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Sample records for 46369-46418 medicare program

  1. Medicare

    MedlinePlus

    ... receiving health services. . . . . . . . . 15 If you have other health insurance. . . . . . . . . . . 15 Contacting Social Security Visit our website At ... 2048 What is Medicare? Medicare is our country’s health insurance program for people age 65 or older. People ...

  2. Medicare

    Cancer.gov

    The Centers for Medicare & Medicaid Services administers Medicare, a Health Insurance Program for people age 65 or older, some disabled people under age 65, and people of all ages with End-Stage Renal Disease.

  3. Medicare

    MedlinePlus

    Medicare is the U.S. government's health insurance program for people age 65 or older. Some people under age 65 can qualify for Medicare, too. They include those with disabilities, permanent kidney ...

  4. 76 FR 59138 - Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-23

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Medicare Appeals; Adjustment... review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective..., respectively, for Medicare Part A and Part B appeals. Section 940 of the Medicare Prescription...

  5. 77 FR 59618 - Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-09-28

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Medicare Appeals; Adjustment... review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective..., respectively, for Medicare Part A and Part B appeals. Section 940 of the Medicare Prescription...

  6. 78 FR 59702 - Medicare Program; Medicare Appeals: Adjustment to the Amount in Controversy Threshold Amounts for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-27

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Medicare Appeals: Adjustment... review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective..., respectively, for Medicare Part A and Part B appeals. Section 940 of the Medicare Prescription...

  7. Medicare program; medical loss ratio requirements for the Medicare Advantage and the Medicare Prescription Drug Benefit Programs.

    PubMed

    2013-05-23

    This final rule implements new medical loss ratio (MLR) requirements for the Medicare Advantage Program and the Medicare Prescription Drug Benefit Program established under the Patient Protection and Affordable Care Act.

  8. 75 FR 32858 - Medicare Program; Policy and Technical Changes to the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-10

    ...; Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit... Prescription Drug Benefit Programs'' which appeared in the April 15, 2010 Federal Register (FR Doc. 2010-7966... all covered Part D drugs must be included in Part D formularies (75 FR 19767), we indicated that...

  9. Medicare program; Medicare prescription drug benefit. Final rule.

    PubMed

    2005-01-28

    This final rule implements the provisions of the Social Security Act (the Act) establishing and regulating the Medicare Prescription Drug Benefit. The new voluntary prescription drug benefit program was enacted into law on December 8, 2003 in section 101 of Title I of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173). Although this final rule specifies most of the requirements for implementing the new prescription drug program, readers should note that we are also issuing a closely related rule that concerns Medicare Advantage organizations, which, if they offer coordinated care plans, must offer at least one plan that combines medical coverage under Parts A and B with prescription drug coverage. Readers should also note that separate CMS guidance on many operational details appears or will soon appear on the CMS website, such as materials on formulary review criteria, risk plan and fallback plan solicitations, bid instructions, solvency standards and pricing tools, plan benefit packages. The addition of a prescription drug benefit to Medicare represents a landmark change to the Medicare program that will significantly improve the health care coverage available to millions of Medicare beneficiaries. The MMA specifies that the prescription drug benefit program will become available to beneficiaries beginning on January 1, 2006. Generally, coverage for the prescription drug benefit will be provided under private prescription drug plans (PDPs), which will offer only prescription drug coverage, or through Medicare Advantage prescription drug plans (MA PDs), which will offer prescription drug coverage that is integrated with the health care coverage they provide to Medicare beneficiaries under Part C of Medicare. PDPs must offer a basic prescription drug benefit. MA-PDs must offer either a basic benefit or broader coverage for no additional cost. If this required level of coverage is offered, MA-PDs or PDPs, but not

  10. Medicare program; Medicare Shared Savings Program: Accountable Care Organizations. Final rule.

    PubMed

    2015-06-01

    This final rule addresses changes to the Medicare Shared Savings Program including provisions relating to the payment of Accountable Care Organizations participating in the Medicare Shared Savings Program. Under the Medicare Shared Savings Program, providers of services and suppliers that participate in an Accountable Care Organizations continue to receive traditional Medicare fee-for-service payments under Parts A and B, but the Accountable Care Organizations may be eligible to receive a shared savings payment if it meets specified quality and savings requirements.

  11. 75 FR 58407 - Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-09-24

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Medicare Appeals; Adjustment... review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective... and judicial review at $100 and $1,000, respectively, for Medicare Part A and Part B appeals....

  12. Medicare program: Medicare Advantage and Prescription Drug Benefit programs: final marketing provisions. Final rule.

    PubMed

    2008-09-18

    This final rule revises the Medicare Advantage (MA) program (Part C) and Medicare Prescription Drug Benefit Program (Part D). The regulation contains new regulatory provisions regarding marketing processes for both programs. The revisions to the Part C and Part D programs are based on lessons we have learned since 2006, the initial year of the prescription drug program and the revised MA program.

  13. 42 CFR 421.304 - Medicare integrity program contractor functions.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Medicare integrity program contractor functions. 421.304 Section 421.304 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Medicare Integrity...

  14. 76 FR 52955 - Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-24

    ... HUMAN SERVICES Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports.... SUMMARY: This notice announces public meetings of the Technical Advisory Panel on Medicare Trustee Reports... assumptions in projecting Medicare health spending for Parts C and D and may make recommendations to...

  15. Cost of schizophrenia in the Medicare program.

    PubMed

    Feldman, Rachel; Bailey, Robert A; Muller, James; Le, Jennifer; Dirani, Riad

    2014-06-01

    Medicare beneficiaries diagnosed with non-schizoaffective schizophrenia (MBS) in a 5% national Medicare fee-for-service sample from 2003-2007 were followed for 1-6 years. Medicare population and cost estimates also were made from 2001-2009. Service utilization and Medicare (and beneficiary share) payments for all services except prescription drugs were analyzed. Although adults with schizophrenia make up approximately 1% of the US adult population, they represent about 1.5% of Medicare beneficiaries. MBSs are disproportionately male and minority compared to national data describing the overall schizophrenia population. They also are younger than the general Medicare population (GMB): males are 9 years younger than females on average, and most enter Medicare long before age 65 through eligibility for social security disability, remaining in the program until death. The cost of care for MBSs in 2009 was, on average, 80% higher than for the average GMB per patient year (2010 dollars), and more than 50% of these costs are attributable to a combination of psychiatric and medical hospitalizations, concentrated in about 30% of MBSs with 1 or more hospitalizations per year. From 2004-2009, total estimated Medicare fee-for-service payments for MBSs increased from $9.4 billion to $11.5 billion, excluding Part D prescription drugs and payments for services to MBSs in Medicare for less than 1 year. Study results characterize utilization and costs for other services and suggest opportunities for further study to inform policy to improve access and continuity of care and decrease costs to the Medicare program associated with this population.

  16. 42 CFR 417.550 - Special Medicare program requirements.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... HEALTH CARE PREPAYMENT PLANS Medicare Payment: Cost Basis § 417.550 Special Medicare program requirements... 42 Public Health 3 2011-10-01 2011-10-01 false Special Medicare program requirements. 417.550 Section 417.550 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND...

  17. 75 FR 71189 - Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-22

    ... Federal Register on January 28, 2005 (70 FR 4588 through 4741 and 70 FR 4194 through 4585, respectively... Medicare Part D prescription drug plan sponsors (72 FR 68700). In April 2008, we published a final rule to address policy and technical changes to the Part D program (73 FR 20486). In September 2008 and...

  18. 76 FR 61103 - Medicare Program; Comprehensive Primary Care Initiative

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-03

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Comprehensive Primary Care... announces a solicitation for health care payer organizations to participate in the Comprehensive Primary Care initiative (CPC), a multipayer model designed to improve primary care. DATES: Letter of...

  19. Capitation and the Medicare program: History, issues, and evidence

    PubMed Central

    Langwell, Kathryn M.; Hadley, James P.

    1986-01-01

    This article reviews the history of capitation in the Medicare program and examines issues and research findings related to Medicare capitation. Specific capitation issues and related research findings reviewed include: the feasibility and extent of health maintenance organization participation in Medicare; plan marketing; beneficiary choice behavior; quality of care; and the use and cost of services. In addition, areas requiring further study are noted, and the potential for extensions of capitation under Medicare are explored. PMID:10311935

  20. 77 FR 29647 - Medicare Program; Solicitation for Proposals for the Medicare Graduate Nurse Education...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-18

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Solicitation for Proposals for... 15 pages supporting documentation. Because of staffing and resource limitations, we cannot accept... of the eligible partners with respect to the provision of qualified training; and (2) the...

  1. 76 FR 21431 - Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-15

    ....564, 422.624, and 422.626 published April 4, 2003 at 68 FR 16652 are effective June 6, 2011... (70 FR 4588 through 4741 and 70 FR 4194 through 4585, respectively). As we have gained experience with... involving Medicare Advantage (MA) organizations and Medicare Part D prescription drug plan sponsors (72...

  2. Medicare

    MedlinePlus

    ... quality measures for nursing homes Learn more Address change/Medicare card issue? Lost or incorrect Medicare card? Select your card issue Select your card issue... Change your name or address Replace a lost or ...

  3. 76 FR 19655 - Medicare Program; Waiver Designs in Connection With the Medicare Shared Savings Program and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-07

    .... \\3\\ 75 FR 70165 (2010). \\4\\ Information about the workshop is available on CMS's Web site at http...; Waiver Designs in Connection With the Medicare Shared Savings Program and the Innovation Center AGENCY... Savings Program proposed rule, the Medicare Shared Savings Program is designed to achieve three...

  4. Lessons Learned from the National Medicare & You Education Program

    PubMed Central

    Goldstein, Elizabeth; Teichman, Lori; Crawley, Barbara; Gaumer, Gary; Joseph, Catherine; Reardon, Leo

    2001-01-01

    In fall 1998 CMS implemented the National Medicare Education Program (NMEP) to educate beneficiaries about their Medicare program benefits; health plan choices; supplemental health insurance; beneficiary rights, responsibilities, and protections; and health behaviors. CMS has been monitoring the implementation of the NMEP in six case study sites as well as monitoring each of the information channels for communicating with beneficiaries. This article describes select findings from the case studies, and highlights from assessment activities related to the Medicare & You handbook, the toll-free 1-800-MEDICARE Helpline, Internet, and Regional Education About Choices in Health (REACH). PMID:12500359

  5. Medicare program; clarification of Medicare's accrual basis of accounting policy--HCFA. Final rule.

    PubMed

    1995-06-27

    This final rule revises the Medicare regulations to clarify the concept of "accrual basis of accounting" to indicate that expenses must be incurred by a provider of health care services before Medicare will pay its share of those expenses. This rule does not signify a change in policy but, rather, incorporates into the regulations Medicare's longstanding policy regarding the circumstances under which we recognize, for the purposes of program payment, a provider's claim for costs for which it has not actually expended funds during the current cost reporting period. PMID:10143395

  6. A comparison of hospice programs based on Medicare certification status.

    PubMed

    Sontag, M A

    1996-01-01

    This article presents results from a study of 119 hospice programs in the United States. Personal interviews and questionnaires were utilized to collect data about hospice programs, their directors, nurses, social workers, and chaplains. Specifically, this article describes reasons programs sought Medicare certification, and the perceived advantages and disadvantages to being a Medicare certified program. Characteristics of both certified and non-certified programs are presented, and examined for differences. Potential access barriers such as restrictive admission criteria are examined in this article. Finally, perceptions of staff about hospice services in certified and non-certified programs are compared. Results from this study indicate that Medicare certified programs have longer lengths of stays, were more likely to include a nurse on the first visit, and billed patients more frequently than noncertified programs. Volunteer use was lower in the Medicare certified programs. Staff in Medicare certified programs were much more likely to view patients' medical needs as the primary focus of their programs. Results from this study suggest that Medicare certified programs may reflect a more medical model of palliative care.

  7. Medicare program; Medicare depreciation, useful life guidelines--HCFA. Final rule.

    PubMed

    1983-08-18

    These final rules amend Medicare regulations to clarify which useful life guidelines may be used by providers of health care services to determine the useful life of a depreciable asset for Medicare reimbursement purposes. Current regulations state that providers must utilize the Departmental useful life guidelines or, if none have been published by the Department, either the American Hospital Association (AHA) useful life guidelines of 1973 of IRS guidelines. We are eliminating the reference to IRS guidelines because these are now outdated for Medicare purposes since they have been rendered obsolete either by the IRS or by statutory change. We are also deleting the specific reference to the 1973 AHA guidelines since these guidelines are updated by the AHA periodically. In addition, we are clarifying that certain tax legislation on accelerated depreciation, passed by Congress, does not apply to the Medicare program.

  8. 76 FR 63017 - Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-11

    ... January 28, 2005 Federal Register (70 FR 4588 through 4741 and 70 FR 4194 through 4585, respectively.... For instance, in September 2008 and January 2009, we issued Part C and D regulations (73 FR 54226 and 74 FR 1494, respectively) to implement provisions in the Medicare Improvement for Patients...

  9. 75 FR 71064 - Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-22

    ... CONTACT: Sabrina Ahmed, (410) 786-7499. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2010-28774... accuracy of the proposed rule. IV. Correction of Errors In FR Doc. 2010-28774 filed November 10, 2010, make... HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 417, 422, and 423 RIN...

  10. 75 FR 19677 - Medicare Program; Policy and Technical Changes to the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-04-15

    ... Independent Audit of Sponsoring Organizations under Intermediate Sanction 5. The Ability for CMS to Require... 28, 2005 (70 FR 4588-4741 and 70 FR 4194-4585, respectively). While the provisions of the final rule... Medicare Part D prescription drug plan sponsors (72 FR 68700). In April 2008, we published a final rule...

  11. 77 FR 27778 - Medicare Program; Meeting of the Medicare Economic Index Technical Advisory Panel-May 21, 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-11

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Meeting of the Medicare Economic Index Technical Advisory Panel--May 21, 2012 Correction In notice document 2012-10702 appearing...

  12. 77 FR 69850 - Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual Deductible...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-21

    ... because of entitlement to Medicare under the end-stage renal disease (ESRD) program. Projected monthly costs for disabled enrollees (other than those with ESRD) are prepared in a fashion parallel to the projection for the aged using appropriate actuarial assumptions (see Table 2). Costs for the ESRD program...

  13. Medicare program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs. Final rule.

    PubMed

    2014-05-23

    The final rule will revise the Medicare Advantage (MA) program (Part C) regulations and prescription drug benefit program (Part D) regulations to implement statutory requirements; improve program efficiencies; and clarify program requirements. The final rule also includes several provisions designed to improve payment accuracy.

  14. 42 CFR 424.510 - Requirements for enrolling in the Medicare program.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Requirements for enrolling in the Medicare program. 424.510 Section 424.510 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Requirements...

  15. 42 CFR 424.530 - Denial of enrollment in the Medicare program.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Denial of enrollment in the Medicare program. 424.530 Section 424.530 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Requirements...

  16. Medicare Program: Expanding Uses of Medicare Data by Qualified Entities. Final rule.

    PubMed

    2016-07-01

    This final rule implements requirements under Section 105 of the Medicare Access and CHIP Reauthorization Act of 2015 that expand how qualified entities may use and disclose data under the qualified entity program to the extent consistent with applicable program requirements and other applicable laws, including information, privacy, security and disclosure laws. This rule also explains how qualified entities may create non-public analyses and provide or sell such analyses to authorized users, as well as how qualified entities may provide or sell combined data, or provide Medicare claims data alone at no cost, to certain authorized users. In addition, this rule implements certain privacy and security requirements, and imposes assessments on qualified entities if the qualified entity or the authorized user violates the terms of a data use agreement required by the qualified entity program. PMID:27400462

  17. Medicare Program: Expanding Uses of Medicare Data by Qualified Entities. Final rule.

    PubMed

    2016-07-01

    This final rule implements requirements under Section 105 of the Medicare Access and CHIP Reauthorization Act of 2015 that expand how qualified entities may use and disclose data under the qualified entity program to the extent consistent with applicable program requirements and other applicable laws, including information, privacy, security and disclosure laws. This rule also explains how qualified entities may create non-public analyses and provide or sell such analyses to authorized users, as well as how qualified entities may provide or sell combined data, or provide Medicare claims data alone at no cost, to certain authorized users. In addition, this rule implements certain privacy and security requirements, and imposes assessments on qualified entities if the qualified entity or the authorized user violates the terms of a data use agreement required by the qualified entity program.

  18. 77 FR 38066 - Medicare Program; Announcement of a New Opportunity for Participation in the Advance Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-26

    ..., Medicaid, and Children's Health Insurance Program beneficiaries. One potential mechanism for achieving... partnerships through complementary efforts, including the Medicare Shared Savings Program and initiatives... Register (76 FR 68012), we published a notice entitled ``Medicare Program; Advance Payment Model''...

  19. 75 FR 78247 - Medicare Program; Town Hall Meeting on Physician Quality Reporting System

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-15

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Town Hall Meeting on Physician Quality Reporting System AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice of... Building of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD...

  20. 76 FR 19527 - Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-07

    ...This proposed rule would implement section 3022 of the Affordable Care Act which contains provisions relating to Medicare payments to providers of services and suppliers participating in Accountable Care Organizations (ACOs). Under these provisions, providers of services and suppliers can continue to receive traditional Medicare fee-for-service payments under Parts A and B, and be eligible for......

  1. 75 FR 76471 - Medicare Program; Renewal of the Medicare Evidence Development & Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-08

    ... FR 68780) announcing the establishment of the Medicare Coverage Advisory Committee (MCAC). The... Evidence Development & Coverage Advisory Committee (MEDCAC) AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice announces the renewal of the Medicare...

  2. Making Medicare advantage a middle-class program.

    PubMed

    Glazer, Jacob; McGuire, Thomas G

    2013-03-01

    This paper studies the role of Medicare's premium policy in sorting beneficiaries between traditional Medicare (TM) and managed care plans in the Medicare advantage (MA) program. Beneficiaries vary in their demand for care. TM fully accommodates demand but creates a moral hazard inefficiency. MA rations care but disregards some elements of the demand. We describe an efficient assignment of beneficiaries to these two options, and argue that efficiency requires an MA program oriented to serve the large middle part of the distribution of demand: the "middle class." Current Medicare policy of a "single premium" for MA plans cannot achieve efficient sorting. We characterize the demand-based premium policy that can implement the efficient assignment of enrollees to plans. If only a single premium is feasible, the second-best policy involves too many of the low-demand individuals in MA and a too low level of services relative to the first best. We identify approaches to using premium policy to revitalize MA and improve the efficiency of Medicare.

  3. Making Medicare Advantage a Middle-Class Program

    PubMed Central

    Glazer, Jacob; McGuire, Thomas

    2013-01-01

    This paper studies the role of Medicare's premium policy in sorting beneficiaries between traditional Medicare (TM) and managed care plans in the Medicare Advantage (MA) program. Beneficiaries vary in their demand for care. TM fully accommodates demand but creates a moral hazard inefficiency. MA rations care but disregards some elements of the demand. We describe an efficient assignment of beneficiaries to these two options, and argue that efficiency requires an MA program oriented to serve the large middle part of the distribution of demand: the “middle class.” Current Medicare policy of a “single premium” for MA plans cannot achieve efficient sorting. We characterize the demand-based premium policy that can implement the efficient assignment of enrollees to plans. If only a single premium is feasible, the second-best policy involves too many of the low-demand individuals in MA and a too low level of services relative to the first best. We identify approaches to using premium policy to revitalize MA and improve the efficiency of Medicare. PMID:23454916

  4. Medicare program; requirements for the Medicare incentive reward program and provider enrollment. Final rule.

    PubMed

    2014-12-01

    This final rule implements various provider enrollment requirements. These include: Expanding the instances in which a felony conviction can serve as a basis for denial or revocation of a provider or supplier's enrollment; if certain criteria are met, enabling us to deny enrollment if the enrolling provider, supplier, or owner thereof had an ownership relationship with a previously enrolled provider or supplier that had a Medicare debt; enabling us to revoke Medicare billing privileges if we determine that the provider or supplier has a pattern or practice of submitting claims that fail to meet Medicare requirements; and limiting the ability of ambulance suppliers to "backbill" for services performed prior to enrollment. PMID:25509061

  5. Medicare Program; Reporting and Returning of Overpayments. Final rule.

    PubMed

    2016-02-12

    This final rule requires providers and suppliers receiving funds under the Medicare program to report and return overpayments by the later of the date that is 60 days after the date on which the overpayment was identified; or the date any corresponding cost report is due, if applicable. The requirements in this rule are meant to ensure compliance with applicable statutes, promote the furnishing of high quality care, and to protect the Medicare Trust Funds against fraud and improper payments. This rule provides needed clarity and consistency in the reporting and returning of self-identified overpayments.

