in a particular living space . . . are calculated on the basis of a per diem bed-hold payment rate multiplied by however many days the resident is absent, as opposed to assessing the resident a fixed sum at the time of departure from the facility."[7] MS distinguishes bed-hold payments from payments for admission or readmission, which are "not allowed."[8]
Residents can leave their SNFs for short periods, such as a day or two, to enjoy the holidays with their families and friends without losing Medicare coverage.  Their SNFs, nonetheless, are allowed to bill them to hold their beds under Medicare rules.
For more information, contact attorney Toby S. Edelman ( in the Center for Medicare Advocacy's Washington, DC office at (202) 293-5760.

[1] Medicare Benefit Policy Manual, Pub. 100-02, Ch. 8, §30.7.3. (Example, second paragraph) (  Scroll down to page 35.[2] Medicare Benefit Policy Manual, Pub. 100-02, Ch. 8, §30.7.3. (Example, third paragraph) (  Scroll down to page 35.[3] Medicare Benefit Policy Manual, Pub. 100-02, Ch. 3, §20.1.2. (  Scroll down to page 4.[4] Medicare Claims Processing Manual, Pub. 100-04, Ch. 6, § (  Scroll down to page 45.  Note, unlike Medicaid in some states, the Medicare program does not provide a payment for "bed-hold."
[5] Medicare Claims Processing Manual, Pub. 100-04, Ch. 6, § (  Scroll down to page 45.
[6] Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, § (  Scroll down to pages 56-57.  CMS cites, as authority for this payment option, the Nursing Home Reform Law, 42 U.S.C. §1395i-3(c)(1)(B)(iii), and 42 C.F.R. §483.10(b)(5)-(6).
[7] Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, § (, scroll down to page 57.
[8] Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, § (  Scroll down to page 56.