Since 1987 the Center for Medicare Advocacy has partnered with the Connecticut Department of Social Services (DSS) to appeal Medicare denials for care provided to dually eligible patients that was paid for by Medicaid. Pursuant to agreements with DSS, the Center pursues thousands of Medicare appeals annually for dually eligible nursing home and home health patients. This work lessens the individual beneficiary’s Medicaid liability to the State, challenges inappropriate Medicare denials, and helps ensure Medicaid is the “payer of last resort”.
Over the course of the Connecticut dully-eligible project, the Center has recovered almost $400 million from Medicare appeals. This includes cases that were formally appealed, as well as cases that were part of a settlement with the Centers for Medicare & Medicaid services (CMS) to help resolve a backlog of cases waiting for Administrative Law Judge hearings. As part of this project, the Center also provides training and training materials for SNF and home health providers and continuous legal and technical support.
In addition to the importance of this work for CT’s Medicaid agency and population, the project also helps inform the Center’s other work, which includes helping beneficiaries’ access Medicare-covered care, assisting individuals obtain fair appeals, and monitoring federal policies, providers, and Medicare Advantage plans. We are able to use the insights we gain in the dually-eligible project to provide education and advocacy, track patterns of coverage and appeal problems, and communicate with CMS, Medicare contractors, and policy-makers about systemic issues.