  6. Medicare Program; Reporting and Returning of Overpayments. Final rule.

    PubMed

    2016-02-12

    This final rule requires providers and suppliers receiving funds under the Medicare program to report and return overpayments by the later of the date that is 60 days after the date on which the overpayment was identified; or the date any corresponding cost report is due, if applicable. The requirements in this rule are meant to ensure compliance with applicable statutes, promote the furnishing of high quality care, and to protect the Medicare Trust Funds against fraud and improper payments. This rule provides needed clarity and consistency in the reporting and returning of self-identified overpayments. PMID:26878741

  7. 76 FR 68011 - Medicare Program; Advanced Payment Model

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-02

    ... the initiative and the application process is available on the Innovation Center Web site at http... begin in 2012, and provides information about the model and application process. DATES: Application Submission Deadline: Applicants must submit both the application for the Medicare Shared Savings Program...

  8. 75 FR 52960 - Medicare Program; Rural Community Hospital Demonstration Program: Solicitation of Additional...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-30

    ... the June 2, 2010 Federal Register (75 FR 30918)). B. Participation in the Demonstration To participate... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Rural Community Hospital... hospitals to participate in the Rural Community Hospital Demonstration program for a 5-year period....

  9. 75 FR 67751 - Medicare Program: Community-Based Care Transitions Program (CCTP) Meeting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-03

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program: Community-Based Care... about the upcoming Community-based Care Transitions Program. The meeting is open to the public, but... will be posted on the CMS Care Transitions Web site at...

  10. 78 FR 31283 - Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-23

    ... pertaining to the MA and Prescription Drug program provisions were published on April 12, 2012 (77 FR 22072) and a correction was published June 1, 2012 (77 FR 32407). This final rule implements section 1103 of... enrolling new members, and ultimately contract termination. In the February 22, 2013 Federal Register (78...

  11. 77 FR 22071 - Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-04-12

    ..., using a 5-star system where 5 stars indicates the highest quality, of Part C and D plan sponsors. The... C and D programs. We have established that 3 stars reflects an average level of performance and is... achieve at least a 3-star rating have demonstrated that they have substantially failed to meet...

  12. 42 CFR 460.168 - Reinstatement in other Medicare and Medicaid programs.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 false Reinstatement in other Medicare and Medicaid programs. 460.168 Section 460.168 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Reinstatement in other Medicare and Medicaid programs. To facilitate a participant's reinstatement in...

  13. 42 CFR 421.302 - Eligibility requirements for Medicare integrity program contractors.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... the Medicare program. (3) Complies with conflict of interest provisions in 48 CFR chapters 1 and 3... 42 Public Health 3 2010-10-01 2010-10-01 false Eligibility requirements for Medicare integrity program contractors. 421.302 Section 421.302 Public Health CENTERS FOR MEDICARE & MEDICAID...

  14. 78 FR 53769 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-30

    ... effectiveness of consumer education strategies concerning Medicare, Medicaid and the Children's Health Insurance... enrolled in, or eligible for, Medicare, Medicaid and the Children's Health Insurance Program (CHIP... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH...

  15. 42 CFR 420.410 - Establishment of a program to collect suggestions for improving Medicare program efficiency and...

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Establishment of a program to collect suggestions for improving Medicare program efficiency and to reward suggesters for monetary savings. 420.410 Section 420.410 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM...

  16. 78 FR 57800 - Medicare Program; Obtaining Final Medicare Secondary Payer Conditional Payment Amounts via Web...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-20

    ...; Obtaining Final Medicare Secondary Payer Conditional Payment Amounts via Web Portal AGENCY: Centers for... Medicare Secondary Payer (MSP) Web portal to conform to section 201 of the Medicare IVIG and Strengthening... MSP Web portal. It also requires that we add functionality to the existing MSP Web portal that...

  17. 77 FR 71600 - Medicare Program; Request for Information To Aid in the Design and Development of a Survey...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-12-03

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Request for Information To Aid in the Design and Development of a Survey Regarding Patient Experiences With Emergency Department Care AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Request for...

  18. 42 CFR 419.41 - Calculation of national beneficiary copayment amounts and national Medicare program payment amounts.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... amounts and national Medicare program payment amounts. 419.41 Section 419.41 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM... Calculation of national beneficiary copayment amounts and national Medicare program payment amounts. (a)...

  19. 76 FR 46814 - Medicare Program; Evaluation Criteria and Standards for Quality Improvement Program Contracts...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-03

    ... Restraints, Nursing Home Systemic Improvement, Adverse Drug Events, Quality Reporting and Improvement... Standards for Quality Improvement Program Contracts (10th Statement of Work) AGENCY: Centers for Medicare... Conditions in Nursing Homes-- Pressure Ulcers and Physical Restraints; Developing a learning and...

  20. 76 FR 79193 - Medicare Program; Independence at Home Demonstration Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-21

    ... beneficiaries are defined as Medicare fee-for-service (FFS) patients, who have at least 2 chronic illnesses... practitioners and must have experience providing home-based primary care to patients with multiple chronic illnesses. These practices will also be organized, at least in part, for the purpose of providing...

  1. 76 FR 13418 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-11

    ... MCAC, see the December 14, 1998 Federal Register (63 FR 68780).) This notice announces the May 11, 2011... Evidence Development and Coverage Advisory Committee, May 11, 2011 AGENCY: Centers for Medicare & Medicaid... Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) (``Committee''). The...

  2. 77 FR 15372 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-15

    ... Register (63 FR 68780). This notice announces the Wednesday, May 16, 2012, public meeting of the Committee... Evidence Development and Coverage Advisory Committee--May 16, 2012 AGENCY: Centers for Medicare & Medicaid... Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) (``Committee'') will be held...

  3. 77 FR 64997 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-10-24

    ... December 14, 1998 Federal Register (63 FR 68780). This notice announces the Wednesday, January 30, 2013... Evidence Development and Coverage Advisory Committee--January 30, 2013 AGENCY: Centers for Medicare... meeting of the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) (``Committee'')...

  4. 77 FR 53204 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-31

    ... Register (63 FR 68780). This notice announces the Wednesday, November 14, 2012, public meeting of the... Evidence Development and Coverage Advisory Committee--November 14, 2012 AGENCY: Centers for Medicare... meeting of the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) (``Committee'')...

  5. 76 FR 44011 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-22

    ... Register (63 FR 68780).) This notice announces the September 21, 2011, public meeting of the Committee... Evidence Development and Coverage Advisory Committee--September 21, 2011 AGENCY: Centers for Medicare... meeting of the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) (``Committee'')...

  6. 75 FR 8980 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-02-26

    ... MCAC, see the December 14, 1998 Federal Register (63 FR 68780).) This notice announces the April 21... Evidence Development and Coverage Advisory Committee--April 21, 2010 AGENCY: Centers for Medicare... meeting of the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) (``Committee'')...

  7. 75 FR 73094 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-29

    ... information on MCAC, see the December 14, 1998 Federal Register (63 FR 68780).) This notice announces the... Evidence Development and Coverage Advisory Committee--January 19, 2011 AGENCY: Centers for Medicare... meeting of the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) (``Committee'')...

  8. 78 FR 13059 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-26

    ... information on MCAC, see the December 14, 1998 Federal Register (63 FR 68780). This notice announces the... Evidence Development and Coverage Advisory Committee--May 1, 2013 AGENCY: Centers for Medicare & Medicaid... Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) (``Committee'') will be held...

  9. 76 FR 33565 - Medicare Program; Availability of Medicare Data for Performance Measurement

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-08

    ...This rule proposes to implement new statutory requirements regarding the release and use of standardized extracts of Medicare claims data to measure the performance of providers and suppliers in ways that protect patient privacy. This rule explains how entities can become qualified by CMS to receive standardized extracts of claims data under Medicare Parts A, B, and D for the purpose of......

  10. Medicare Program; Medicare Clinical Diagnostic Laboratory Tests Payment System. Final rule.

    PubMed

    2016-06-23

    This final rule implements requirements of section 216 of the Protecting Access to Medicare Act of 2014 (PAMA), which significantly revises the Medicare payment system for clinical diagnostic laboratory tests. This final rule also announces an implementation date of January 1, 2018 for the private payor rate-based fee schedule required by PAMA. PMID:27373013

  11. 78 FR 75304 - Medicare Program; Medicare Secondary Payer and Certain Civil Money Penalties

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-11

    ... either the Office of Inspector General (OIG) or CMS (See the October 20, 1994 (58 FR 52967) notice titled...; Medicare Secondary Payer and Certain Civil Money Penalties AGENCY: Centers for Medicare & Medicaid Services... rulemaking (ANPRM) solicits public comment on specific practices for which civil money penalties (CMPs)...

  12. Medicare Program; Medicare Clinical Diagnostic Laboratory Tests Payment System. Final rule.

    PubMed

    2016-06-23

    This final rule implements requirements of section 216 of the Protecting Access to Medicare Act of 2014 (PAMA), which significantly revises the Medicare payment system for clinical diagnostic laboratory tests. This final rule also announces an implementation date of January 1, 2018 for the private payor rate-based fee schedule required by PAMA.

  13. 78 FR 78802 - Medicare Program; Right of Appeal for Medicare Secondary Payer Determination Relating to...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-27

    ... Self- Insurance), No Fault Insurance, and Workers' Compensation Laws and Plans AGENCY: Centers for...-fault insurance, and workers' compensation laws or plans when Medicare pursues a Medicare Secondary Payer (MSP) recovery claim directly from the liability insurance (including self-insurance), no...

  14. An Analysis of Medicare's Incentive Payment Program for Physicians in Health Professional Shortage Areas

    ERIC Educational Resources Information Center

    Chan, Leighton; Hart, L. Gary; Ricketts III, Thomas C.; Beaver, Shelli K.

    2004-01-01

    Medicare's Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat Medicare patients in rural and urban areas where there is a shortage of generalist physicians. Purpose: To examine the experience of Alaska, Idaho, North Carolina, South Carolina, and Washington with the MIP program. We determined the program's…

  15. 77 FR 31361 - Medicare and Medicaid Programs; Application by American Osteopathic Association/Healthcare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-25

    ...-Approval of its Ambulatory Surgery Center (ASC) Accreditation Program AGENCY: Centers for Medicare and... Program (AOA/HFAP) for continued recognition as a national accrediting organization for ambulatory surgery...--Ambulatory surgery center Insurance Program; and No. 93.774, Medicare--Supplementary Medical...

  16. Medicare cost controls and program compliance: the rationale of physician claims edits.

    PubMed

    Carter, Darren

    2002-01-01

    This article attempts to demystify and create a context for the enactment of several Medicare cost control and compliance systems for physician reimbursement. The focus is on claims "edits" and Medicare compliance. Portions of Medicare, including health care provider reimbursement, remain fee-for-service programs that can be easily defrauded. To protect the Trust, the Centers for Medicare and Medicaid Services (CMS) has taken a multi-pronged approach, using program administration, enforcement, and rules-based claims editing systems. The Evaluation and Management codes, the Correct Coding Initiative (CCI), and medical necessity rules are claims edits that affect procedure codes. The Medicare program has a complicated system of billing procedures and an apparatus to enforce them. A solid compliance plan must incorporate proper claims editing, because consistent incorrect Medicare billing can be considered abuse. Many resources are available to aid physicians, including computerized tools, new CMS initiatives, and Internet materials.

  17. Medicare program; Medicare and laboratory certification program; enforcement procedures for laboratories--HCFA. Final rule.

    PubMed

    1992-02-28

    These regulations set forth the rules for sanctions that HCFA may impose on laboratories that are found not to meet Federal requirements. These include the principal sanctions of suspending, limiting, or revoking the laboratory's certificate issued under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), and cancelling the laboratory's approval to receive Medicare payment for its services, and the alternative sanctions that may be imposed instead of or before the principal sanctions. These amendments are necessary to conform HCFA regulations to changes made in the law by the Omnibus Budget Reconciliation Act of 1987 (OBRA '87) and the 1988 amendments to section 353 of the Public Health Service Act (PHS Act). The latter are commonly referred to as "CLIA 88". The purpose of the amendments is to ensure that functioning laboratories are capable of providing accurate and reliable test results and that the health of individuals served by the laboratory and that of the general public is not adversely affected by laboratory operations and by testing procedures that do not meet the standards set forth in other subparts of part 493 of the HCFA regulations.

  18. 78 FR 72089 - Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-02

    ... or Medicaid program or the Children's Health Insurance Program (CHIP); revalidating their Medicare... Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment... From the Federal Register Online via the Government Publishing Office ] DEPARTMENT OF HEALTH...

  19. 76 FR 16422 - Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-23

    ... Health Insurance Programs; Provider Enrollment Application Fee Amount for 2011 AGENCY: Centers for... with comment period entitled: ``Medicare, Medicaid, and Children's Health Insurance Programs... Health Insurance Program (CHIP) provider enrollment processes. Specifically, and as stated in 42 CFR...

  20. 76 FR 67567 - Medicare Program; Inpatient Hospital Deductible and Hospital and Extended Care Services...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-01

    ... Medicare Program; Inpatient Hospital Deductible and Hospital and Extended Care Services Coinsurance Amounts... Services RIN 0938-AQ14 Medicare Program; Inpatient Hospital Deductible and Hospital and Extended Care.... ACTION: Notice. SUMMARY: This notice announces the inpatient hospital deductible and the hospital...

  1. 76 FR 37120 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-24

    ..., and Children's Health Insurance (CHIP) programs. This meeting is open to the public. DATES: Meeting..., Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). Informing Medicare, Medicaid and... availability of other health coverage that may be available to them (for example, via health...

  2. Medicare Beneficiary Counseling Programs: What Are They and Do They Work?

    PubMed Central

    McCormack, Lauren A.; Schnaier, Jenny A.; Lee, A. James; Garfinkel, Steven A.

    1996-01-01

    Medicare beneficiaries face myriad rules, conditions, and exceptions under the Medicare program. As a result, State Information, Counseling, and Assistance (ICA) programs were established or enhanced with Federal funding as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. ICA programs utilize a volunteer-based and locally-sponsored support system to deliver free and unbiased counseling on the Medicare program and related health insurance issues. This article discusses the effectiveness of the ICA model. Because the ICA programs serve as a vital link between HCFA and its beneficiaries, information about the programs' success may be useful to HCFA and other policymakers during this era of consumer information. PMID:10165027

  3. 78 FR 26038 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-January Through March 2013

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-03

    ... (CMS), HHS. ACTION: Notice. SUMMARY: This quarterly notice lists CMS manual instructions, substantive... through March 2013, relating to the Medicare and Medicaid programs and other programs administered by CMS... & Medicaid Services (CMS) is responsible for administering the Medicare and Medicaid programs...

  4. 78 FR 45233 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-April Through June 2013

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-26

    ... (CMS), HHS. ACTION: Notice. SUMMARY: This quarterly notice lists CMS manual instructions, substantive... through June 2013, relating to the Medicare and Medicaid programs and other programs administered by CMS... & Medicaid Services (CMS) is responsible for administering the Medicare and Medicaid programs...

  5. Medicare program: changes to the Medicare claims appeal procedures. Final rule.

    PubMed

    2009-12-01

    Under the procedures in this final rule, Medicare beneficiaries and, under certain circumstances, providers and suppliers of health care services can appeal adverse determinations regarding claims for benefits under Medicare Part A and Part B pursuant to sections 1869 and 1879 of the Social Security Act (the Act). Section 521 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) amended section 1869 of the Act to provide for significant changes to the Medicare claims appeal procedures. After publication of a proposed rule implementing the section 521 changes, additional new statutory requirements for the appeals process were enacted in Title IX of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). In March 2005, we published an interim final rule with comment period to implement these statutory changes. This final rule responds to comments on the interim final rule regarding changes to these appeal procedures, makes revisions where warranted, establishes the final implementing regulations, and explains how the new procedures will be put into practice.

  6. Medicare Program; Obtaining Final Medicare Secondary Payer Conditional Payment Amounts via Web Portal. Final rule.

    PubMed

    2016-05-17

    This final rule specifies the process and timeline for expanding CMS' existing Medicare Secondary Payer (MSP) Web portal to conform to section 201 of the Medicare IVIG and Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act). The final rule specifies a timeline for developing a multifactor authentication solution to securely permit authorized users other than the beneficiary to access CMS' MSP conditional payment amounts and claims detail information via the MSP Web portal. It also requires that we add functionality to the existing MSP Web portal that permits users to: Notify us that the specified case is approaching settlement; obtain time and date stamped final conditional payment summary statements and amounts before reaching settlement; and ensure that relatedness disputes and any other discrepancies are addressed within 11 business days of receipt of dispute documentation.

  7. 75 FR 65360 - Medicare and Medicaid Programs; Application by the Joint Commission for Deeming Authority for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-10-22

    ... the Joint Commission for Deeming Authority for Psychiatric Hospitals AGENCY: Centers for Medicare... organization for psychiatric hospitals that wish to participate in the Medicare or Medicaid programs. Section... from a psychiatric hospital provided certain requirements are met. Section 1861(f) of the...

  8. 76 FR 66931 - Medicare Program; Accountable Care Organization Accelerated Development Learning Sessions; Center...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-28

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Accountable Care Organization... Organizations (ACOs) deliver better care and reduce costs. We invite all new or existing ACO entities to register a team of senior executives to attend the in- person ADLS. The ADLS will provide executives...

  9. 75 FR 72830 - Medicare Program; Quality Improvement Organization (QIO) Contracts: Solicitation of Proposals...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-26

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Quality Improvement... fulfills the Secretary's obligation under section 1153(i) of the Social Security Act (the Act) to provide at least 6 months' advance notice of the expiration dates of contracts with out- of-State...

  10. 76 FR 29249 - Medicare Program; Pioneer Accountable Care Organization Model: Request for Applications

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-20

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Pioneer Accountable Care... participate in the Pioneer Accountable Care Organization Model for a period beginning in 2011 and ending...://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care-models/pioneer-aco . Application...

  11. 42 CFR 413.87 - Payments for Medicare+Choice nursing and allied health education programs.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Payments for Medicare+Choice nursing and allied... NURSING FACILITIES Specific Categories of Costs § 413.87 Payments for Medicare+Choice nursing and allied... reimbursement for approved nursing and allied health education programs and the methodology for determining...

  12. 42 CFR 413.87 - Payments for Medicare+Choice nursing and allied health education programs.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Payments for Medicare+Choice nursing and allied... NURSING FACILITIES Specific Categories of Costs § 413.87 Payments for Medicare+Choice nursing and allied... reimbursement for approved nursing and allied health education programs and the methodology for determining...

  13. 42 CFR 413.87 - Payments for Medicare+Choice nursing and allied health education programs.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Payments for Medicare+Choice nursing and allied... NURSING FACILITIES Specific Categories of Costs § 413.87 Payments for Medicare+Choice nursing and allied... reimbursement for approved nursing and allied health education programs and the methodology for determining...

  14. 42 CFR 413.87 - Payments for Medicare+Choice nursing and allied health education programs.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Payments for Medicare+Choice nursing and allied... NURSING FACILITIES Specific Categories of Costs § 413.87 Payments for Medicare+Choice nursing and allied... reimbursement for approved nursing and allied health education programs and the methodology for determining...

  15. 42 CFR 413.87 - Payments for Medicare+Choice nursing and allied health education programs.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Payments for Medicare+Choice nursing and allied... NURSING FACILITIES Specific Categories of Costs § 413.87 Payments for Medicare+Choice nursing and allied... reimbursement for approved nursing and allied health education programs and the methodology for determining...

  16. 76 FR 28195 - Medicare Program; Hospice Wage Index for Fiscal Year 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-16

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part 418 RIN 0938-AQ31 Medicare Program; Hospice Wage Index for Fiscal Year 2012 Correction In proposed rule document 2011-10689 appearing on...

  17. 78 FR 38043 - Medicare and Medicaid Programs; Application From the American Osteopathic Association/Health...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-06-25

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare and Medicaid Programs; Application From.... ADDRESSES: In commenting, please refer to file code CMS-3285-PN. Because of staff and resource limitations... & Medicaid Services, Department of Health and Human Services, Attention: CMS-3285-PN, P.O. Box...

