Comments 45 and 46

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Medicare Advocacy Project
Fmreerinn your rncd*!~reriyhts
Grcatcr Boeton Legal Servicee
197 Frirr~dSlrrel,

Rt.r\lc~t~,Mb.

04114

(617) 371-1234, or toll-trcc (800) 328 3206
FAX 1617)
. . 371-1222

www.~bls.org

May ?, 3007

OMB D z ~ kOfficer: 0VB Human Resources and Housing Branch
Attention Camlyn 1n\ rrr
Nea Executive Office Building
Room 10235
Wsh~ngton,DC 20503
kax numbcr: 1UL-j33-69 14

Re:

Important Ivlessnge from Medrcnre, CMS-R-193(OMBY: 095 0693:
n ~ ~ ; ~ Nllrit
t I ~ tcl u( n i k r ItalB CMS-1OWli (OMR# C19~8-N1.w)
72 Fed.Rep, 17169 (April 6.2007'1

'l'hc Mcdicarc Advocacy I'mjcct, C'rrcntcr Ro.qton legal Scrvicca, works to instirc, rhar
b~fnssachusr~u
Medicart: brnrliciaries receive the Medicare and Medicare-related coverage and
services to whlch they are entitled. Our clients include indlvrdual and groups ot elders and
yascn~~s
~ b i r l ldiraL,;litier, ~skecially.
tliilrst witli l a w i~it~llles.
Ott Lel~alluf uul c,licrli,, we wuuld
like to submit [he following comments regarding the Centcrs for Modtcnrc & Mcdicaid Scrvlccs'
(CMS) draft nvtircs for Vr,rlirarr. ;md Mrdic~rcXdvnntagc Ilospital i~~paticnts:Itrapur~urri
~Vlcssagefrom Afcdicctri (IM)
and Dcruilcd A'oricc of Discharge.
'

'

Overall, the dr3fc norices are clearer and more undersr.mdsble than previous versions. In
partlc\!lar. the dcscnplion ot discharge rights in the (IMj is n~t-~t-c
prt-itiicnenr, cnncise. and 1isef111
lo patients. Addirionally. rhe information about patienr liablllry pending appeals is clearer and
easier to understand.
We Gugzest the followrng revls~on:;to the notlces and adQhons to ~nstructtonsIn ordw ro hclp
pnticn ts Ixncfit wkcn thcy rcccivc a copy of rhcir sig~icdIM PI ~ U u
I dis~lialye,LUtilakc lltr
notrcen even more reahble and user-friendly, and to insure timely delivery of this notice.

Help Patients Benefit From the IhiI Upon Discharge.
We xre concerned that upon receiving 1 copy of thejr signed LM prior ro dischat~e follow
up notlcc '), many patlcnrs w ~ l tall
l to rcad or use ~tbecause they w ~ l not
l rcallrc that rt rclatc.5 to

r.1W-14-20Q7 16:05

OMB/O IRA

202 395 5167

HcaderNarne

-

May 1. 2007
Pq(c 2
thclr impcndi~iecl~rchalpe.To help patlents knt,fit fr-o~r>
d ~ follow
r
up noticc. wc suggsr rlrr
folll2wjog:

C h a n ~ ethc titlc nf r h t IM t o irlclude the word. "discharge" ( i I: "cln Imporranr Mcssagc
I rnw ISfedi~u~e
uboru Your Inpurrear unti ni~r.horgeRiphas "1;
= 111the first .xclilsn listili~I~uspiullnpstienf rights, add a bullet .alerting persons rhnt they
wrll rcLelvt. ;Icopy of lhelr slgncd noricc 111iurto discharge: and
I(quin l i ~ ~ ~ ~and
; f ,Mzdicdre
~ls
Advantogc plans to deliver the follow up noticc md
c.q)lnin its relevance whcn parlrnts ar r LVIJof rhar dischmgc.
In the & r ~ - h 23, 2007. Revrsrotu trro tit. hnpor rtrrrl Messace from ,4Iedzcnre. CMS i ,iJica~rsir
added the bullct tclltng pc.rsolrs iu call 1-800 Medicarc lr'thcy 1i;lvc insufficient time to consider
their rrglit~ !u address concerns "that bcncficiarics may LC given [he noticc on rhc.ir way uui of
the hospir~l." 'We qucry. hnwrvci, whclhw this infoxmallon ivlll achlally lldp patienu. First.
CMS has not incli~alccl~h.it 1-800 penonncl havc the a~~lllurity
UIexrend the dendlinc for ptlcnu
14.1 file a QIO appeal. Second. cvcn if1-800 pc~svnnelhave the nuthonty to il~te~\cne,
ir i6 not
always po.saihlc to iracli a Live person on a timcly basis. Wr. ~lrcrrforesuggest that thl; bul1r.r hr
ikletcd.