  18. 76 FR 67801 - Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-02

    ... Body 4. Leadership and Management Structure 5. Processes To Promote Evidence-Based Medicine, Patient.... In the April 7, 2011 Federal Register (76 FR 19528), we published the Shared Savings Program proposed...-based purchasing initiatives, please refer to section I.A. of the proposed rule (76 FR 19530)....

  19. 76 FR 54599 - Medicare Program; Medicare Advantage and Prescription Drug Benefit Programs

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-01

    ... on (70 FR 4588 through 4741 and 70 FR 4194 through 4585, respectively). As we gained more experience... programs and issued a proposed rule on May 16, 2008 (73 FR 28556) that would have clarified existing... September 18, 2008 IFC (73 FR 54226), our November 14, 2008 IFC (73 FR 67406), our November 21,...

  20. 75 FR 8982 - Medicare Program; Request for Nominations for Members for the Medicare Evidence Development...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-02-26

    ... in the Federal Register (63 FR 68780) announcing establishment of the Medicare Coverage Advisory... November 24, 1998. On January 26, 2007 the Secretary published a notice in the Federal Register (72 FR 3853... life care; Bayesian statistics; clinical epidemiology; clinical trial methodology; knee, hip, and...

  1. 75 FR 78705 - Medicare Program; Request for Nominations for Members for the Medicare Evidence Development...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-16

    ... trial methodology; knee, hip, and other joint replacement surgery; ophthalmology; psychopharmacology... in the Federal Register (63 FR 68780) announcing establishment of the Medicare Coverage Advisory... November 24, 1998. On January 26, 2007 the Secretary published a notice in the Federal Register (72 FR...

  2. Medicare program; appeals of CMS or CMS contractor determinations when a provider or supplier fails to meet the requirements for Medicare billing privileges. Final rule.

    PubMed

    2008-06-27

    This final rule implements a number of regulatory provisions that are applicable to all providers and suppliers, including durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers. This final rule establishes appeals processes for all providers and suppliers whose enrollment, reenrollment or revalidation application for Medicare billing privileges is denied and whose Medicare billing privileges are revoked. It also establishes timeframes for deciding enrollment appeals by an Administrative Law Judge (ALJ) within the Department of Health and Human Services (DHHS) or the Departmental Appeals Board (DAB), or Board, within the DHHS; and processing timeframes for CMS' Medicare fee-for-service (FFS) contractors. In addition, this final rule allows Medicare FFS contractors to revoke Medicare billing privileges when a provider or supplier submits a claim or claims for services that could not have been furnished to a beneficiary. This final rule also specifies that a Medicare contractor may establish a Medicare enrollment bar for any provider or supplier whose billing privileges have been revoked. Lastly, the final rule requires that all providers and suppliers receive Medicare payments by electronic funds transfer (EFT) if the provider or supplier, is submitting an initial enrollment application to Medicare, changing their enrollment information, revalidating or re-enrolling in the Medicare program. PMID:18677828

  3. 75 FR 44313 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-28

    ... rule (75 FR 1844), entitled ``Medicare and Medicaid Programs; Electronic Health Record Incentive... technology are coordinated. In the interim final rule published on January 13, 2010 (75 FR 2014) entitled... related proposed rule published on March 10, 2010, (75 FR 11328) entitled ``Proposed Establishment...

  4. 75 FR 81885 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Correcting Amendment

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-29

    .... Background In FR Doc. 2010-17207 (75 FR 44314) the final rule entitled ``Medicare and Medicaid Programs... rule (75 FR 16236) on the electronic prescribing of controlled substances. We are aligning our... the Preamble In FR Doc. 2010-17207 of July 28, 2010, we make the following corrections: ] 1. On...

  5. 78 FR 72155 - Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-02

    ... January 1, 2012, did function for 3 or more years (76 FR 70289). The 3-year MLR is designed to represent a...) Prospective Payment System (PPS) On August 12, 2010, we published in the Federal Register a final rule (75 FR... Register, a final rule (76 FR 70228 through 70316) titled, ``Medicare Program; End-Stage Renal...

  6. 75 FR 49215 - Medicare Program; End-Stage Renal Disease Quality Incentive Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-12

    .... 110-275) NQF National Quality Forum PPS Prospective payment system QIP Quality incentive program... on http://www.medicare.gov that was modeled after Nursing Home Compare and continues to be used by... national averages for total performance and individual quality measure performance. We believe...

  7. Individualizing Medicare.

    PubMed

    Chollet, D J

    1999-05-01

    Despite the enactment of significant changes to the Medicare program in 1997, Medicare's Hospital Insurance trust fund is projected to be exhausted just as the baby boom enters retirement. To address Medicare's financial difficulties, a number of reform proposals have been offered, including several to individualize Medicare financing and benefits. These proposals would attempt to increase Medicare revenues and reduce Medicare expenditures by having individuals bear risk--investment market risk before retirement and insurance market risk after retirement. Many fundamental aspects of these proposals have yet to be worked out, including how to guarantee a baseline level of saving for health insurance after retirement, how retirees might finance unanticipated health insurance price increases after retirement, the potential implications for Medicaid of inadequate individual saving, and whether the administrative cost of making the system fair and adequate ultimately would eliminate any rate-of-return advantages from allowing workers to invest their Medicare contributions in corporate stocks and bonds.

  8. Individualizing Medicare.

    PubMed

    Chollet, D J

    1999-05-01

    Despite the enactment of significant changes to the Medicare program in 1997, Medicare's Hospital Insurance trust fund is projected to be exhausted just as the baby boom enters retirement. To address Medicare's financial difficulties, a number of reform proposals have been offered, including several to individualize Medicare financing and benefits. These proposals would attempt to increase Medicare revenues and reduce Medicare expenditures by having individuals bear risk--investment market risk before retirement and insurance market risk after retirement. Many fundamental aspects of these proposals have yet to be worked out, including how to guarantee a baseline level of saving for health insurance after retirement, how retirees might finance unanticipated health insurance price increases after retirement, the potential implications for Medicaid of inadequate individual saving, and whether the administrative cost of making the system fair and adequate ultimately would eliminate any rate-of-return advantages from allowing workers to invest their Medicare contributions in corporate stocks and bonds. PMID:10915458

  9. 42 CFR 417.550 - Special Medicare program requirements.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    .... (a) Principle. CMS pays the full reasonable cost incurred by an HMO or CMP for activities that are... decreases in the number of Medicare enrollees. (2) Obtaining independent certification of the HMO's or...

  10. 42 CFR 417.550 - Special Medicare program requirements.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... requirements. (a) Principle. CMS pays the full reasonable cost incurred by an HMO or CMP for activities that... decreases in the number of Medicare enrollees. (2) Obtaining independent certification of the HMO's or...

  11. 42 CFR 417.550 - Special Medicare program requirements.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... requirements. (a) Principle. CMS pays the full reasonable cost incurred by an HMO or CMP for activities that... decreases in the number of Medicare enrollees. (2) Obtaining independent certification of the HMO's or...

  12. 42 CFR 421.316 - Limitation on Medicare integrity program contractor liability.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... Contractors § 421.316 Limitation on Medicare integrity program contractor liability. (a) A MIP contractor, a... services to a MIP contractor is not in violation of any criminal law or civilly liable under any law of...

  13. 42 CFR 421.316 - Limitation on Medicare integrity program contractor liability.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Contractors § 421.316 Limitation on Medicare integrity program contractor liability. (a) A MIP contractor, a... services to a MIP contractor is not in violation of any criminal law or civilly liable under any law of...

  14. 77 FR 37678 - Medicare and Medicaid Programs; Application From American Association for Accreditation of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-22

    ... American Association for Accreditation of Ambulatory Surgery Facilities for Continued Approval of Its Ambulatory Surgery Facilities Accreditation Program AGENCY: Centers for Medicare and Medicaid Services, HHS... application from the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)...

  15. Public financing of the Medicare program will make its uniform structure increasingly costly to sustain.

    PubMed

    Baicker, Katherine; Shepard, Mark; Skinner, Jonathan

    2013-05-01

    The US Medicare program consumes an ever-rising share of the federal budget. Although this public spending can produce health and social benefits, raising taxes to finance it comes at the cost of slower economic growth. In this article we describe a model incorporating the benefits of public programs and the cost of tax financing. The model implies that the "one-size-fits-all" Medicare program, with everyone covered by the same insurance policy, will be increasingly difficult to sustain. We show that a Medicare program with guaranteed basic benefits and the option to purchase additional coverage could lead to more unequal health spending but slower growth in taxation, greater overall well-being, and more rapid growth of gross domestic product. Our framework highlights the key trade-offs between Medicare spending and economic prosperity.

  16. Public Financing Of The Medicare Program Will Make Its Uniform Structure Increasingly Costly To Sustain

    PubMed Central

    Baicker, Katherine; Shepard, Mark; Skinner, Jonathan

    2013-01-01

    The US Medicare program consumes an ever-rising share of the federal budget. Although this public spending can produce health and social benefits, raising taxes to finance it comes at the cost of slower economic growth. In this article we describe a model incorporating the benefits of public programs and the cost of tax financing. The model implies that the “one-size-fits-all” Medicare program, with everyone covered by the same insurance policy, will be increasingly difficult to sustain. We show that a Medicare program with guaranteed basic benefits and the option to purchase additional coverage could lead to more unequal health spending but slower growth in taxation, greater overall well-being, and more rapid growth of gross domestic product. Our framework highlights the key trade-offs between Medicare spending and economic prosperity. PMID:23650321

  17. 75 FR 32480 - Funding Opportunity: Affordable Care Act Medicare Beneficiary Outreach and Assistance Program...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-08

    ... HUMAN SERVICES Administration on Aging Funding Opportunity: Affordable Care Act Medicare Beneficiary...: Availability of funding opportunity announcement. Funding Opportunity Title/Program Name: Affordable Care Act... Protection and Affordable Care Act of 2010 (Affordable Care Act). Catalog of Federal Domestic...

  18. 42 CFR 420.410 - Establishment of a program to collect suggestions for improving Medicare program efficiency and...

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... Section 420.410 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... monetary savings to the Medicare program. (b) General rule. CMS may make payment for adopted suggestions.... (g) Basis for reward payment—(1) General rule. If CMS determines that it is appropriate to make...

  19. 78 FR 5458 - Medicare Program; Request for Information To Aid in the Design and Development of a Survey...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-01-25

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Request for Information To Aid in the Design and Development of a Survey Regarding Patient and Family Member/Friend Experiences With Hospice Care AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Request for...

  20. Fraud fighters gain muscle. As fraud cases mount, fledgling program aims to step up policing of Medicare contractors.

    PubMed

    Hallam, K; Taylor, M

    1999-08-16

    The use of fiscal intermediaries to police Medicare claims has come under the spotlight, mainly because many of those contractors have themselves settled Medicare or Medicaid fraud charges. One answer: the new Medicare Integrity Program, which will beef up federal fraud fighters. PMID:10557464

  1. Medicare program; end-stage renal disease prospective payment system, quality incentive program, and bad debt reductions for all Medicare providers. Final rule.

    PubMed

    2012-11-01

    This final rule updates and makes revisions to the end-stage renal disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2013. This rule also sets forth requirements for the ESRD quality incentive program (QIP), including for payment year (PY) 2015 and beyond. In addition, this rule implements changes to bad debt reimbursement for all Medicare providers, suppliers, and other entities eligible to receive Medicare payment for bad debt and removes the cap on bad debt reimbursement to ESRD facilities. (See the Table of Contents for a listing of the specific issues addressed in this final rule.)

  2. Medical care program compliance--a year 2000 recipient perspective of Medicare claims.

    PubMed

    Eddy, C A; Liberman, A; Falen, T

    2000-12-01

    This article provides a brief assessment of patient and provider views and concerns regarding reimbursements under the Medicare program. Specifically targeted is the payment of pharmaceutical claims. Also addressed are the ongoing and respective responsibilities of individual clinical providers, associated hospitals, and recipients of care. A summation of significant results of direct interviews and follow-up discussions with 10 Medicare recipients also is provided.

  3. 77 FR 9179 - Medicare Program; Reporting and Returning of Overpayments

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-02-16

    ... regulations related to Medicare overpayments. (See the March 25, 1998 (63 FR 14506) and January 25, 2002 (67 FR 3662) proposed rules.) On March 23, 2010, the Patient Protection and Affordable Care Act (Pub. L... Federal Register, (63 FR 58400) the OIG published a notice stating-- is intended to facilitate...

  4. Medicare program; Medicare ambulance MMA temporary rate increases beginning July 1, 2004. Interim final rule with comment period.

    PubMed

    2004-07-01

    This interim final rule codifies the four payment provisions for Medicare covered ambulance services contained in section 414 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA).

  5. 78 FR 46339 - Medicare, Medicaid, and Children's Health Insurance Programs: Announcement of Temporary Moratoria...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-31

    ... Children's Health Insurance Program (CHIP). Section 6401(a) of the Affordable Care Act added a new section... titled, ``Medicare, Medicaid, and Children's Health Insurance Programs; Additional Screening Requirements... and the Children's Health Insurance Program (CHIP) The February 2, 2011 final rule also...

  6. The Affordable Care Act and the Medicare program: the engines of true health reform.

    PubMed

    Kinney, Eleanor D

    2013-01-01

    The Patient Protection and Affordable Care Act and its amendments by the Health Care and Education Reconciliation Act of 2010 constitute landmark legislation known as the Affordable Care Act (ACA). The ACA has made many changes in the Medicare program as part of comprehensive health reform for the U.S. health care sector. Title III of the ACA pertains to improving the efficiency and quality of health care. Title VI calls for greater program integrity for all federally funded health insurance programs. Collectively, the changes in Medicare in these two titles address the three major problems that the Medicare program has faced since its inception: cost and volume inflation, quality assurance, and fraud and abuse. These changes, if successfully implemented, will have a dramatic impact on the reform of the American health care sector. The policy-making process in the Medicare program is exemplary of the process of "muddling through," as described by the Yale economist Charles E. Lindblom. Nevertheless, these changes may also prepare the Medicare program to be transformed, through several incremental changes in upcoming years, into a single payer system.

  7. The ephemeral accountable care organization-an unintended consequence of the Medicare shared savings program.

    PubMed

    Harvey, H Benjamin; Gowda, Vrushab; Gazelle, G Scott; Pandharipande, Pari V

    2014-02-01

    A fundamental element of health care payment reform under the Affordable Care Act is the development of Accountable Care Organizations (ACOs). The ACO model employs shared-risk contracts to better align the interests of health care providers and payers with the intent of driving efficiency and quality in care. The Medicare Shared Savings Program is the most popular of the Medicare ACO programs, with over 200 health systems across the nation participating at this time. However, a pitfall in the way that the Medicare Shared Savings Program is structured, specifically the benchmarking and rebasing method, could make it difficult for even top-performing ACOs to achieve sustained success, thereby threatening the long-term viability of the program. In this paper, we present this pitfall to the radiology community as well as potential solutions that can be considered by CMS moving forward.

  8. The ephemeral accountable care organization-an unintended consequence of the Medicare shared savings program.

    PubMed

    Harvey, H Benjamin; Gowda, Vrushab; Gazelle, G Scott; Pandharipande, Pari V

    2014-02-01

    A fundamental element of health care payment reform under the Affordable Care Act is the development of Accountable Care Organizations (ACOs). The ACO model employs shared-risk contracts to better align the interests of health care providers and payers with the intent of driving efficiency and quality in care. The Medicare Shared Savings Program is the most popular of the Medicare ACO programs, with over 200 health systems across the nation participating at this time. However, a pitfall in the way that the Medicare Shared Savings Program is structured, specifically the benchmarking and rebasing method, could make it difficult for even top-performing ACOs to achieve sustained success, thereby threatening the long-term viability of the program. In this paper, we present this pitfall to the radiology community as well as potential solutions that can be considered by CMS moving forward. PMID:24360903

  9. Medicare Part D and the Federal Employees Health Benefits Program: A Comparison of Prescription Drug Coverage

    PubMed Central

    Lovett, Annesha

    2013-01-01

    Background There is much debate currently about how to restructure the Medicare program to achieve better value for the money. Many have cited the Federal Employees Health Benefits Program (FEHBP) as a model for reform. Objective To compare drug coverage and cost-sharing between Medicare Part D and the FEHBP plans. Methods A cross-sectional comparison was conducted of January 2009 data obtained from the Centers for Medicare & Medicaid Services, the Office of Personnel Management, and 3 health plan websites. Regression analysis and t-tests were used to examine drug coverage, copayment, and coinsurance amounts among Medicare Part D and FEHBP plans. The final study sample of Medicare Part D plans consisted of 19 formularies, covering 63% of total Part D enrollment. These 19 formularies represented 232 stand-alone prescription drug plans. In addition, 5 prescription drug plans or formularies in the FEHBP plans were included, which represents 70% of total FEHBP enrollment. Results The results of this study reveal that formulary coverage of the top drugs dispensed and sold in the United States in 2009 ranged from 72% to 94% (average, 84%) in Medicare Part D plans and from 85% to 99% (average, 94%) in the FEHBP plans (P <.01). The mean copayment for generic drugs in Medicare Part D plans was $4.53 compared with a mean of $7.67 (P <.05) in the FEHBP plans. The difference between the 2 programs in mean copayment for brand-name drugs was nonsignificant. For generic drugs, the mean coinsurance rate was 17% for Medicare Part D plans and a mean of 20% for the FEHBP plans (P <.05). Conclusions This analysis shows that there are differences in prescription drug coverage and cost-sharing among plans within Medicare Part D and the FEHBP. To avoid extreme increases in payroll taxes and other revenues or major cutbacks in services, Medicare must explore ways to change the healthcare system to achieve better value for the money. The experience of the FEHBP suggests a possible means of

  10. 75 FR 69682 - Medicare and Medicaid Programs; Approval of Det Norske Veritas Healthcare for Deeming Authority...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-15

    ..., 2010 Federal Register (75 FR 43531), we published a proposed notice announcing DNVHC's request for... Norske Veritas Healthcare for Deeming Authority for Critical Access Hospitals AGENCY: Centers for... program for critical access hospitals seeking to participate in the Medicare or Medicaid programs....

  11. 78 FR 38679 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-06-27

    ... Program. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2013-10234 of May 10, 2013 (78 FR 27486... errors. ] III. Correction of Errors In FR Doc. 2013-10234 of May 10, 2013 (78 FR 27486), make the...-AR53 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and...

  12. 77 FR 70785 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-27

    ... the Children's Health Insurance Program (CHIP). This meeting is open to the public. DATES: Meeting..., Medicare, Medicaid and the Children's Health Insurance Program (CHIP). Enhancing the federal government's... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH...

  13. 76 FR 11782 - Medicare, Medicaid, and Children's Health Insurance Programs; Renewal, Expansion, and Renaming of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-03

    ... with or who are eligible for Medicare, Medicaid and the Children's Health Insurance Program (CHIP... Insurance Assistance Programs (SHIPs), health insurance plans, aging, Web health education, e-prescribing... insurance exchanges, and minority health education. We are requesting that all curricula vitae include...

  14. 77 FR 37681 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-22

    ... Health Insurance Program (CHIP). This meeting is open to the public. ] DATES: Meeting Date: Thursday... enrolled in, or eligible for, Medicare, Medicaid and the Children's Health Insurance Program (CHIP... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH...

  15. 78 FR 12327 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-22

    ... the Children's Health Insurance Program (CHIP). This meeting is open to the public. DATES: Meeting..., Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). Enhancing the federal governments... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH...

  16. 76 FR 61365 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-04

    ... the Children's Health Insurance Program (CHIP). This meeting is open to the public. DATES: Meeting..., Medicare, Medicaid and the Children's Health Insurance Program (CHIP). Enhancing the Federal government's... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH...

  17. 78 FR 32661 - Medicare, Medicaid, and Children's Health Insurance Programs; Renewal of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-31

    ... the Children's Health Insurance Program (CHIP), and also expanded the availability of other options... are eligible for Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) about options... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH...

  18. 78 FR 32664 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-31

    ... the Children's Health Insurance Program (CHIP). This meeting is open to the public. DATES: Meeting... enrolled in, or eligible for, Medicare, Medicaid and the Children's Health Insurance Program (CHIP... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH...

  19. ACOs in real life: a reflection on the Medicare Shared Savings Program.

    PubMed

    Behm, Craig R

    2015-01-01

    The Medicare Shared Savings Program introduced Accountable Care Organizations (ACOs) as one potential method for meeting the often-cited triple aim of better individual care, improved population health, and lower cost. Built on concepts originating from HMOs and then Medicare Advantage plans, ACOs provide incentives based on total cost of care rather than any individual provider's cost. Early quality and cost results are mixed, and, more importantly, so is physician response. The ACO program still has potential to be a bright spot for the future of healthcare, but until there is widespread physician engagement, achieving the triple aim is likely to remain elusive.

  20. Medical students' attitudes on physician fraud and abuse in the Medicare and Medicaid programs.

    PubMed

    Keenan, C E; Brown, G C; Pontell, H N; Geis, G

    1985-03-01

    The authors in this paper report the findings of a survey of medical students at the University of California, Irvine, California College of Medicine regarding their views on the Medicare and Medicaid programs and on the problem of fraud and abuse in these government medical benefit programs. The students were asked their views on four issues: (a) the quality of various aspects of Medicare and Medicaid; (b) the seriousness and prevalence of physician fraud and abuse in the programs; (c) the punishment that should be given to violators; and (d) the causes and prevention of fraud and abuse in Medicare and Medicaid. They viewed fraud and abuse as serious but not as being widespread. They believed that physicians who violate program regulations are not likely to be punished by official agencies. They favored moderate penalties for violations. Explanations offered by the students for fraud and abuse focused on physicians' attitudes and motivations as well as on the structure of the Medicare and Medicaid programs.

  1. Assessing Medicare's hospital pay-for-performance programs and whether they are achieving their goals.

    PubMed

    Kahn, Charles N; Ault, Thomas; Potetz, Lisa; Walke, Thomas; Chambers, Jayne Hart; Burch, Samantha

    2015-08-01

    Three separate pay-for-performance programs affect the amount of Medicare payment for inpatient services to about 3,400 US hospitals. These payments are based on hospital performance on specified measures of quality of care. A growing share of Medicare hospital payments (6 percent by 2017) are dependent upon how hospitals perform under the Hospital Readmissions Reduction Program, the Value-Based Purchasing Program, and the Hospital-Acquired Condition Reduction Program. In 2015 four of five hospitals subject to these programs will be penalized under one or more of them, and more than one in three major teaching hospitals will be penalized under all three. Interactions among these programs should be considered going forward, including overlap among measures and differences in scoring performance. PMID:26240240

  2. 77 FR 4908 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-02-01

    ... INFORMATION: I. Background In FR Doc. 2011-19719 of August 18, 2011 (76 FR 51476), the final rule entitled... Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2012 Rates; Corrections AGENCY: Centers...

  3. 78 FR 15882 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-13

    ... FR 60315) included several corrections to figures and data for the Hospital Readmissions Reduction... August 31, 2012 Federal Register (77 FR 53258), we published a final rule entitled ``Medicare Program... the October 3, 2012 Federal Register (77 FR 60315); October 17, 2012 Federal Register (77 FR...

  4. 76 FR 10598 - Medicare and Medicaid Programs; Approval of the Joint Commission for Deeming Authority for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-25

    ... to Comments In the October 22, 2010 Federal Register (75 FR 65360), we published a proposed notice... Joint Commission for Deeming Authority for Psychiatric Hospitals AGENCY: Centers for Medicare & Medicaid... Commission for recognition as a national accreditation program for psychiatric hospitals seeking...

  5. 75 FR 60640 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-10-01

    .... Background In FR Doc. 2010-19092 of August 16, 2010 (75 FR 50042), there were a number of technical errors... FR Doc. 2010-19092 of August 16, 2010, make the following corrections: A. Corrections to the Preamble..., 485, and 489 RIN 0938-AP80; RIN 0938-AP33 Medicare Program; Hospital Inpatient Prospective...

  6. 76 FR 34633 - Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-14

    .... SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2011-9644 of May 5, 2011 (76 FR 25788), there were a number...InpatientPPS/01_overview.asp ). III. Correction of Errors In FR Doc. 2011-9644 of May 5, 2011 (76 FR 25788... Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for Acute...

  7. 78 FR 7434 - Medicare Program: Notice of Two Membership Appointments to the Advisory Panel on Hospital...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-01

    ... Program; Solicitation of Two Nominations to the Advisory Panel on Hospital Outpatient Payment'' (77 FR... Appointments to the Advisory Panel on Hospital Outpatient Payment AGENCY: Centers for Medicare & Medicaid... announces two new membership appointments to the Advisory Panel on Hospital Outpatient Payment (HOP,...

  8. 77 FR 27869 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-11

    ... Web page at: http://www.gpo.gov/fdsys/browse/collection.action?collectionCode=FR . Free public access... CFR Parts 412, 413, 424, et. al Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year...

  9. 76 FR 59263 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-26

    ... care hospital quality measures. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2011-19719 of August 18, 2011 (76 FR 51476), the final rule entitled ``Medicare Program; Hospital Inpatient Prospective... requirements. IV. Correction of Errors In FR Doc. 2011-19719 of August 18, 2011 (76 FR 51476), make...

  10. 77 FR 53257 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-31

    ... Printing Office Web page at: http://www.gpo.gov/fdsys/browse/collection.action?collectionCode=FR . Free... 42 CFR Parts 412, 413, 424, et al. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal...

  11. 77 FR 5213 - Medicare Program; Emergency Medical Treatment and Labor Act (EMTALA): Applicability to Hospital...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-02-02

    ... previously discussed the applicability of EMTALA to hospital inpatients in the May 9, 2002 (67 FR 31475... Hospital IPPS proposed rule (73 FR 23669) entitled, ``Medicare Program; Proposed Changes to the Hospital... to as the FY 2003 IPPS proposed rule) and the September 9, 2003 (68 FR 53243) stand-alone final...

  12. 77 FR 60315 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-10-03

    .... SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2012-19079 of August 31, 2012 (77 FR 53258), there were a... effective date requirements. ] IV. Correction of Errors In FR Doc. 2012-19079 of August 31, 2012 (77 FR...-AR12 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and...

  13. 76 FR 25459 - Medicare & Medicaid Programs; Influenza Vaccination Standard for Certain Participating Providers...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-04

    ..., Long-Term Care Facilities, and Home Health Agencies'' (67 FR 61808) that removed the patient-specific... Participation: Immunization Standard for Long Term Care Facilities'' (70 FR 58834) that requires participating... 42 CFR Parts 482, 485, 491, et al. Medicare & Medicaid Programs; Influenza Vaccination Standard...

  14. 78 FR 63984 - Medicare and Medicaid Programs: Application From the Joint Commission for Continued Approval of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-10-25

    ... Medicare or Medicaid programs. Section 1865(b)(3)(A) of the Social Security Act (the Act) requires that... certain requirements are met. Sections 1861(o) and 1891 of the Social Security Act (the Act), establish... participation. If an accrediting organization is recognized by the Secretary as having standards...

  15. Evaluation of Student Outcomes after Participating in a Medicare Outreach Program

    ERIC Educational Resources Information Center

    Hollingsworth, Joshua C.; Teeter, Benjamin S.; Westrick, Salisa C.

    2015-01-01

    This article describes the development of a service-learning project and analysis of student pharmacists' participation therein. Using a mixed-methods approach, this study analyzed student pharmacists' knowledge and attitudes after volunteering in the inaugural Medicare Outreach Program, a collaboration between the School of Pharmacy and State…

  16. 78 FR 38594 - Medicare and Medicaid Programs; Requirements for Long Term Care Facilities; Hospice Services

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-06-27

    ... the June 5, 2008 final rule (73 FR 32088) titled ``Medicare and Medicaid Program: Hospice Conditions..., 2010 (75 FR 65282). In that rule, we proposed to revise the requirements that an institution would have...'' (76 FR 9503). The interim final rule added separate standards at Sec. Sec. 483.75(r) and (s)....

  17. 75 FR 65282 - Medicare and Medicaid Programs; Requirements for Long Term Care Facilities; Hospice Services

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-10-22

    ... forth requirements consistent with requirements in the June 5, 2008 final rule (73 FR 32088) entitled... skilled nursing facility (SNF) in the Medicare program, or as a nursing facility (NF) in the Medicaid... the hospice) is required to have the lead in providing required end-of-life care to SNF residents...

  18. 78 FR 59704 - Medicare, Medicaid, and CLIA Programs; Clinical Laboratory Improvement Amendments of 1988...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-27

    ... Services (HHS). Under section 1861(s) of the Social Security Act (the Act), the Medicare program will only..., the state generally must demonstrate that: It has state laws in effect that provide for a state... of the costs associated with establishing, maintaining, and improving the CLIA computer system,...

  19. 76 FR 78741 - Medicare, Medicaid, Children's Health Insurance Programs; Transparency Reports and Reporting of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-19

    ...This proposed rule would require applicable manufacturers of drugs, devices, biologicals, or medical supplies covered by Medicare, Medicaid or the Children's Health Insurance Program (CHIP) to report annually to the Secretary certain payments or transfers of value provided to physicians or teaching hospitals (``covered recipients''). In addition, applicable manufacturers and applicable group......

  20. 76 FR 65885 - Medicare Program; Changes to the Ambulatory Surgical Centers Patient Rights Conditions for Coverage

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-24

    ... rule (75 FR 21207) in the Federal Register entitled, ``Medicare Programs; Ambulatory Surgical Centers... November 18, 2008 Hospital Outpatient PPS Update for CY 2009 final rule (73 FR 68502), which contained a Cf...'' because competency is not a ``health and safety'' law. This is a technical correction and makes no...

  1. Report to the Congress on Nursing and Other Nonphysician Health Professions Educational Programs Reimbursed under Medicare.

    ERIC Educational Resources Information Center

    Health Resources and Services Administration (DHHS/PHS), Rockville, MD. Bureau of Health Professions.

    This report provides information on approved educational activities for nursing and other nonphysician health professions for which reimbursement is made to hospitals under the Medicare program. Information was summarized from an examination of existing data and a special study of the variations that exist in hospital educational activities. The…

  2. 78 FR 17677 - Medicare and Medicaid Programs: Application From the American Osteopathic Association/Healthcare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-22

    ...-Approval of Its Hospital Accreditation Program AGENCY: Centers for Medicare and Medicaid Services, HHS...) for continued recognition as a national accrediting organization for hospitals that wish to... covered services in a hospital provided certain requirements are met by the hospital. Section 1861(e)...

  3. 75 FR 45699 - Medicare Program: Changes to the Hospital Outpatient Prospective Payment System and CY 2010...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-03

    ... (FR) on November 20, 2009, entitled ``Medicare Program: Changes to the Hospital Outpatient Prospective..., (410) 786-0378. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. E0-26499 of November 20, 2009 (74 FR 60316) (hereinafter referred to as the CY 2010 OPPS/ASC final rule), there were several...

  4. 77 FR 55479 - Medicare, Medicaid, and CHIP Programs: Research and Analysis on Impact of CMS Programs on the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-09-10

    ... and Analysis on Impact of CMS Programs on the Indian Health Care System AGENCY: Centers for Medicare... expansion of research on the impact of CMS programs on the Indian health care system through a single source... health care services to American Indian/ Alaska Native (AI/AN) people through a network of...

  5. 78 FR 5459 - Medicare Program; Request for Information To Aid in the Design and Development of a Survey...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-01-25

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Request for Information To Aid in the Design and Development of a Survey Regarding Patient Experiences With Hospital Outpatient...: Request for information. SUMMARY: This document is a request for information regarding hospital...

  6. Evaluation of a high-risk case management pilot program for Medicare beneficiaries with Medigap coverage.

    PubMed

    Hawkins, Kevin; Parker, Paula M; Hommer, Cynthia E; Bhattarai, Gandhi R; Huang, Jinghua; Wells, Timothy S; Ozminkowski, Ronald J; Yeh, Charlotte S

    2015-04-01

    The objective was to evaluate the 3-year experience of a high-risk case management (HRCM) pilot program for adults with an AARP Medicare Supplement (Medigap) Insurance Plan. Participants were provided in-person visits as well as telephonic and mailed services to improve care coordination from December 1, 2008, to December 31, 2011. Included were adults who had an AARP Medigap Insurance Plan, resided in 1 of 5 pilot states, and had a Hierarchical Condition Category score>3.74, or were referred into the program. Propensity score weighting was used to adjust for case-mix differences among 2015 participants and 7626 qualified but nonparticipating individuals. Participants were in the program an average of 15.4 months. After weighting, multiple regression analyses were used to estimate differences in quality of care and health care expenditures between participants and nonparticipants. Increased duration in the program was associated with fewer hospital readmissions. Additionally, participants were significantly more likely to have recurring office visits and recommended laboratory tests. The program demonstrated $7.7 million in savings over the 3 years, resulting in a return on investment of $1.40 saved for every dollar spent on the program. Savings increased each year from 2009 to 2011 and with longer length of engagement. The majority of savings were realized by the federal Medicare program. This study focused on quality of care and savings for an HRCM program designed solely for Medicare members with Medicare Supplement coverage. This program had a favorable impact on quality of care and demonstrated savings over a 3-year period.

  7. Should the Medicare ESRD program fund daily and nocturnal hemodialysis?

    PubMed

    Agar, John W M

    2007-12-01

    A recently published paper concluded that funding for conventional hemodialysis (CHD) should be maintained and that the newer methods of short daily (sDHD) and nocturnal home hemodialysis (NHHD) be denied funding through Medicare until a randomized control trial (RCT) on the benefits of sDHD and/or NHHD are complete. This conclusion is irrespective of the fact that RCT methodology has never been required of CHD itself and irrespective that a host of observational studies (OS) have already confirmed comparative outcome and cost benefit from these novel regimens. It begs the question: How can any RCT of dialysis modality, frequency, duration, location, and lifestyle impact ever be fairly (or ethically) completed? It also invokes a classic Catch-22 funding argument--funding should not be accorded without a fair and ethical RCT, yet a fair and ethical RCT of widely disparate lifestyle-impacting dialysis modalities is effectively impossible. Meanwhile, the better observational outcomes and cost-efficiencies of sDHD and NHHD remain tantalizingly attainable. It is time to recognize that a RCT may not be the best way to evaluate complex dialysis modalities and that available data is adequate to developing funding models. PMID:18038753

  8. Should the Medicare ESRD program fund daily and nocturnal hemodialysis?

    PubMed

    Agar, John W M

    2007-12-01

    A recently published paper concluded that funding for conventional hemodialysis (CHD) should be maintained and that the newer methods of short daily (sDHD) and nocturnal home hemodialysis (NHHD) be denied funding through Medicare until a randomized control trial (RCT) on the benefits of sDHD and/or NHHD are complete. This conclusion is irrespective of the fact that RCT methodology has never been required of CHD itself and irrespective that a host of observational studies (OS) have already confirmed comparative outcome and cost benefit from these novel regimens. It begs the question: How can any RCT of dialysis modality, frequency, duration, location, and lifestyle impact ever be fairly (or ethically) completed? It also invokes a classic Catch-22 funding argument--funding should not be accorded without a fair and ethical RCT, yet a fair and ethical RCT of widely disparate lifestyle-impacting dialysis modalities is effectively impossible. Meanwhile, the better observational outcomes and cost-efficiencies of sDHD and NHHD remain tantalizingly attainable. It is time to recognize that a RCT may not be the best way to evaluate complex dialysis modalities and that available data is adequate to developing funding models.

  9. Medicare and Medicaid programs; revaluation of assets; correction--HCFA. Correcting amendments.

    PubMed

    1993-04-01

    This document contains corrections to final regulations (BPD-311-F) that were published September 23, 1992 (F.R. Doc. 92-22582) (57 FR 43906). The regulations describe new limitations on the valuations of assets acquired as the result of changes in ownership occurring on or after July 18, 1984. These changes affect hospitals and skilled nursing facilities under the Medicare program, and hospitals, nursing facilities, and intermediate care facilities for the mentally retarded under the Medicaid program. PMID:10125233

  10. Avoiding randomization failure in program evaluation, with application to the Medicare Health Support program.

    PubMed

    King, Gary; Nielsen, Richard; Coberley, Carter; Pope, James E; Wells, Aaron

    2011-02-01

    We highlight common problems in the application of random treatment assignment in large-scale program evaluation. Random assignment is the defining feature of modern experimental design, yet errors in design, implementation, and analysis often result in real-world applications not benefiting from its advantages. The errors discussed here cover the control of variability, levels of randomization, size of treatment arms, and power to detect causal effects, as well as the many problems that commonly lead to post-treatment bias. We illustrate these issues by identifying numerous serious errors in the Medicare Health Support evaluation and offering recommendations to improve the design and analysis of this and other large-scale randomized experiments.

  11. TMA Uncovers Medicare Mistakes.

    PubMed

    Sorrel, Amy Lynn

    2015-07-01

    The Texas Medical Association recently uncovered some major Medicare mistakes that show just why some physicians talk about leaving the federal program. Investigations and advocacy by TMA staff put Medicare on the path to a fix. PMID:26201065

  12. TMA Uncovers Medicare Mistakes.

    PubMed

    Sorrel, Amy Lynn

    2015-07-01

    The Texas Medical Association recently uncovered some major Medicare mistakes that show just why some physicians talk about leaving the federal program. Investigations and advocacy by TMA staff put Medicare on the path to a fix.

  13. 77 FR 29001 - Medicare and Medicaid Program; Regulatory Provisions to Promote Program Efficiency, Transparency...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-16

    ... these goals while maintaining high standards for the quality of care delivered to Medicare and Medicaid...) system, the National Healthcare Safety Network (NHSN) that is included in the ESRD Quality Incentive... deemed to meet Medicare standards if they are certified by one of the national accrediting...

  14. Collateral sanctions for criminal convictions in the Medicare and Medicaid programs.

    PubMed

    Griffith, R A

    1990-01-01

    Under current federal and state laws, physicians convicted of Medicare and Medicaid program-related crimes face numerous possible sanctions that may be imposed in addition to the applicable criminal penalties. In this article, the author describes some of the collateral sanctions that physicians and their attorneys should be aware of in order to make informed decisions concerning the proper defense strategy in a criminal case.

  15. Medicare program; competitive acquisition for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) and other issues. Final rule.

    PubMed

    2007-04-10

    This final rule establishes competitive bidding programs for certain Medicare Part B covered items of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) throughout the United States in accordance with sections 1847(a) and (b) of the Social Security Act. These competitive bidding programs, which will be phased in over several years, utilize bids submitted by DMEPOS suppliers to establish applicable payment amounts under Medicare Part B.

  16. Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. Final rule.

    PubMed

    2016-09-16

    This final rule establishes national emergency preparedness requirements for Medicare- and Medicaid-participating providers and suppliers to plan adequately for both natural and man-made disasters, and coordinate with federal, state, tribal, regional, and local emergency preparedness systems. It will also assist providers and suppliers to adequately prepare to meet the needs of patients, residents, clients, and participants during disasters and emergency situations. Despite some variations, our regulations will provide consistent emergency preparedness requirements, enhance patient safety during emergencies for persons served by Medicare- and Medicaid-participating facilities, and establish a more coordinated and defined response to natural and man-made disasters.

  17. Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. Final rule.

    PubMed

    2016-09-16

    This final rule establishes national emergency preparedness requirements for Medicare- and Medicaid-participating providers and suppliers to plan adequately for both natural and man-made disasters, and coordinate with federal, state, tribal, regional, and local emergency preparedness systems. It will also assist providers and suppliers to adequately prepare to meet the needs of patients, residents, clients, and participants during disasters and emergency situations. Despite some variations, our regulations will provide consistent emergency preparedness requirements, enhance patient safety during emergencies for persons served by Medicare- and Medicaid-participating facilities, and establish a more coordinated and defined response to natural and man-made disasters. PMID:27658313

  18. Medicare program; revisions to the Medicare Advantage and Part D prescription drug contract determinations, appeals, and intermediate sanctions processes. Final rule with comment period.