Make tlra Notices hlorc User-friendly arrtl Readable
A? WP. rnlrj~t~o~rrcl
above. the noticcs art ~encrallyclcd and undentnndtlhlc. 'I'o make !I~cmmore
vvncic,e and use-fr~cndly.we rer:ulomend the following:

.

In the Ikl hnld the deadline for requesting QlO rcvicw lo c ~ l the
l readex's attention to
rhii k.~i~ical
infomation;
An rhc 1V;riclcte tlrc bullet advising paticnrs lo conuc,.! 1-600 bfcdicruc i f they do nor
01ir1kthey have suffic~cnrtinic ri, appeal, for [he reasons mmt~nnr.dabov*;
R c q ~ ~ itl~at
r r irrrvrrnatioo written into thc I)erailrrlNorice of Discharge bc legi hlc.

Ensure 'I'imclynelivcry of tho "Follow up Notice'' so PaGenb who want to will have tile
Opportunity to Excrcisc their Appeal Righb
Accn~cli~~g
lo the regulations. hap1t81.q and plans rrtust deliver the follow up noticc rlli Tar in
nclb~nceof discharge as possible, but no1 more thnn 2 calcnchr day; Lcfure.discharge."11 C.t'.H.
$ 9 405.1205 ( t ) ( I ) ; 422.620 (ciil). Becousc rhcrr. i s no dcidline for delivering thi* noticr, Oul
crjncern is that many puicnts cndd ~ . r c . c i ~it~too
c late, n h thcy havc ins^ ally meaningful
opportuntry to txclciar heir appeal righls. Boticcs will LC. :.useless to patients i t thcy art.
clolivmd as [hey are pacli~ngto Irnvr cu beir~gwheeled our thc door.

To pio1l1vle the rimely dclivcry of thc f~-~llt:~w-up
noticc, we suggest the following.

Require rhar thc pntlcnt's aieltaiurc, with date and time ot dclivt..~)~
bc obidncd on rhe
t'ollo~+~-u\~
~rcllirc.and thar a copy be ltept in fhr. paticnr's ~ccord.The jnformot~oncoulrl

P .03/07

be recordsf! in the "Additional inform at in^^" section. This will allow CMS ul rrionitor
whcc~[he notices NC actually dilivcred. ulill di~coumgchoosyitals from delivenng not~ics
loo late. and hc.lp assutc that nobce i3 wtlully delivered to the patlcnr.) Rwl~.nringthe
~rccu-di i warranted givcn [ts jrnporlxr~cein ensuring thc parimts aclually receive rhc
norice in timc to ccl~rsidrrtheir appeal nghts. This assurunce far outwughs any argument
a ho~pitalJ I I ~ ~ raSC
~ I L sUg,ocatln&that tlris ir LOO burdensome a re~lturernenr.

CMS should devisa (1 stond~rilto nrersure whether notlccs are ~.lelivered''s
farm
advance of drsch;~rge;o possible." 42 C.14.K.$6 405.1205 kjil):422.621)(c.)(l). Such a
starida~clrhould require that rhc disrhiugr rlotice ideally hc dtlivt~rd~opatienu no l a m
than rhe day prior to discllarge or, if specific, idcnrificd information 1s not ava~lablcuntil
thc ti;iy of dschzrge, at 1cut ~ I V C1io111.s
prior to dschargc. The stn~lclardshould also
speclficdly prohihir hospjrals from, adopdng a blankel policy of delivcnng tlic ~.s?llceson
thc day of d i ~ ~ l ~ o r g ~ .

Thank

)IOU

for thc opronulri[v lo submit thcsc cornnwlrts on behalf of ourclicn~u
Very kuly yours,

Dianc F I'aulsnn
Semior Auvrney

C ~ ~ T FOR
E R ME~IC%?E
ADVOCACY,INC.
r l n l VERMONT AVENUE, N.W.,

JUITJC lUUl
\VASWINGPOrJ, nC.Z M 0 G
(202) 21G0028
FAX (2M)Xl6-0119
www.madlf are.e~oiv8u.u-yr.
g

rrromuu
Julith A. 6rc1n.

Bra0 S Vlrhani'
P.mrla A. Mcliram

till b r m
A l f n d 3. Chtplin, Jr.
ioby Bbrlmrn

Vicki Gottliich
htw~
N#m(YT
~

Lure IZ. E t . u r : r ~
wwq
%TY

T RmnrlruA. . k 9 h h r n

' r ~ d dslmrm-

Abtrail C. Cow

OP COWHihlL
Bbllr ILd*
WryWoy b l r l n o Y l n k *
~ ~ m ~ b
t .umr
6

hlny 1.2007

1wdml~1

OW3 Dnk Officer OMU Human Resources and Housing Brwrch
Anention Carolyn Lovclt
Ncw Execirtjvc Officc Building
Koom 10235
Washington, I)(' 'L(lsO3