    PubMed

    2007-12-01

    This rule with comment period finalizes the Medicare program provisions relating to contract determinations involving Medicare Advantage (MA) organizations and Medicare Part D prescription drug plan sponsors, including eliminating the reconsideration process for review of contract determinations, revising the provisions related to appeals of contract determinations, and clarifying the process for MA organizations and Part D plan sponsors to complete corrective action plans. In this final rule with comment period, we also clarify the intermediate sanction and civil money penalty (CMP) provisions that apply to MA organizations and Medicare Part D prescription drug plan sponsors, modify elements of their compliance plans, retain voluntary self-reporting for Part D sponsors and implement a voluntary self-reporting recommendation for MA organizations, and revise provisions to ensure HHS has access to the books and records of MA organizations and Part D plan sponsors' first tier, downstream, and related entities. Although we have decided not to finalize the mandatory self-reporting provisions that we proposed, CMS remains committed to adopting a mandatory self-reporting requirement. To that end, we are requesting comments that will assist CMS in crafting a future proposed regulation for a mandatory self-reporting requirement. PMID:18064773

  19. 77 FR 26553 - Medicare Program; Meeting of the Medicare Economic Index Technical Advisory Panel-May 21, 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-04

    ... adjustment. For more information on the Panel, see the October 7, 2011 Federal Register (76 FR 62415). You... Economic Index Technical Advisory Panel--May 21, 2012 AGENCY: Centers for Medicare & Medicaid Services (CMS... Economic Index Technical Advisory Panel (``the Panel'') will be held on Monday, May 21, 2012. The...

  20. Health Care Financing Administration--Medicare and Medicaid programs; protection of patients' funds. Final regulation.

    PubMed

    1980-07-24

    This rule sets forth expanded standards for protection of personal funds of patients in skilled nursing facilities (SNFs) and intermediate care facilities (ICFs) that participate in the Medicare or Medicaid programs. The changes are required for SNFs by Section 21(a) of Pub. L. 95-142, the Medicare-Medcaid Anti-Fraud and Abuse Amendments of 1977, and for ICFs by Section 8(c) of Pub. L. 95-292, the End-Stage Renal Disease Amendments of 1978. The intent is to safeguard patient funds from misuse by facilities, and to assure that personal funds held by the the facilities are fully accounted for and made available to patients when they need or want them. PMID:10297939

  1. 75 FR 49029 - Medicare Program; End-Stage Renal Disease Prospective Payment System

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-12

    ... Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Parts 410, 413 and 414 Medicare... HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 410, 413 and 414 RIN 0938... AV Arteriovenous BIPA Medicare, Medicaid, and SCHIP (State Children's Health Insurance...

  2. Special report on reimbursement. Medicare program abandons 1986 malpractice rule.

    PubMed

    Manning, M M

    1992-01-01

    Hospitals with claims "properly pending" before fiscal intermediaries or in the courts need do nothing in order to obtain corrected reimbursement for fiscal years so pending. However, to speed processing of corrected reimbursements for fiscal years pending in appeals before the PRRB, hospitals should request that the Board determine its jurisdiction and remand to the fiscal intermediary for payment as soon as possible. It will be helpful to include with any such request a copy of the notice of program reimbursement and the original appeal letter for each fiscal year under appeal. Despite the fact that HCFA Ruling 91-1 effectively concedes that HCFA has applied an invalid regulation to all fiscal years since May 1, 1986, HCFA counsel have stated that HCFA will not permit reopening of closed cost reports to correct the inappropriate apportionment of malpractice insurance costs. Nevertheless, hospitals that do not presently have a claim or appeal pending have several options. Under the Provider Reimbursement Manual, HIM-15, sections 2930-2931, fiscal intermediaries are required to reopen cost reports filed within the three-year reopening period to correct errors. Accordingly, should a fiscal intermediary deny a provider's reopening request, the provider should seriously consider taking an appeal to the PRRB. The PRRB's jurisdiction to review fiscal intermediary denials of requests to reopen cost reports was affirmed by the United States Court of Appeals for the Ninth Circuit, see State of Oregon v. Bowen, 854 F.2d 346 (9th Cir. 1988), a decision that is controlling in California, Oregon, Washington, Nevada, Arizona, Montana, Idaho, Hawaii, Alaska, Guam, and the Northern Mariana Islands.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:10117365

  3. Adding A Spending Metric To Medicare's Value-Based Purchasing Program Rewarded Low-Quality Hospitals.

    PubMed

    Das, Anup; Norton, Edward C; Miller, David C; Ryan, Andrew M; Birkmeyer, John D; Chen, Lena M

    2016-05-01

    In fiscal year 2015 the Centers for Medicare and Medicaid Services expanded its Hospital Value-Based Purchasing program by rewarding or penalizing hospitals for their performance on both spending and quality. This represented a sharp departure from the program's original efforts to incentivize hospitals for quality alone. How this change redistributed hospital bonuses and penalties was unknown. Using data from 2,679 US hospitals that participated in the program in fiscal years 2014 and 2015, we found that the new emphasis on spending rewarded not only low-spending hospitals but some low-quality hospitals as well. Thirty-eight percent of low-spending hospitals received bonuses in fiscal year 2014, compared to 100 percent in fiscal year 2015. However, low-quality hospitals also began to receive bonuses (0 percent in fiscal year 2014 compared to 17 percent in 2015). All high-quality hospitals received bonuses in both years. The Centers for Medicare and Medicaid Services should consider incorporating a minimum quality threshold into the Hospital Value-Based Purchasing program to avoid rewarding low-quality, low-spending hospitals.

  4. Adding A Spending Metric To Medicare's Value-Based Purchasing Program Rewarded Low-Quality Hospitals.

    PubMed

    Das, Anup; Norton, Edward C; Miller, David C; Ryan, Andrew M; Birkmeyer, John D; Chen, Lena M

    2016-05-01

    In fiscal year 2015 the Centers for Medicare and Medicaid Services expanded its Hospital Value-Based Purchasing program by rewarding or penalizing hospitals for their performance on both spending and quality. This represented a sharp departure from the program's original efforts to incentivize hospitals for quality alone. How this change redistributed hospital bonuses and penalties was unknown. Using data from 2,679 US hospitals that participated in the program in fiscal years 2014 and 2015, we found that the new emphasis on spending rewarded not only low-spending hospitals but some low-quality hospitals as well. Thirty-eight percent of low-spending hospitals received bonuses in fiscal year 2014, compared to 100 percent in fiscal year 2015. However, low-quality hospitals also began to receive bonuses (0 percent in fiscal year 2014 compared to 17 percent in 2015). All high-quality hospitals received bonuses in both years. The Centers for Medicare and Medicaid Services should consider incorporating a minimum quality threshold into the Hospital Value-Based Purchasing program to avoid rewarding low-quality, low-spending hospitals. PMID:27140997

  5. Medicare and Medicaid Programs; Fire Safety Requirements for Certain Health Care Facilities. Final rule.

    PubMed

    2016-05-01

    This final rule will amend the fire safety standards for Medicare and Medicaid participating hospitals, critical access hospitals (CAHs), long-term care facilities, intermediate care facilities for individuals with intellectual disabilities (ICF-IID), ambulatory surgery centers (ASCs), hospices which provide inpatient services, religious non-medical health care institutions (RNHCIs), and programs of all-inclusive care for the elderly (PACE) facilities. Further, this final rule will adopt the 2012 edition of the Life Safety Code (LSC) and eliminate references in our regulations to all earlier editions of the Life Safety Code. It will also adopt the 2012 edition of the Health Care Facilities Code, with some exceptions. PMID:27192728

  6. State Regulatory Enforcement and Nursing Home Termination from the Medicare and Medicaid Programs

    PubMed Central

    Li, Yue; Harrington, Charlene; Spector, William D; Mukamel, Dana B

    2010-01-01

    Objectives Nursing homes certified by the Medicare and/or Medicaid program are subject to federally mandated and state-enforced quality and safety standards. We examined the relationship between state quality enforcement and nursing home terminations from the two programs. Study Design Using data from a survey of state licensure and certification agencies and other secondary databases, we performed bivariate and multivariate analyses on the strength of state quality regulation in 2005, and nursing home voluntary terminations (decisions made by the facility) or involuntary terminations (imposed by the state) in 2006–2007. Principal Findings Involuntary terminations were rarely imposed by state regulators, while voluntary terminations were relatively more common (2.16 percent in 2006–2007) and varied considerably across states. After controlling for facility, market, and state covariates, nursing homes in states implementing stronger quality enforcement were more likely to voluntarily terminate from the Medicare and Medicaid programs (odds ratio=1.53, p=.018). Conclusions Although involuntary nursing home terminations occurred rarely in most states, nursing homes in states with stronger quality regulations tend to voluntarily exit the publicly financed market. Because of the consequences of voluntary terminations on patient care and access, state regulators need to consider the effects of increased enforcement on both enhanced quality and the costs of termination. PMID:20819106

  7. 76 FR 59136 - Medicare and Medicaid Programs; Application by Community Health Accreditation Program for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-23

    ... 24, 2011. ADDRESSES: In commenting, please refer to file code CMS-2377-PN. Because of staff and... Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-2377-PN, P.O. Box..., Attention: CMS-2377-PN, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850. 4. By hand...

  8. 76 FR 65909 - Medicare and Medicaid Program; Regulatory Provisions To Promote Program Efficiency, Transparency...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-24

    ... requirements. ASCs also may be deemed to meet Medicare standards if they are certified by one of the national... homes must be surveyed for compliance with certification standards at intervals of between 12 and 15... patient care, by eliminating or reducing requirements that impede quality patient care or that...

  9. 77 FR 13697 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 2

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-07

    ... Medicare & Medicaid Services CPOE--Computerized Physician Order Entry CY--Calendar Year EHR--Electronic... Ambulatory Health Plan PAPD--Planning Advance Planning Document PFFS--Private Fee-For-Service PHO--Physician... Health Plan POS--Place of Service PPO--Preferred Provider Organization PQRI--Physician Quality...

  10. Eligibility for the Medicare buy-in programs, based on a survey of income and program participation simulation.

    PubMed

    Rupp, K; Sears, J

    2000-01-01

    Medicare buy-in programs are designed to reduce out-of-pocket expenses of beneficiaries with modest income and assets. This article provides estimates of the size of the Medicare beneficiary population eligible for the Qualified Medicare Beneficiary (QMB) program, the Specified Low-Income Medicare Beneficiary (SLMB) program, and the Qualified Individual-1 (QI-1) program. The buy-in programs use the same resource limits (twice those used in the Supplemental Security Income (SSI) program) but different thresholds for determining income eligibility. The QMB program uses 100 percent of the poverty line as the cutoff, QI-1 covers persons above 120 percent but at or below 135 percent of the poverty line, and the SLMB program is in between. Making informed judgments about the rate of participation in the buy-in programs and the need for outreach requires an accurate estimate of the size of the eligible population. If that population is underestimated, policymakers might come to unduly optimistic conclusions about current buy-in participation. In contrast, an overestimate may make current participation seem too low. If policymakers react to an upwardly biased estimate of the eligible population by increasing outreach, they are bound to be disappointed by the results of that effort. Estimates of the eligible population from past studies of the QMB and SLMB programs range from 5.1 million to 9.1 million. In the absence of new information, it is difficult to judge the accuracy of those estimates because the methodologies had substantial shortcomings that might bias the results. The most common shortcomings include the lack of high-quality, monthly income data and the lack of information on assets from the same data file that was used to estimate participation and income eligibility for Medicare. The current study uses the most recently available (as of August 2000) Survey of Income and Program Participation (SIPP) file that is matched to the Social Security Administration

  11. 77 FR 19288 - Medicare Program; Renewal of Deeming Authority of the Utilization Review Accreditation Commission...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-30

    ... specifying the Medicare requirements that must be met for a Medicare Advantage Organization (MAO) to enter... XVIII of the Social Security Act (the Act), which specifies the services that an MAO must provide...

  12. Twenty years of Medicare and Medicaid: Covered populations, use of benefits, and program expenditures

    PubMed Central

    Gornick, Marian; Greenberg, Jay N.; Eggers, Paul W.; Dobson, Allen

    1985-01-01

    Marian Gornick is Director, Division of Beneficiary Studies, in the Office of Research, Health Care Financing Administration. She has been involved in research studies relating to Medicare and Medicaid since the programs were first implemented. Jay N. Greenberg is on the faculty of the Heller Graduate School, Brandeis University. Dr. Greenberg serves as the Associate Director for Research of the school's Health Policy Center. Paul W. Eggers is Chief, Program Evaluation Branch, in the Office of Research, Health Care Financing Administration (HCFA). Dr. Eggers’ research activities involve the evaluation of the impact of HCFA programs on the beneficiaries. Allen Dobson is Director, Office of Research, Health Care Financing Administration. Dr. Dobson is responsible for directing the planning and development of the Agency's research agenda. PMID:10311371

  13. 75 FR 36610 - Medicare and Medicaid Programs: Changes to the Hospital and Critical Access Hospital Conditions...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-28

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 482 and 485 RIN 0938-AQ06 Medicare...: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-3228-P... Human Services, Attention: CMS-3228-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD...

  14. 77 FR 43329 - Medicaid Program; State Allotments for Payment of Medicare Part B Premiums for Qualifying...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-24

    ... for Payment of Medicare Part B Premiums for Qualifying Individuals (QIs) for FY 2012 AGENCY: Centers... States' final allotments available to pay the Medicare Part B premiums for Qualifying Individuals (QIs.... DATES: The final QI allotments for payment of Medicare Part B premiums for FY 2011 are effective...

  15. 76 FR 16793 - Medicare and Medicaid Programs; Renewal of Deeming Authority of the National Committee for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-25

    ... FR 73087) in the Federal Register announcing re-approval of Medicare Advantage Deeming Authority of... Deeming Authority of the National Committee for Quality Assurance for Medicare Advantage Health... Medicare Advantage Deeming Authority of the National Committee for Quality Assurance (NCQA) for...

  16. Medicare in a consumer-choice environment: competitor or residual program?

    PubMed

    Etheredge, L

    1996-01-01

    The Medicare provisions of the reconciliation bill and President Clinton's proposals would both allow many new health plans to compete for Medicare enrollees and structure a competitive, consumer-choice system. Medicare will enter this new environment with serious shortcomings. The logic of market competition will call for upgrading many aspects of Medicare if it is to be successful. Among Medicare's features that need to be reconsidered are benefits, consumer focus, premium financing, payment policies, provider arrangements, performance accountability, management systems, risk adjustment and market strategies, social mission responsibilities, and research and development. PMID:12856666

  17. Physician-owned Surgical Hospitals Outperform Other Hospitals in the Medicare Value-based Purchasing Program

    PubMed Central

    Ramirez, Adriana G; Tracci, Margaret C; Stukenborg, George J; Turrentine, Florence E; Kozower, Benjamin D; Jones, R Scott

    2016-01-01

    Background The Hospital Value-Based Purchasing Program measures value of care provided by participating Medicare hospitals while creating financial incentives for quality improvement and fostering increased transparency. Limited information is available comparing hospital performance across healthcare business models. Study Design 2015 hospital Value-Based Purchasing Program results were used to examine hospital performance by business model. General linear modeling assessed differences in mean total performance score, hospital case mix index, and differences after adjustment for differences in hospital case mix index. Results Of 3089 hospitals with Total Performance Scores (TPS), categories of representative healthcare business models included 104 Physician-owned Surgical Hospitals (POSH), 111 University HealthSystem Consortium (UHC), 14 US News & World Report Honor Roll (USNWR) Hospitals, 33 Kaiser Permanente, and 124 Pioneer Accountable Care Organization affiliated hospitals. Estimated mean TPS for POSH (64.4, 95% CI 61.83, 66.38) and Kaiser (60.79, 95% CI 56.56, 65.03) were significantly higher compared to all remaining hospitals while UHC members (36.8, 95% CI 34.51, 39.17) performed below the mean (p < 0.0001). Significant differences in mean hospital case mix index included POSH (mean 2.32, p<0.0001), USNWR honorees (mean 2.24, p 0.0140) and UHC members (mean =1.99, p<0.0001) while Kaiser Permanente hospitals had lower case mix value (mean =1.54, p<0.0001). Re-estimation of TPS did not change the original results after adjustment for differences in hospital case mix index. Conclusions The Hospital Value-Based Purchasing Program revealed superior hospital performance associated with business model. Closer inspection of high-value hospitals may guide value improvement and policy-making decisions for all Medicare Value-Based Purchasing Program Hospitals. PMID:27502368

  18. Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations--Revised Benchmark Rebasing Methodology, Facilitating Transition to Performance-Based Risk, and Administrative Finality of Financial Calculations. Final rule.

    PubMed

    2016-06-10

    Under the Medicare Shared Savings Program (Shared Savings Program), providers of services and suppliers that participate in an Accountable Care Organization (ACO) continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, but the ACO may be eligible to receive a shared savings payment if it meets specified quality and savings requirements. This final rule addresses changes to the Shared Savings Program, including: Modifications to the program's benchmarking methodology, when resetting (rebasing) the ACO's benchmark for a second or subsequent agreement period, to encourage ACOs' continued investment in care coordination and quality improvement; an alternative participation option to encourage ACOs to enter performance-based risk arrangements earlier in their participation under the program; and policies for reopening of payment determinations to make corrections after financial calculations have been performed and ACO shared savings and shared losses for a performance year have been determined. PMID:27295736

  19. Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations--Revised Benchmark Rebasing Methodology, Facilitating Transition to Performance-Based Risk, and Administrative Finality of Financial Calculations. Final rule.

    PubMed

    2016-06-10

    Under the Medicare Shared Savings Program (Shared Savings Program), providers of services and suppliers that participate in an Accountable Care Organization (ACO) continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, but the ACO may be eligible to receive a shared savings payment if it meets specified quality and savings requirements. This final rule addresses changes to the Shared Savings Program, including: Modifications to the program's benchmarking methodology, when resetting (rebasing) the ACO's benchmark for a second or subsequent agreement period, to encourage ACOs' continued investment in care coordination and quality improvement; an alternative participation option to encourage ACOs to enter performance-based risk arrangements earlier in their participation under the program; and policies for reopening of payment determinations to make corrections after financial calculations have been performed and ACO shared savings and shared losses for a performance year have been determined.

  20. Three large-scale changes to the Medicare program could curb its costs but also reduce enrollment

    PubMed Central

    Eibner, Christine; Goldman, Dana P.; Sullivan, Jeffrey; Garber, Alan M.

    2013-01-01

    Medicare spending accounts for a substantial fraction of Federal spending, and significant program changes may be necessary for long-run fiscal balance. We used a microsimulation approach to estimate how benefit changes to Medicare–including Part A, for hospital care, premiums, premium support credits, and changing the eligibility age–affect long-term Medicare spending and enrollment. All policies considered reduce spending, with reductions ranging from 2.4 to 24 percent between 2012 and 2036. However, the policies also reduce coverage among the elderly. To achieve significant costs savings without causing substantial uninsurance among seniors, benefits changes would likely need to occur in combination with other options. PMID:23650322

  1. Medicare and Medicaid Programs; Electronic Health Record Incentive Program--Stage 3 and Modifications to Meaningful Use in 2015 Through 2017. Final rules with comment period.

    PubMed

    2015-10-16

    This final rule with comment period specifies the requirements that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to qualify for Medicare and Medicaid electronic health record (EHR) incentive payments and avoid downward payment adjustments under the Medicare EHR Incentive Program. In addition, it changes the Medicare and Medicaid EHR Incentive Programs reporting period in 2015 to a 90-day period aligned with the calendar year. This final rule with comment period also removes reporting requirements on measures that have become redundant, duplicative, or topped out from the Medicare and Medicaid EHR Incentive Programs. In addition, this final rule with comment period establishes the requirements for Stage 3 of the program as optional in 2017 and required for all participants beginning in 2018. The final rule with comment period continues to encourage the electronic submission of clinical quality measure (CQM) data, establishes requirements to transition the program to a single stage, and aligns reporting for providers in the Medicare and Medicaid EHR Incentive Programs.

  2. 77 FR 227 - Medicare Program; Payment Policies Under the Physician Fee Schedule, Five-Year Review of Work...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-01-04

    ... physician payment not previously identified. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2011-28597 of November 28, 2011 (76 FR 73026), the final rule with comment period entitled ``Medicare Program.... Correction of Errors 0 In FR Doc. 2011-28597 of November 28, 2011 (76 FR 73026), the final rule with...

  3. 76 FR 32409 - Medicare Program; Five-Year Review of Work Relative Value Units Under the Physician Fee Schedule

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-06

    ... final rule with comment period (75 FR 73328 through 73329). During our clinical review to assess the... comment period (75 FR 73226 through 73227), as described above, in the AMA RUC's review of Site-of-Service... 42 CFR Part 414 Medicare Program; Five-Year Review of Work Relative Value Units Under the...

  4. 76 FR 73025 - Medicare Program; Payment Policies Under the Physician Fee Schedule, Five-Year Review of Work...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-28

    ... Schedule, Five-Year Review of Work Relative Value Units, Clinical Laboratory Fee Schedule: Signature on... Medicare Program; Payment Policies Under the Physician Fee Schedule, Five-Year Review of Work Relative... public, including any personally identifiable or confidential business information that is included in...

  5. 76 FR 18930 - Medicare Programs: Changes to the End-Stage Renal Disease Prospective Payment System Transition...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-06

    ... published a final rule (75 FR 49030 through 49214) in the Federal Register, entitled ``Medicare Program; End... the transition budget-neutrality adjustment. As described in the CY 2011 ESRD PPS final rule (75 FR... FR 49082), we explained that section 1881(b)(14)(E)(iii) of the Act requires that we make...

  6. Medicare Program; FY 2017 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements. Final rule.

    PubMed

    2016-08-01

    This final rule will update the hospice wage index, payment rates, and cap amount for fiscal year (FY) 2017. In addition, this rule changes the hospice quality reporting program, including adopting new quality measures. Finally, this final rule includes information regarding the Medicare Care Choices Model (MCCM).

  7. 76 FR 30170 - Office of the Assistant Secretary for Planning and Evaluation; Medicare Program; Meeting of the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-24

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of the Assistant Secretary for Planning and Evaluation; Medicare Program; Meeting... in nature and will focus on the actuarial and economic assumptions and methods by which...

  8. Medicare Program; FY 2017 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements. Final rule.

    PubMed

    2016-08-01

    This final rule will update the hospice wage index, payment rates, and cap amount for fiscal year (FY) 2017. In addition, this rule changes the hospice quality reporting program, including adopting new quality measures. Finally, this final rule includes information regarding the Medicare Care Choices Model (MCCM). PMID:27529902

  9. 78 FR 69926 - Privacy Act of 1974, as Amended; Computer Matching Program (SSA/Centers for Medicare & Medicaid...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-11-21

    ... From the Federal Register Online via the Government Publishing Office SOCIAL SECURITY ADMINISTRATION Privacy Act of 1974, as Amended; Computer Matching Program (SSA/ Centers for Medicare & Medicaid Services (CMS))--Match Number 1076 AGENCY: Social Security Administration (SSA). ACTION: Notice of...

  10. Medicare and Medicaid programs; advance directives--HCFA. Interim final rule with comment period.

    PubMed

    1992-03-01

    This interim final rule amends the Medicare and Medicaid regulations governing provider agreements and contracts to establish requirements for States, hospitals, nursing facilities, skilled nursing facilities, providers of home health care or personal care services, hospice programs and prepaid health plans concerning advance directives. An advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when an individual's condition makes him or her unable to express his or her wishes. The intent of these provisions is to enhance an individual's control over medical treatment decisions. This rule implements sections 4206 and 4751 of the Omnibus Budget Reconciliation Act of 1990 (OBRA '90), Public Law 101-508.

  11. 77 FR 9931 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-October Through December 2011

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-02-21

    ... Medicare-Approved Lung Volume JoAnna Baldwin, MS (410) 786-7205 Reduction Surgery Facilities. XIV Medicare-Approved Bariatric Surgery Kate Tillman, RN, MAS (410) 786-9252 Facilities. XV Fluorodeoxyglucose...

  12. Recovery of Renal Function among ESRD Patients in the US Medicare Program

    PubMed Central

    Mohan, Sumit; Huff, Edwin; Wish, Jay; Lilly, Michael; Chen, Shu-Cheng; McClellan, William M.

    2013-01-01

    Background Patients started on long term hemodialysis have typically had low rates of reported renal recovery with recent estimates ranging from 0.9–2.4% while higher rates of recovery have been reported in cohorts with higher percentages of patients with acute renal failure requiring dialysis. Study Design Our analysis followed approximately 194,000 patients who were initiated on hemodialysis during a 2-year period (2008 & 2009) with CMS-2728 forms submitted to CMS by dialysis facilities, cross-referenced with patient record updates through the end of 2010, and tracked through December 2010 in the CMS SIMS registry. Results We report a sustained renal recovery (i.e no return to ESRD during the available follow up period) rate among Medicare ESRD patients of > 5% - much higher than previously reported. Recovery occurred primarily in the first 2 months post incident dialysis, and was more likely in cases with renal failure secondary to etiologies associated with acute kidney injury. Patients experiencing sustained recovery were markedly less likely than true long-term ESRD patients to have permanent vascular accesses in place at incident hemodialysis, while non-White patients, and patients with any prior nephrology care appeared to have significantly lower rates of renal recovery. We also found widespread geographic variation in the rates of renal recovery across the United States. Conclusions Renal recovery rates in the US Medicare ESRD program are higher than previously reported and appear to have significant geographic variation. Patients with diagnoses associated with acute kidney injury who are initiated on long-term hemodialysis have significantly higher rates of renal recovery than the general ESRD population and lower rates of permanent access placement. PMID:24358285

  13. 75 FR 14606 - Medicare Program; Request for Nominations to the Advisory Panel on Ambulatory Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-03-26

    ...; Center for Medicare Management, Hospital & Ambulatory Policy Group, Division of Outpatient Care; 7500... components of the Medicare hospital Outpatient Prospective Payment System (OPPS). The Charter requires that... consist of a chair and up to 15 members who are full- time employees of hospitals, hospital systems,...

  14. 77 FR 60703 - Medicare and Medicaid Programs; Announcement of Application From Hospital Requesting Waiver for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-10-04

    ... Application From Hospital Requesting Waiver for Organ Procurement Service Area AGENCY: Centers for Medicare... announces a hospital's request for a waiver from the requirement to have an agreement with its designated.... Once an OPO has been designated for an area, hospitals in that area that participate in Medicare...

  15. 77 FR 17070 - Medicare and Medicaid Programs; Application From Det Norske Veritas Healthcare (DNVHC) for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-23

    ... covered services in a hospital provided certain requirements are met. Section 1861(e) of the Social.... Accreditation by an accrediting organization is voluntary and is not required for Medicare participation. If an... public comment on whether DNVHC's requirements meet or exceed the Medicare conditions for...

  16. 77 FR 51540 - Medicare Program; Approved Renewal of Deeming Authority of the Accreditation Association for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-24

    ... Authority of the Accreditation Association for Ambulatory Health Care, Inc. for Medicare Advantage Health... Medicare Advantage ``deeming authority'' of the Accreditation Association for Ambulatory Health Care, Inc... apply for MA deeming authority are generally recognized by the health care industry as entities...

  17. 77 FR 31364 - Medicare Program; Approved Renewal of Deeming Authority of the Utilization Review Accreditation...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-25

    ... the March 30, 2012, Federal Register (77 FR 19288), we published a proposed notice announcing URAC's..., the March 30, 2012 proposed notice (77 FR 19288) also solicited public comments regarding whether URAC... regulations specifying the Medicare requirements that must be met for a Medicare Advantage Organization...

  18. 75 FR 23851 - Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-05-04

    ...We are proposing to revise the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems. In addition, in the Addendum to this proposed rule, we describe the proposed changes to the amounts and factors used to determine the rates for Medicare acute......

  19. 78 FR 43533 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-19

    ...This proposed rule would revise the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2014 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this proposed rule, we describe the proposed changes to the amounts and factors used to determine......

  20. 76 FR 50224 - Medicare Program; Accountable Care Organization Accelerated Development Learning Sessions; Center...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-12

    ... Accelerated Development Learning Sessions; Center for Medicare and Medicaid Innovation, September 15th and... Registration: Registration for the second ADLS will remain open until capacity has been reached for the... Medicare and Medicaid Innovation (Innovation Center) for the purpose of examining new ways of...

  1. Medicare Advantage Plans Pay Hospitals Less Than Traditional Medicare Pays.

    PubMed

    Baker, Laurence C; Bundorf, M Kate; Devlin, Aileen M; Kessler, Daniel P

    2016-08-01

    There is ongoing debate about how prices paid to providers by Medicare Advantage plans compare to prices paid by fee-for-service Medicare. We used data from Medicare and the Health Care Cost Institute to identify the prices paid for hospital services by fee-for-service (FFS) Medicare, Medicare Advantage plans, and commercial insurers in 2009 and 2012. We calculated the average price per admission, and its trend over time, in each of the three types of insurance for fixed baskets of hospital admissions across metropolitan areas. After accounting for differences in hospital networks, geographic areas, and case-mix between Medicare Advantage and FFS Medicare, we found that Medicare Advantage plans paid 5.6 percent less for hospital services than FFS Medicare did. Without taking into account the narrower networks of Medicare Advantage, the program paid 8.0 percent less than FFS Medicare. We also found that the rates paid by commercial plans were much higher than those of either Medicare Advantage or FFS Medicare, and growing. At least some of this difference comes from the much higher prices that commercial plans pay for profitable service lines.

  2. Medicare Advantage Plans Pay Hospitals Less Than Traditional Medicare Pays.

    PubMed

    Baker, Laurence C; Bundorf, M Kate; Devlin, Aileen M; Kessler, Daniel P

    2016-08-01

    There is ongoing debate about how prices paid to providers by Medicare Advantage plans compare to prices paid by fee-for-service Medicare. We used data from Medicare and the Health Care Cost Institute to identify the prices paid for hospital services by fee-for-service (FFS) Medicare, Medicare Advantage plans, and commercial insurers in 2009 and 2012. We calculated the average price per admission, and its trend over time, in each of the three types of insurance for fixed baskets of hospital admissions across metropolitan areas. After accounting for differences in hospital networks, geographic areas, and case-mix between Medicare Advantage and FFS Medicare, we found that Medicare Advantage plans paid 5.6 percent less for hospital services than FFS Medicare did. Without taking into account the narrower networks of Medicare Advantage, the program paid 8.0 percent less than FFS Medicare. We also found that the rates paid by commercial plans were much higher than those of either Medicare Advantage or FFS Medicare, and growing. At least some of this difference comes from the much higher prices that commercial plans pay for profitable service lines. PMID:27503970

  3. The Medicare Electronic Health Record Incentive Program: Provider Performance on Core and Menu Measures

    PubMed Central

    Wright, Adam; Feblowitz, Joshua; Samal, Lipika; McCoy, Allison B; Sittig, Dean F

    2014-01-01

    Objective To measure performance by eligible health care providers on CMS’s meaningful use measures. Data Source Medicare Electronic Health Record Incentive Program Eligible Professionals Public Use File (PUF), which contains data on meaningful use attestations by 237,267 eligible providers through May 31, 2013. Study Design Cross-sectional analysis of the 15 core and 10 menu measures pertaining to use of EHR functions reported in the PUF. Principal Findings Providers in the dataset performed strongly on all core measures, with the most frequent response for each of the 15 measures being 90–100 percent compliance, even when the threshold for a particular measure was lower (e.g., 30 percent). PCPs had higher scores than specialists for computerized order entry, maintaining an active medication list, and documenting vital signs, while specialists had higher scores for maintaining a problem list, recording patient demographics and smoking status, and for providing patients with an after-visit summary. In fact, 90.2 percent of eligible providers claimed at least one exclusion, and half claimed two or more. Conclusions Providers are successfully attesting to CMS’s requirements, and often exceeding the thresholds required by CMS; however, some troubling patterns in exclusions are present. CMS should raise program requirements in future years. PMID:24359554

  4. Medicare program; End-Stage Renal Disease prospective payment system, quality incentive program, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies. Final rule.

    PubMed

    2014-11-01

    This final rule will update and make revisions to the End-Stage Renal Disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2015. This rule also finalizes requirements for the ESRD quality incentive program (QIP), including for payment years (PYs) 2017 and 2018. This rule will also make a technical correction to remove outdated terms and definitions. In addition, this final rule sets forth the methodology for adjusting Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) fee schedule payment amounts using information from the Medicare DMEPOS Competitive Bidding Program (CBP); makes alternative payment rules for certain DME under the Medicare DMEPOS CBP; clarifies the statutory Medicare hearing aid coverage exclusion and specifies devices not subject to the hearing aid exclusion; will not update the definition of minimal self-adjustment; clarifies the Change of Ownership (CHOW) and provides for an exception to the current requirements; revises the appeal provisions for termination of a CBP contract, including the beneficiary notification requirement under the Medicare DMEPOS CBP, and makes a technical change to the regulation related to the conditions for awarding contracts for furnishing infusion drugs under the Medicare DMEPOS CBP.

  5. 75 FR 1843 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-01-13

    ... Consumer Assessment of Healthcare Providers and Systems CCN CMS Certification Numbers CHIP Children's Health Insurance Program CHIPRA Children's Health Insurance Program Reauthorization Act of 2009 CMS.... Children's Hospitals c. Medicaid Professionals Program Eligibility d. Calculating Patient...

  6. Voucherizing Medicare.

    PubMed

    Oberlander, Jonathan

    2014-04-01

    This article explores the evolving language of Medicare reform and recent conflicts over "voucherizing" Medicare. The Medicare reform debate is, in part, a contest over how to frame policy alternatives in order to enhance (or diminish) their political viability. "Voucherizing" has emerged as a powerful rhetorical weapon in that fight. Yet the accompanying debate is often misleading about both the current state of Medicare and the necessity of altering its programmatic structure to ensure future stability. PMID:24305847

  7. 75 FR 73086 - Medicare and Medicaid Programs; Renewal of Deeming Authority of the National Committee for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-29

    ... requirements that must be met in order for an Medicare Advantage Organization (MAO) to enter into a contract... Social Security Act (the Act), which specifies the services that an MAO must provide and the...

  8. 76 FR 39110 - Medicare Program; Section 3113: The Treatment of Certain Complex Diagnostic Laboratory Tests...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-05

    ... Certain Complex Diagnostic Laboratory Tests Demonstration AGENCY: Centers for Medicare & Medicaid Services... participate in the Treatment of Certain Complex Diagnostic Laboratory Tests Demonstration. The Demonstration... complex diagnostic laboratory test under the Demonstration. The statute requires a Report to Congress...

  9. 76 FR 66931 - Medicare Program: Notice of Two Membership Appointments to the Advisory Panel on Ambulatory...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-28

    ... Notice On March 25, 2011, a notice appeared in the Federal Register (76 FR 16788), entitled ``Medicare... Classification (APC) Groups (the Panel). The two appointments are for 4-year periods through January 31,...

  10. Medicare program; payment to health maintenance organizations and competitive medical plans--HCFA. Proposed rule.

    PubMed

    1984-05-25

    These proposed regulations would implement section 114 of the Tax Equity and Fiscal Responsibility Act of 1982. This provision of the law amended section 1876 of the Social Security Act, which authorizes Medicare reimbursement to eligible organizations on a prospective basis for those organizations that have a risk contract or on a reasonable cost basis for those that have a cost contract. The definition of an eligible organization includes both health maintenance organizations (HMOs) that meet the definition of a qualified HMO under the Public Health Service Act and competitive medical plans (CMPs). The purpose of this proposal is to set forth the requirements that an entity must meet in order to be (1) eligible to enter into a Medicare contract (either risk or reasonable cost) as an eligible organization and (2) reimbursed by Medicare on a capacitation basis (either prospectively or retrospectively) for items and services furnished to Medicare enrollees. PMID:10299521

  11. 77 FR 31362 - Medicare and Medicaid Programs; Application From the Community Health Accreditation Program for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-25

    ... the Community Health Accreditation Program for Continued Approval of Its Hospice Accreditation Program... conditions. A national accrediting organization applying for approval of its accreditation program under part... for continued approval of its accreditation program every 6 years or as we determine. Community...

  12. Medicare program; coverage and payment of ambulance services; inflation update for CY 2004. Final rule with comment period.

    PubMed

    2003-12-01

    This final rule provides the sunset date for the interim bonus payment for rural ambulance mileage of 18 through 50 miles as required by the Medicare, Medicaid and State Child Health Insurance Program Benefits Improvement and Protection Act of 2000 (BIPA) and provides notice of the annual Ambulance Inflation Factor (AIF) for ambulance services for calendar year (CY) 2004. The statute requires that this inflation factor be applied in determining the fee schedule amounts and payment limits for ambulance services.

  13. Medicare program; inpatient rehabilitation facility prospective payment system for federal fiscal year 2015.

    PubMed

    2014-08-01

    This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2015 as required by the statute. This final rule finalizes a policy to collect data on the amount and mode (that is, Individual, Concurrent, Group, and Co-Treatment) of therapy provided in the IRF setting according to therapy discipline, revises the list of diagnosis and impairment group codes that presumptively meet the "60 percent rule'' compliance criteria, provides a way for IRFs to indicate on the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) form whether the prior treatment and severity requirements have been met for arthritis cases to presumptively meet the "60 percent rule'' compliance criteria, and revises and updates quality measures and reporting requirements under the IRF quality reporting program (QRP). This rule also delays the effective date for the revisions to the list of diagnosis codes that are used to determine presumptive compliance under the "60 percent rule'' that were finalized in FY 2014 IRF PPS final rule and adopts the revisions to the list of diagnosis codes that are used to determine presumptive compliance under the "60 percent rule'' that are finalized in this rule. This final rule also addresses the implementation of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), for the IRF prospective payment system (PPS), which will be effective when ICD-10-CM becomes the required medical data code set for use on Medicare claims and IRF-PAI submissions.

  14. Medicare program; inpatient rehabilitation facility prospective payment system for federal fiscal year 2015.

    PubMed

    2014-08-01

    This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2015 as required by the statute. This final rule finalizes a policy to collect data on the amount and mode (that is, Individual, Concurrent, Group, and Co-Treatment) of therapy provided in the IRF setting according to therapy discipline, revises the list of diagnosis and impairment group codes that presumptively meet the "60 percent rule'' compliance criteria, provides a way for IRFs to indicate on the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) form whether the prior treatment and severity requirements have been met for arthritis cases to presumptively meet the "60 percent rule'' compliance criteria, and revises and updates quality measures and reporting requirements under the IRF quality reporting program (QRP). This rule also delays the effective date for the revisions to the list of diagnosis codes that are used to determine presumptive compliance under the "60 percent rule'' that were finalized in FY 2014 IRF PPS final rule and adopts the revisions to the list of diagnosis codes that are used to determine presumptive compliance under the "60 percent rule'' that are finalized in this rule. This final rule also addresses the implementation of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), for the IRF prospective payment system (PPS), which will be effective when ICD-10-CM becomes the required medical data code set for use on Medicare claims and IRF-PAI submissions. PMID:25122947

  15. 76 FR 67991 - Medicare Program; Final Waivers in Connection With the Shared Savings Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-02

    ... and B, and encourage investment in infrastructure and redesigned care processes for high quality and... considerations (Waiver Designs in Connection with the Shared Savings Program and the Innovation Center (76 FR... Savings Program (Shared Savings Program: Accountable Care Organizations (76 FR 19528))...

  16. 75 FR 79173 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-July Through September 2010

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-17

    ... lung volume reduction surgery facilities, a list of Medicare-approved clinical trials for... includes a listing of Medicare-approved clinical trials for fluorodeoxyglucose positron emission tomography... every 3 months in the Federal Register. We published our first notice June 9, 1988 (53 FR...

  17. 75 FR 58789 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-April Through June 2010

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-09-24

    ... clinical trials for fluorodeoxyglucose positron emissions tomogrogphy for dementia, and a list of Medicare... includes a listing of Medicare-approved clinical trials for fluorodeoxyglucose positron emission tomography... least every 3 months in the Federal Register. We published our first notice June 9, 1988 (53 FR...

  18. Numeracy and Medicare Part D: the importance of choice and literacy for numbers in optimizing decision making for Medicare's prescription drug program.

    PubMed

    Wood, Stacey; Hanoch, Yaniv; Barnes, Andrew; Liu, Pi-Ju; Cummings, Janet; Bhattacharya, Chandrima; Rice, Thomas

    2011-06-01

    Studies on decision making have come to challenge the idea that having more choice is necessarily better. The Medicare prescription drug program (Part D) has been designed to maximize choice for the consumer but has simultaneously created a highly complex decision task with dozens of options. In this study, in a sample of 121 adults, we examined the impact that increasing choice options has on decision-making abilities in older versus younger adults. Consistent with our hypotheses, we found that participants performed better with less choice versus more choice, and that older adults performed worse than younger adults across conditions. We further examined the role that numeracy may play in making these decisions and the role of more traditional cognitive variables such as working memory, executive functioning, intelligence, and education. Finally, we examined how personality style may interact with cognitive variables and age in decision making. Regression analysis revealed that numeracy is related to performance across the lifespan. When controlling for additional measures of cognitive ability, we found that although age was no longer associated with performance, numeracy remained significant. In terms of decision style, personality characteristics were not related to performance. Our results add to the mounting evidence for the critical role of numeracy in decision making across decision domains and across the lifespan. PMID:21553984

  19. Numeracy and Medicare Part D: the importance of choice and literacy for numbers in optimizing decision making for Medicare's prescription drug program.