Fax number: 202-395-6974
Re:

knportiu11Message )inm Mcdicnrc, ChfS R-193(OMB#: 093-0692);
Oetniled Notice of Dischirge, CMS-1 On66 (OMl3#:W38-Ncwj
72 Fad. Rcg 1 7169 (Apnl 6.2007)

Ucar Sir or Madam:
Ihc Ccnter for Medicwe Advucacy, Lic., w d n to oMmn Medicare coverage for persons
with Mctlilic:arz, and to enforcc rights to related health car h ~low-income
.
pcople.
ShllOrS, md persons with disabili1im. We appreciate thc oppoxtunity to submit llrz
fulluwi~~$
co~lrnwntsrcgnrding the Cenrers for Mrsrlicae & &Airaid Skmccs' (CMS)
draft notices for Medic= aut:l Mcdicare Advantap hospital inpatients: Inryor.rc7tlt
Mr~*trgrfrorrrrhfedih'cnrrand Dctailad Ilroriceaf Discharge

Ova-all, thr draft notices are clearer and more wulcr-s(iv~riahlcthan prcvious versione. In
p ~ i c u l a rthe
, descripliv~rof discharge rights m the Irnporta~Message is nivre
pro~~~ii~e~lt,
crmc~scand uscful to patients. .WGonally, the mfnrmation about pacient
liability pendin# apprals is clearer and more comprehensible.

We suggest the following revisions to the notices and additions to instruotions to help
patients h e f i t &am the second Important Message upon discharge; to ensure timely
delivery of this notice, and to make both notices more readable and user-friendly.

Help Patients Benefit From the Important Message Upon Discharge.
We are concerned that upon receiving the copy of the Important Message prior to
discharge ("follow up notice"), many patients will fail to read or use it because they will
not realize that it relates to their impending discharge. To help patients benefit fiom the
follow up notice, we suggest the following:

Change the title to include the word, "discharge" (i.e, "An Important Message
From Medicare abour Your Inpatient and Discharge Rights'?;
J
n the first section listing hospital inpatient rights, add a bullet alerting persons
that they will receive a copy of the notice prior to discharge; and
Require hospitals and Medicare Advantage plans to deliver the follow up notice
and explain its relevance when patients are told of their discharge.
Ensure Timely Delivery of the Second Impotlant Message to Afford Patients the
Opportunity to Exercise their Appeal Rights

Hospitals and plans must deliver the second Important Message "as far in advance of
discharge as possible, but not more than 2 calendar days before discharge." 42 CFR $4
405.1205 (c)(l); 422.620 (c)(l). Because there is no deadline for delivering the follow
up notice, many patients could receive it too late, after they have lost any meaningful
opportunity to exercise their appeal rights. Notices will be useless to patients if they are
delivered as they are packing to leave or being wheeled out the door.
In the Revisions to the Important Messagefiom Medicare, CMS indicates it added the
bullet telling persons to call 1-800-Medicare if they have insufficient time to consider
their rights, to address concerns "that beneficiaries may be given the notice on their way
out of the hospital." Revisions to the Important Message from Medicare (March 23,
2007). However, we do not understand how this information helps patients. First, CMS
has not indicated that 1-800 operators have the authority to extend the deadline for
patients to file a QIO appeal. Second, even if 1-800 operators have the authority to
intervene, 1-800-Medicare does not have the capacity to respond quickly enough.
To promote the timely delivery of the follow-up notice, we suggest the following:
Require that the patient's signature, with date and time of delivery, is obtained on
the follow-up notice and that a copy is kept in the patient's record. The
information could be recorded in the "Additional Information" section. This
record will allow CMS to monitor when the notices are actually delivered and will
discourage hospitals fiom deliverins them too late. (It will also help to assure that
notice is actually delivered to the patient.) Requiring the record is warranted
given its importance in ensuring the patients actually receive the notice in time to
consider their appeal rights.

CMS should devise a standard to m e z s ~ whether
e
no5ces are delivered "as far in
advance cf dischargs as possible." d.2 CFR $8 405.1205 (c)(l); 422.620(c)(l).
Such a standard should require t w the disckiarge notice is delivered to patients on
the day pricr to discharge or, If qzcific, identified infonnation is not available
until the day of discharge, requir~that the nctice is delivered at least five hours
prior t3 discharge. T;?e s+m8.2rc!shvald aiso specifically prohibit hospitals fiom
adopti3~a blarket policy of delivering the notices on the day of discharge.
Make the Notices More User-friendly and Readable
As we mentioced above, the notices are generally clearer and more understandable. To
make them more coccise and user-fiendly, we recommend the following:

In the Important Message, bold the deadline for requesting QIO review to call the
reader's attention to this critical information;
In the Imporrant Message, delete t5e bullet advising patients to contact 1-800Medicare if they do not think they have sufficient time to appeal, for the reasons
mentioned above;
Require that information written into the Detailed Notice of Discharge is legible.
We thank you for the opportunity to submit these comments.
Sincerelv,

Senior Policy Attorney
Managing Attorney