    PubMed

    Wood, Stacey; Hanoch, Yaniv; Barnes, Andrew; Liu, Pi-Ju; Cummings, Janet; Bhattacharya, Chandrima; Rice, Thomas

    2011-06-01

    Studies on decision making have come to challenge the idea that having more choice is necessarily better. The Medicare prescription drug program (Part D) has been designed to maximize choice for the consumer but has simultaneously created a highly complex decision task with dozens of options. In this study, in a sample of 121 adults, we examined the impact that increasing choice options has on decision-making abilities in older versus younger adults. Consistent with our hypotheses, we found that participants performed better with less choice versus more choice, and that older adults performed worse than younger adults across conditions. We further examined the role that numeracy may play in making these decisions and the role of more traditional cognitive variables such as working memory, executive functioning, intelligence, and education. Finally, we examined how personality style may interact with cognitive variables and age in decision making. Regression analysis revealed that numeracy is related to performance across the lifespan. When controlling for additional measures of cognitive ability, we found that although age was no longer associated with performance, numeracy remained significant. In terms of decision style, personality characteristics were not related to performance. Our results add to the mounting evidence for the critical role of numeracy in decision making across decision domains and across the lifespan.

  20. Medicare and Medicaid programs; physicians' referrals to health care entities with which they have financial relationships--HCFA. Proposed rule.

    PubMed

    1998-01-01

    This proposed rule would incorporate into regulations the provisions of sections 1877 and 1903(s) of the Social Security Act. Under section 1877, if a physician or a member of a physician's immediate family has a financial relationship with a health care entity, the physician may not make referrals to that entity for the furnishing of designated health services under the Medicare program, unless certain exceptions apply. The following services are designated health services: Clinical laboratory services. Physical therapy services. Occupational therapy services. Radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services. Radiation therapy services and supplies. Durable medical equipment and supplies. Parenteral and enteral nutrients, equipment, and supplies. Prosthetics, orthotics, and prosthetic devices and supplies. Home health services. Outpatient prescription drugs. Inpatient and outpatient hospital services. In addition, section 1877 provides that an entity may not present or cause to be presented a Medicare claim or bill to any individual, third party payer, or other entity for designated health services furnished under a prohibited referral, nor may the Secretary make payment for a designated health service furnished under a prohibited referral. Section 1903(s) of the Social Security Act extended aspects of the referral prohibition to the Medicaid program. It denies payment under the Medicaid program to a State for certain expenditures for designated health services. Payment would be denied if the services are furnished to an individual on the basis of a physician referral that would result in the denial of payment for the services under Medicare if Medicare covered the services to the same extent and under the same terms and conditions as under the State plan. This proposed rule incorporates these statutory provisions into the Medicare and Medicaid regulations and interprets certain aspects of the

  1. Medicare program; hospital inpatient value-based purchasing program. Final rule.

    PubMed

    2011-05-01

    This final rule implements a Hospital Inpatient Value-Based Purchasing program (Hospital VBP program or the program) under section 1886(o) of the Social Security Act (the Act), under which value-based incentive payments will be made in a fiscal year to hospitals that meet performance standards with respect to a performance period for the fiscal year involved. The program will apply to payments for discharges occurring on or after October 1, 2012, in accordance with section 1886(o) (as added by section 3001(a) of the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act)). Scoring in the Hospital VBP program will be based on whether a hospital meets or exceeds the performance standards established with respect to the measures. By adopting this program, we will reward hospitals based on actual quality performance on measures, rather than simply reporting data for those measures. PMID:21548401

  2. Economic Impact of an Advanced Illness Consultation Program within a Medicare Advantage Plan Population

    PubMed Central

    Colaberdino, Vincent; Marshall, Colleen; DuBose, Paul; Daitz, Mitchell

    2016-01-01

    Abstract Background: In the United States the quality and cost associated with medical treatment for individuals experiencing an advanced illness is highly variable and is often misaligned with the patient's and family's quality of life values and priorities. Many of the obstacles that stand in the way of aligning the care that an individual receives with their priorities are well understood in the context of behavioral science. Through employing behavioral based approaches to improve the quality of communication and shared decision making processes among patients, providers and families it is possible to enhance the efficiency of delivering care which is also more highly aligned with the individual's preferences. Objectives: The study objectives were to measure the economic impact of a proprietary advanced illness behavioral consultation program, the Vital Decisions Living Well Consultation Program (LWCP), on the cost of care delivered during the last six and three months of life for enrolled members in a Medicare Advantage plan. Study design: Retrospective matched case control analysis examined medical, pharmaceutical, and capitation expenses after an offset by premium revenue. Methods: The treatment population consisted of participating members of the LWCP who died between October 1, 2011 and March 31, 2013 (N = 1755). The control population consisted of plan members who died between July 1, 2008 and June 1, 2011, prior to the introduction of the LWCP (N = 5560). Criteria used to match treatment subjects with one or more control subjects were diagnosis, age at death, and health care costs incurred prior to the time under examination. A paired t-test evaluated the significance of differences between the matched treatment and control members. Results: The mean cost reduction during the last six months of life for treatment members compared to matched control group members was $13,956 (p < 0.001) during the last six months of life and $9,285 (p < 0

  3. 42 CFR 421.500 - Medicare review function.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Medicare review function. 421.500 Section 421.500 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Medical Review § 421.500 Medicare review function....

  4. 42 CFR 411.32 - Basis for Medicare secondary payments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Basis for Medicare secondary payments. 411.32 Section 411.32 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Insurance...

  5. 42 CFR 411.33 - Amount of Medicare secondary payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Amount of Medicare secondary payment. 411.33 Section 411.33 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Insurance...

  6. 76 FR 54953 - Medicare Program; Changes to the Electronic Prescribing (eRx) Incentive Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-06

    ... information on which professionals are eligible to participate in the eRx Incentive Program, we refer readers...://www.cms.gov/ERxIncentive/05_Eligible%20Professionals.asp#TopOfPage . Under section 1848(m)(2) of the... and 2010 PFS final rules with comment period (73 FR 69847 through 69852 and 74 FR 61849 through...

  7. 76 FR 2453 - Medicare Program; Hospital Inpatient Value-Based Purchasing Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-01-13

    ... section 1886(b)(3)(B)(vii) of the Act in the FY ] 2005 IPPS final rule (69 FR 49078) and codified the... the Hospital IQR program in the FY 2006 IPPS final rule (70 FR 47420). C. Hospital Inpatient Quality... for a subsequent fiscal year. In the FY 2007 IPPS final rule (71 FR 48045), we amended our...

  8. 76 FR 26489 - Medicare Program; Hospital Inpatient Value-Based Purchasing Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-06

    ... the Act in the FY 2005 IPPS final rule (69 FR 49078) and codified the applicable percentage increase... program in the FY 2006 IPPS final rule (70 FR 47420). C. Hospital Inpatient Quality Reporting Under... subsequent fiscal year. In the FY 2007 IPPS final rule (71 FR 48045), we amended our regulations at Sec....

  9. 77 FR 67368 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-July through September 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-09

    ...Anna Baldwin, MS. (410) 786-7205 Volume Reduction Surgery Facilities. XIV Medicare-Approved Bariatric Kate Tillman, RN, (410) 786-9252 Surgery Facilities. MAS. XV Fluorodeoxyglucose Positron Stuart...

  10. 77 FR 11130 - Medicare Program; Application by the American Association of Diabetes Educators (AADE) for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-02-24

    ... commenting, please refer to file code CMS-3259-PN. Because of staff and resource limitations, we cannot..., Department of Health and Human Services, Attention: CMS-3259-PN, P.O. Box 8016, Baltimore, MD 21244-8016... for Medicare & Medicaid Services, Department of Health and Human Services, Attention:...

  11. 42 CFR 423.2315 - Medicare Coverage Gap Discount Program Agreement.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... years from the date of payment of the invoice. (6) Comply with the audit and dispute resolution...) Maintain up-to-date NDC listings with the electronic database vendors for which the manufacturer provides... on the invoice, as part of the Medicare Part D Discount Information, or upon audit or dispute...

  12. 42 CFR 423.2315 - Medicare Coverage Gap Discount Program Agreement.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... years from the date of payment of the invoice. (6) Comply with the audit and dispute resolution...) Maintain up-to-date NDC listings with the electronic database vendors for which the manufacturer provides... on the invoice, as part of the Medicare Part D Discount Information, or upon audit or dispute...

  13. 42 CFR 423.2315 - Medicare Coverage Gap Discount Program Agreement.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... years from the date of payment of the invoice. (6) Comply with the audit and dispute resolution...) Maintain up-to-date NDC listings with the electronic database vendors for which the manufacturer provides... on the invoice, as part of the Medicare Part D Discount Information, or upon audit or dispute...

  14. 77 FR 24409 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-04-24

    ... INFORMATION CONTACT: Erick Chuang, (410) 786-1816. SUPPLEMENTARY INFORMATION: I. Regulatory Overview In FR Doc. 2011-26812 of November 30, 2011 (76 FR 74122) and FR Doc. 2011-33751 of January 4, 2012 (77 FR 217... for payment in the claims year but did not meet the Medicare requirements for payment (76 FR...

  15. 75 FR 5599 - Medicare and Medicaid Programs; Announcement of Applications From Hospitals Requesting Waiver for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-02-03

    ... Applications From Hospitals Requesting Waiver for Organ Procurement Service Area AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice with comment period. SUMMARY: Two hospitals have requested waivers of statutory requirements that would otherwise require the hospitals to enter into an...

  16. 76 FR 78926 - Medicare and Medicaid Programs; Announcement of Application From Hospital Requesting Waiver for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-20

    ... Application From Hospital Requesting Waiver for Organ Procurement Service Area AGENCY: Centers for Medicare... announces a waiver request from Pioneer Community Hospital to participate in an Organ Procurement... the Social Security Act (the Act) which provides that a hospital may obtain a waiver from...

  17. 77 FR 9255 - Medicare Program: Notice of Six Membership Appointments to the Advisory Panel on Hospital...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-02-16

    ..., 2011 final rule, (76 FR 74363)) to address appropriate supervision level for hospital outpatient... FR 72708). The notice requested nominations to be added to the Panel by replacing one Panel member... Appointments to the Advisory Panel on Hospital Outpatient Payment AGENCY: Centers for Medicare &...

  18. 77 FR 51542 - Medicare Program; Solicitation of Two Nominations to the Advisory Panel on Hospital Outpatient...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-24

    ... Nominations to the Advisory Panel on Hospital Outpatient Payment AGENCY: Centers for Medicare & Medicaid... Advisory Panel on Hospital Outpatient Payment (HOP, the Panel). There will be two vacancies on the Panel... Classification (APC) groups and their associated weights, and supervision of hospital outpatient services....

  19. 75 FR 59274 - Medicare and Medicaid Programs; Announcement of Application from Hospital Requesting Waiver for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-09-27

    ... Application from Hospital Requesting Waiver for Organ Procurement Service Area AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice with comment period. SUMMARY: A hospital has requested a waiver of statutory requirements that would otherwise require the hospital to enter into an...

  20. 77 FR 24495 - Medicare and Medicaid Programs; Announcement of Application From a Hospital Requesting Waiver for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-04-24

    ... increase organ donations; and (2) will ensure equitable treatment of patients referred for transplants... Application From a Hospital Requesting Waiver for Organ Procurement Service Area AGENCY: Centers for Medicare... with its designated Organ Procurement Organization (OPO). The request was made in accordance...

  1. 77 FR 51539 - Medicare and Medicaid Programs; Announcement of Application From a Hospital Requesting Waiver for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-24

    ... increase organ donations; and (2) will ensure equitable treatment of patients referred for transplants... Application From a Hospital Requesting Waiver for Organ Procurement Service Area AGENCY: Centers for Medicare... Organ Procurement Organization (OPO). The request was made in accordance with section 1138(a)(2) of...

  2. 78 FR 98 - Medicare and Medicaid Programs; Announcement of Application From a Hospital Requesting Waiver for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-01-02

    ... increase organ donations; and (2) will assure equitable treatment of patients referred for transplants... Application From a Hospital Requesting Waiver for Organ Procurement Service Area AGENCY: Centers for Medicare... with its designated Organ Procurement Organization (OPO). The request was made in accordance...

  3. 76 FR 67743 - Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-02

    ... enrollment issues. SUPPLEMENTARY INFORMATION: I. Background In the February 2, 2011 Federal Register (76 FR..., among other things, provisions related to the submission of application fees as part of the Medicare... non-physician practitioner organizations), CMS-855S or associated Internet-based PECOS...

  4. 77 FR 71423 - Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-30

    ... enrollment issues. SUPPLEMENTARY INFORMATION: ] I. Background In the February 2, 2011 Federal Register (76 FR..., among other things, provisions related to the submission of application fees as part of the Medicare... non-physician practitioner organizations), CMS-855S or associated Internet-based PECOS...

  5. 78 FR 74229 - Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-10

    ... or confidential business information that is included in a comment. We post all comments received... Clinical Studies--Revisions of Medicare Coverage Requirements B. Ultrasound Screening for Abdominal Aortic... FFS Fee-for-service FOBT Fecal occult blood test FQHC Federally qualified health center FR...

  6. 75 FR 50041 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-16

    ...We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems and to implement certain provisions of the Affordable Care Act and other legislation. In addition, we describe the changes to the amounts and factors used to determine......

  7. 77 FR 19290 - Medicare and Medicaid Programs; Renewal of Deeming Authority of the Accreditation Association for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-30

    ... Deeming Authority of the Accreditation Association for Ambulatory Health Care, Inc. for Medicare Advantage... Care, Inc. (AAAHC) for Health Maintenance Organizations and Preferred Provider Organizations for a term... generally recognized by the health care industry as entities that accredit HMOs and PPOs. As we specify...

  8. 76 FR 28988 - Medicare Program; Accelerated Development Sessions for Accountable Care Organizations-June 20, 21...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-19

    ... Sessions for Accountable Care Organizations--June 20, 21, and 22, 2011 AGENCY: Centers for Medicare... functions of an Accountable Care Organization (ACO) and ways to build their organization's capacity to succeed as an ACO. This 3-day, in-person ADS is to help new ACOs deliver better care and reduce costs....

  9. 78 FR 58385 - Medicare Program; Prospective Payment System for Federally Qualified Health Centers; Changes to...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-23

    ... period (57 FR 24961) and the April 3, 1996 final rule (61 FR 14640). Regulations pertaining to FQHCs are... provided on or after January 1, 2011. Accordingly, in the CY 2011 Medicare PFS final rule (75 FR 73417... Center RIA Regulatory Impact Analysis RHC Rural Health Clinic SNF Skilled Nursing Facility UDS...

  10. 78 FR 8535 - Medicare Program: Comprehensive End-Stage Renal Disease Care Model Announcement

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-06

    ... Disease Care Model Announcement AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION... the testing of the Comprehensive End- Stage Renal Disease (ESRD) Care Model, a new initiative from the... populations. One population is beneficiaries with end- stage renal disease (ESRD). This population has...

  11. 78 FR 26437 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-06

    ... FR 51476). To be consistent with these other Medicare payment systems and streamline the published... presented in last year's SNF PPS update notice for FY 2013 (77 FR 46214, August 2, 2012). Crosswalk to FY... center FR Federal Register FY Fiscal year GAO Government Accountability Office HCPCS Healthcare...

  12. 78 FR 47935 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-06

    ... Hospital Inpatient PPS (IPPS) final rule (76 FR 51476). To be consistent with these other Medicare payment... Federally qualified health center FR Federal Register FY Fiscal year GAO Government Accountability Office... rule reflect an update to the rates that we published in the SNF PPS update notice for FY 2013 (77...

  13. 76 FR 31340 - Medicare Program; Notification of Closure of St. Vincent's Medical Center

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-31

    ... process for qualifying hospitals to apply to CMS to receive direct graduate medical education (GME) and indirect medical education (IME) FTE resident cap slots from the hospital that closed. The procedures we.... Vincent's Medical Center AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION:...

  14. 77 FR 46439 - Medicare Program; Prior Authorization for Power Mobility Device (PMD) Demonstration

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-03

    ... in 60-day and 30-day Federal Register notices that published on February 7, 2012 (77 FR 6124) and May 29, 2012 (77 FR 31616), respectively. The information collection requirements are approved under OMB... Mobility Device (PMD) Demonstration AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS....

  15. 78 FR 61191 - Medicare Program; FY 2014 Inpatient Prospective Payment Systems: Changes to Certain Cost...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-10-03

    ... August 19, 2013 Federal Register (78 FR 50496)), we made payment and policy changes under the Medicare... Periods That Span More Than One Federal Fiscal Year In the FY 2014 IPPS/LTCH PPS final rule (78 FR 50645... this final rule''. We described that process as follows (78 FR 50646): t cost report settlement,...

  16. 78 FR 31472 - Medicare and Medicaid Programs; Survey, Certification and Enforcement Procedures; Extension of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-24

    ... proposed rule, which was published in the April 5, 2013 Federal Register (78 FR 20564 through 20581). In...: The comment period for the proposed rule published in the April 5, 2013 Federal Register (78 FR 20564... Medicare & Medicaid Services (CMS), HHS. ACTION: Proposed rule; extension of the comment period....

  17. 78 FR 42778 - Medicare Program; Comprehensive ESRD Care Initiative; Extension of the Submission Deadlines for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-17

    ... beneficiaries with ESRD regarding the functional status, quality of life, and overall well-being, as well as... quality of care for this population, while lowering total per-capita expenditures under the Medicare... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH...

  18. 78 FR 20564 - Medicare and Medicaid Programs; Survey, Certification and Enforcement Procedures

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-04-05

    ... standards required by the Medicare CoPs, requirements, CfCs, and conditions for certification. Any national... all AOs and other national standard-setting organizations to develop Conditions of Participation. We... standards. E. Application and Reapplication Procedures for National Accreditation Organizations (Sec....

  19. 77 FR 25283 - Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-04-27

    ..., and may be subject to additional Federal and State quality standards. Additionally, the Medicare and..., ``Additional Supplier Standards'' (October 11, 2000, 65 FR 60366). A final rule titled, ``Requirements for... Rule'' (January 2, 2009, 74 FR 166). A final rule titled, ``The National Provider Identifier...

  20. 78 FR 50495 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-19

    ... Physician Order and Certification for Payment of Hospital Inpatient Services under Medicare Part A Issues. Susanne Seagrave, (410) 786-0044, Physician Order and Certification for Payment of Inpatient... line FQHC Federally qualified health center FR Federal Register FTE Full-time equivalent FUH...

  1. 78 FR 27485 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-10

    ... Inpatient Services under Medicare Part A. Ann Marshall, (410) 786-3059, Requirement for Physician Order for... fiscal year FPL Federal poverty line FQHC Federally qualified health center FR Federal Register FTE Full... Provider-Specific File PS&R Provider Statistical and Reimbursement PQRS Physician Quality Reporting...

  2. 76 FR 34712 - Medicare Program; Pioneer Accountable Care Organization Model; Extension of the Submission...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-14

    ..., better health care, and lower per-capita costs for Medicare, Medicaid, and Children's Health Insurance... 20, 2011 Federal Register (76 FR 29249). On the Innovation Center Web site, we specified that the... June 8, 2011 Federal Register (76 FR 33306), we published a correction notice that corrected our...

  3. Medicare Rights and Protections

    MedlinePlus

    CENTERS for MEDICARE & MEDICAID SERVICES Medicare Rights & Protections This official government booklet has important information about: Your rights & protections in: ■ ■ Original Medicare ■ ■ Medicare Advantage Plan or other Medicare health ...

  4. Medicare Program; Final Waivers in Connection With the Shared Savings Program. Final rule.

    PubMed

    2015-10-29

    This final rule finalizes waivers of the application of the physician self-referral law, the Federal anti-kickback statute, and the civil monetary penalties (CMP) law provision relating to beneficiary inducements to specified arrangements involving accountable care organizations (ACOs) under section 1899 of the Social Security Act (the Act) (the "Shared Savings Program''), as set forth in the Interim Final Rule with comment period (IFC) dated November 2, 2011. As explained in greater detail below, in light of legislative changes that occurred after publication of the IFC, this final rule does not finalize waivers of the application of the CMP law provision relating to "gainsharing'' arrangements. Section 1899(f) of the Act, as added by the Affordable Care Act, authorizes the Secretary to waive certain fraud and abuse laws as necessary to carry out the provisions of section 1899 of the Act. PMID:26524770

  5. Medicare Program; Final Waivers in Connection With the Shared Savings Program. Final rule.

    PubMed

    2015-10-29

    This final rule finalizes waivers of the application of the physician self-referral law, the Federal anti-kickback statute, and the civil monetary penalties (CMP) law provision relating to beneficiary inducements to specified arrangements involving accountable care organizations (ACOs) under section 1899 of the Social Security Act (the Act) (the "Shared Savings Program''), as set forth in the Interim Final Rule with comment period (IFC) dated November 2, 2011. As explained in greater detail below, in light of legislative changes that occurred after publication of the IFC, this final rule does not finalize waivers of the application of the CMP law provision relating to "gainsharing'' arrangements. Section 1899(f) of the Act, as added by the Affordable Care Act, authorizes the Secretary to waive certain fraud and abuse laws as necessary to carry out the provisions of section 1899 of the Act.

  6. Linking Evidence-Based Program Participant Data with Medicare Data: The Consenting Process and Correlates of Retrospective Participant Consents

    PubMed Central

    Ritter, Philip Lloyd; Ory, Marcia G.; Smith, Matthew Lee; Jiang, Luohua; Alonis, Audrey; Laurent, Diana D.; Lorig, Kate

    2015-01-01

    As part of a nation-wide study of the Chronic Disease Self-Management Program (National Study), older participants were asked to consent to have their Medicare data matched with study data. This provided an opportunity to examine the consenting process and compare consenters, refusers, and non-responders. We compared the three groups on a large number of variables. These included demographic, National Study participation, health indicator, health behavior, and health-care utilization variables. We assessed differences in 6-month change scores for time-varying variables. We also examined whether asking participants to consent prior to the final questionnaire impacted completion of that questionnaire. Of 616 possible participants, 42% consented, 44% refused, and 14% failed to respond. Differences by ethnicity were found, with Hispanics more likely to consent. There was a consistent tendency for those who participated most in the National Study to consent. With the exception of number of chronic diseases, there was no evidence of health indicators or health behaviors being associated with consenting. Participants with more physician visits and more nights in the hospital were also more likely to consent. Those asked to consent before the 12-month follow-up questionnaire were less likely to complete that questionnaire than those who were asked after. Fewer than half consented to link to their Medicare data. The greater willingness to consent by those who participated most suggests that willingness to consent may be part of program engagement. Consenters had more diseases, more MD visits, and more nights in the hospital, suggesting that greater contact with the medical system may be associated with willingness to consent. This indicates that examinations of Medicare data based only on those willing to consent could introduce bias. Asking for consent appears to reduce participation in the larger study. PMID:25964908

  7. Eligibility For And Enrollment In Medicare Part D Medication Therapy Management Programs Varies By Plan Sponsor.

    PubMed

    Stuart, Bruce; Hendrick, Franklin B; Shen, Xian; Dai, Mingliang; Tom, Sarah E; Dougherty, J Samantha; Miller, Laura M

    2016-09-01

    Medicare Part D prescription drug plans must offer medication therapy management to beneficiaries with multiple chronic conditions and high drug expenditures. However, plan sponsors have considerable latitude in setting eligibility criteria. Newly available data indicate that enrollment rates in medication therapy management among stand-alone prescription drug plans and Medicare Advantage drug plans averaged only 10 percent in 2012. The enrollment variation across plan sponsors-from less than 0.2 percent to more than 57.0 percent-was associated with the restrictiveness of their eligibility criteria. For example, enrollment was 16.4 percent in plans requiring two chronic conditions versus 9.2 percent in plans requiring three, and 12.7 percent in plans requiring the use of any Part D drug versus 4.4 percent in plans requiring the use of drugs in specific classes. This variation represents inequities in access to medication therapy management across plans and results in missed opportunities for interventions that might improve therapeutic outcomes and reduce spending. The new Part D Enhanced Medication Therapy Management model of the Centers for Medicare and Medicaid Services has the potential to significantly increase the impact of medication therapy management by aligning financial incentives with improvements in medication use and encouraging innovation. PMID:27605635

  8. 42 CFR 424.66 - Payment to entities that provide coverage complementary to Medicare Part B.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... complementary to Medicare Part B. 424.66 Section 424.66 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT To Whom... Medicare Part B. (a) Conditions for payment. Medicare may pay an entity for Part B services furnished by...

  9. 76 FR 68467 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-April Through June 2011

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-04

    ... Federal Register (76 FR 48564), technology has advanced since we published our first notice on June 9... site and information covered by this quarterly notice. In the August 8, 2011 notice (76 FR 48564), we...-7205 Cardiology-National MS. Cardiovascular Data Registry Sites. IX Medicare's Active Coverage-...

  10. 75 FR 36785 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-January Through March 2010

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-28

    ... Federal Register. We published our first notice June 9, 1988 (53 FR 21730). Although we are not mandated... description of our Medicare manuals may wish to review Table I of our first three notices (53 FR 21730, 53 FR 36891, and 53 FR 50577) published in 1988, and the notice published March 31, 1993 (58 FR 16837)....

  11. 42 CFR 420.410 - Establishment of a program to collect suggestions for improving Medicare program efficiency and...

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... suggestion. Suggester means an individual, a group of individuals, or a legal entity such as a corporation... individual, group of individuals or legal entity, such as a corporation, partnership or professional...) Exclusions. Medicare contractors, their officers and employees, individuals who work for Federal...

  12. 75 FR 14905 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-October Through December 2009

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-03-26

    ... clinical trials for fluorodeoxyglucose positron emissions tomogrogphy for dementia, and a list of Medicare...-approved clinical trials for fluorodeoxyglucose positron emission tomography (FDG-PET) for dementia and... every 3 months in the Federal Register. We published our first notice June 9, 1988 (53 FR...

  13. 77 FR 49799 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-April Through June 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-17

    ... (CMS), HHS. ACTION: Notice. SUMMARY: This quarterly notice lists CMS manual instructions, substantive... efficiently. Section 1871(c) of the Act requires that we publish a list of all Medicare manual instructions... information and will be available earlier than we publish our quarterly notice. We believe the Web site...

  14. Choice Inconsistencies Among the Elderly: Evidence from Plan Choice in the Medicare Part D Program

    PubMed Central

    Abaluck, Jason; Gruber, Jonathan

    2010-01-01

    We evaluate the choices of elders across their insurance options under the Medicare Part D Prescription Drug plan, using a unique data set of prescription drug claims matched to information on the characteristics of choice sets. We document that elders place much more weight on plan premiums than on expected out of pocket costs; value plan financial characteristics beyond any impacts on their own financial expenses or risk; and place almost no value on variance reducing aspects of plans. Partial equilibrium welfare analysis implies that welfare would have been 27% higher if patients had all chosen rationally. PMID:21857716

  15. 42 CFR 422.108 - Medicare secondary payer (MSP) procedures.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Medicare secondary payer (MSP) procedures. 422.108 Section 422.108 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Benefits and Beneficiary Protections §...

  16. Medicare: Physician Compare

    MedlinePlus

    ... by the Centers for Medicare & Medicaid Services 7500 Security Boulevard, Baltimore, MD 21244 Sign Up / Change Plans Your Medicare Costs What Medicare Covers Drug Coverage (Part D) Supplements & ...

  17. Changes in Low-Value Services in Year 1 of the Medicare Pioneer Accountable Care Organization Program

    PubMed Central

    Schwartz, Aaron L.; Chernew, Michael E.; Landon, Bruce E.; McWilliams, J. Michael

    2016-01-01

    Importance Wasteful practices are widespread in the US health care system. It is unclear if payment models intended to improve health care efficiency, such as the Medicare accountable care organization (ACO) programs, discourage the provision of low-value services. Objective To assess whether the first year of the Medicare Pioneer ACO program was associated with a reduction in use of low-value services. Design, Setting and Participants In a difference-in-differences analysis, we compared use of low-value services between Medicare fee-for-service beneficiaries attributed to provider groups that entered the Pioneer program (ACO group) and beneficiaries attributed to other providers (control group) before (2009–2011) vs. after (2012) Pioneer ACO contracts began. We adjusted comparisons for beneficiaries’ sociodemographic and clinical characteristics and for geography. We decomposed estimates according to service characteristics (clinical category, price, and sensitivity to patient preferences) and compared estimates between subgroups of ACOs with higher vs. lower baseline use of low-value services. Main Outcomes and Measures Use of, and spending on, 31 services in instances that provide minimal clinical benefit. Results During the pre-contract period, trends in use of low-value services were similar for the ACO and control groups. The first year of ACO contracts was associated with a differential reduction of 0.8 low-value services per 100 beneficiaries for the ACO group (95% CI: −1.2, −0.4; P<0.001), corresponding to a 1.9% reduction in service quantity (95% CI: −2.9%, −0.9%) and a 4.5% differential reduction in spending on low-value services (95% CI: −7.5%, −1.4%; P=0.004). Differential reductions were similar for services less vs. more sensitive to patient preferences and for higher- vs. lower-priced services. ACOs with higher than their markets average baseline levels of low-value service use experienced greater service reductions (−1.2 services

  18. 78 FR 21610 - Expansion Funds for the Support of the Senior Medicare Patrol (SMP) Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-04-11

    .../Program Name: Health Care Fraud Prevention Program Expansion and SMP Capacity Building Grants. Announcement Type: Health Care Fraud Prevention Program Expansion Capacity. Funding Opportunity Number: Program.... Award Information A. Purpose of the Program: Health Care Fraud Prevention Program Expansion. B....

  19. The Role of Geography in the Assessment of Quality: Evidence from the Medicare Advantage Program.

    PubMed

    Soria-Saucedo, Rene; Xu, Peng; Newsom, Jack; Cabral, Howard; Kazis, Lewis E

    2016-01-01

    The Affordable Care Act set in motion a renewed emphasis on quality of care evaluation. However, the evaluation strategies of quality by the Centers for Medicare and Medicaid Services do not consider geography when comparisons are made among plans. Using an overall measure of a plan's quality in the public sector--the Medicare Advantage (MA) star ratings--we explored the impact of geography in these ratings. We identified 2,872 U.S counties in 2010. The geographic factor predicted a larger fraction of the MA ratings' compared to socio-demographic factors which explained less. Also, after the risk adjustments, almost half of the U.S. states changed their ranked position in the star ratings. Further, lower MA star ratings were identified in the Southeastern region. These findings suggest that the geographic component effect on the ratings is not trivial and should be considered in future adjustments of the metric, which may enhance the transparency, accountability, and importantly level the playing field more effectively when comparing quality across health plans.

  20. The Role of Geography in the Assessment of Quality: Evidence from the Medicare Advantage Program

    PubMed Central

    Soria-Saucedo, Rene; Xu, Peng; Newsom, Jack; Cabral, Howard; Kazis, Lewis E.

    2016-01-01

    The Affordable Care Act set in motion a renewed emphasis on quality of care evaluation. However, the evaluation strategies of quality by the Centers for Medicare and Medicaid Services do not consider geography when comparisons are made among plans. Using an overall measure of a plan’s quality in the public sector—the Medicare Advantage (MA) star ratings—we explored the impact of geography in these ratings. We identified 2,872 U.S counties in 2010. The geographic factor predicted a larger fraction of the MA ratings’ compared to socio-demographic factors which explained less. Also, after the risk adjustments, almost half of the U.S. states changed their ranked position in the star ratings. Further, lower MA star ratings were identified in the Southeastern region. These findings suggest that the geographic component effect on the ratings is not trivial and should be considered in future adjustments of the metric, which may enhance the transparency, accountability, and importantly level the playing field more effectively when comparing quality across health plans. PMID:26727371

  1. Medicare Program; OBRA '87 conforming amendments; correction--HCFA. Final rule; correction.

    PubMed

    1991-05-20

    Federal Register document No. 91-4415, beginning on page 8832 of the issue of Friday March 1, 1991, conformed numerous sections of the HCFA regulations with self-executing provisions of the Omnibus Budget Reconciliation Act of 1987. A one-page revision, dealing with the application of the Medicare blood deductible, was unintentionally omitted from column 2 of page 8852, where only the heading "P. Part 489" appears. Also omitted was a conforming change needed in section 482.12(c)(1)(iv) to reflect the amendment made by section 9336(a) of the Omnibus Budget Reconciliation Act of 1986 (Pub. L. 99-509). Section 9336(a) removed the provision that limited Medicare coverage of optometrist services to aphakia. This means that any optometrist services permitted by State medical practice laws are now covered. This notice corrects the omissions by publishing the amendment to part 489, which was discussed in section "D" of the preamble in the first column of page 8834, and including the revision of section 482.12(e)(1)(iv). The notice also makes numerous other minor corrections.

  2. An Economic History of Medicare Part C

    PubMed Central

    Mcguire, Thomas G; Newhouse, Joseph P; Sinaiko, Anna D

    2011-01-01

    Context: Twenty-five years ago, private insurance plans were introduced into the Medicare program with the stated dual aims of (1) giving beneficiaries a choice of health insurance plans beyond the fee-for-service Medicare program and (2) transferring to the Medicare program the efficiencies and cost savings achieved by managed care in the private sector. Methods: In this article we review the economic history of Medicare Part C, known today as Medicare Advantage, focusing on the impact of major changes in the program's structure and of plan payment methods on trends in the availability of private plans, plan enrollment, and Medicare spending. Additionally, we compare the experience of Medicare Advantage and of employer-sponsored health insurance with managed care over the same time period. Findings: Beneficiaries' access to private plans has been inconsistent over the program's history, with higher plan payments resulting in greater choice and enrollment and vice versa. But Medicare Advantage generally has cost more than the traditional Medicare program, an overpayment that has increased in recent years. Conclusions: Major changes in Medicare Advantage's payment rules are needed in order to simultaneously encourage the participation of private plans, the provision of high-quality care, and to save Medicare money. PMID:21676024

  3. 42 CFR 424.515 - Requirements for reporting changes and updates to, and the periodic revalidation of Medicare...

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ..., and the periodic revalidation of Medicare enrollment information. 424.515 Section 424.515 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Requirements for Establishing and Maintaining...

  4. Medicare program; changes to the requirements for Part D prescribers. Interim final rule with comment period.

    PubMed

    2015-05-01

    This interim final rule with comment period revises requirements related to beneficiary access to covered Part D drugs. Under these revised requirements, pharmacy claims and beneficiary requests for reimbursement for Medicare Part D prescriptions, written by prescribers other than physicians and eligible professionals who are permitted by state or other applicable law to prescribe medications, will not be rejected at the point of sale or denied by the plan if all other requirements are met. In addition, a plan sponsor will not reject a claim or deny a beneficiary request for reimbursement for a drug when prescribed by a prescriber who does not meet the applicable enrollment or opt-out requirement without first providing provisional coverage of the drug and individualized written notice to the beneficiary. This interim final rule with comment period also revises certain terminology to be consistent with existing policy and to improve clarity. PMID:25985480

  5. 42 CFR 424.540 - Deactivation of Medicare billing privileges.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Deactivation of Medicare billing privileges. 424.540 Section 424.540 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Requirements...

  6. 42 CFR 423.462 - Medicare secondary payer procedures.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Medicare secondary payer procedures. 423.462 Section 423.462 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Coordination of Part...

  7. How Successful Is Medicare Advantage?

    PubMed Central

    Newhouse, Joseph P; McGuire, Thomas G

    2014-01-01

    Context Medicare Part C, or Medicare Advantage (MA), now almost 30 years old, has generally been viewed as a policy disappointment. Enrollment has vacillated but has never come close to the penetration of managed care plans in the commercial insurance market or in Medicaid, and because of payment policy decisions and selection, the MA program is viewed as having added to cost rather than saving funds for the Medicare program. Recent changes in Medicare policy, including improved risk adjustment, however, may have changed this picture. Methods This article summarizes findings from our group's work evaluating MA's recent performance and investigating payment options for improving its performance even more. We studied the behavior of both beneficiaries and plans, as well as the effects of Medicare policy. Findings Beneficiaries make “mistakes” in their choice of MA plan options that can be explained by behavioral economics. Few beneficiaries make an active choice after they enroll in Medicare. The high prevalence of “zero-premium” plans signals inefficiency in plan design and in the market's functioning. That is, Medicare premium policies interfere with economically efficient choices. The adverse selection problem, in which healthier, lower-cost beneficiaries tend to join MA, appears much diminished. The available measures, while limited, suggest that, on average, MA plans offer care of equal or higher quality and for less cost than traditional Medicare (TM). In counties, greater MA penetration appears to improve TM's performance. Conclusions Medicare policies regarding lock-in provisions and risk adjustment that were adopted in the mid-2000s have mitigated the adverse selection problem previously plaguing MA. On average, MA plans appear to offer higher value than TM, and positive spillovers from MA into TM imply that reimbursement should not necessarily be neutral. Policy changes in Medicare that reform the way that beneficiaries are charged for MA plan

  8. Medicare program; revision to accrual basis of accounting policy--HCFA. Proposed rule.

    PubMed

    1998-05-18

    Current policy provides that payroll taxes a provider becomes obligated to remit to governmental agencies are included in allowable costs under Medicare only in the cost reporting period in which payment (upon which the payroll taxes are based) is actually made to an employee. Therefore, for payroll accrued in one year but not paid until the next year, the associated payroll taxes on the payroll are not an allowable cost until the next year. This proposed rule would make one exception, in the situation where payment would be made to the employee in the current year but for the fact the regularly scheduled payment date is after the end of the year. In that case, the rule would require allowance in the current year of accrued taxes on payroll that is accrued through the end of the year but not paid until the beginning of the next year, thus allowing accrued taxes on end-of-the year payroll in the same year that the accrual of the payroll itself is allowed. The effect of this proposal is not on the allowability of cost but rather only on the timing of payment; that is, the cost of payroll taxes on and-of-the-year payroll would be allowable in the current period rather than in the following period. PMID:10179345

  9. 76 FR 558 - Office of the Assistant Secretary for Planning and Evaluation; Medicare Program; Meeting of the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-01-05

    ... of the Technical Advisory Panel on Medicare Trustee Reports AGENCY: Assistant Secretary for Planning... Technical Advisory Panel on Medicare Trustee Reports (Panel). Notice of these meetings is given under the... discussion is expected to focus on highly technical aspects of estimation involving economics and...

  10. 76 FR 72707 - Office of the Assistant Secretary for Planning and Evaluation; Medicare Program; Meeting of the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-25

    ... of the Technical Advisory Panel on Medicare Trustee Reports AGENCY: Assistant Secretary for Planning... Technical Advisory Panel on Medicare Trustee Reports (Panel). Notice of these meetings is given under the... discussion is expected to focus on highly technical aspects of estimation involving economics and...

  11. 76 FR 19360 - Office of the Assistant Secretary for Planning and Evaluation; Medicare Program; Meeting of the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-07

    ... of the Technical Advisory Panel on Medicare Trustee Reports AGENCY: Assistant Secretary for Planning... Technical Advisory Panel on Medicare Trustee Reports (Panel). Notice of these meetings is given under the... estimation involving economics and actuarial science. Panelists are not restricted, however, in the...

  12. 78 FR 41013 - Medicare and Medicaid Programs; Home Health Prospective Payment System Rate Update for CY 2014...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-09

    ...-15766, published on Wednesday, July 3, 2013 (78 FR 40272), there was an error that is identified and... was ``-$18.6 Million'' instead of ``$18.6 Million.'' IV. Correction of Errors In FR Doc. 2013-15766... HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 431 RIN 0938-AR52 Medicare...

  13. Medicare program; end-stage renal disease program; prospective reimbursement for dialysis services and approval of special purpose renal dialysis facilities--HCFA. Final rule.

    PubMed

    1983-05-11

    These regulations change the reimbursement system by which Medicare pays for outpatient maintenance dialysis and related physician and laboratory services. These changes establish a prospective method of payment for maintenance dialysis, whether furnished at home or in a hospital-based or independent dialysis facility, and revise other aspects of the reimbursement system to encourage home dialysis and provide incentives for economy and efficiency in furnishing these services. These amendments implement section 2145 of the Omnibus Budget Reconciliation Act of 1981. We expect that these changes will improve our administration of the end-stage renal disease program and enable us to control the rapidly growing costs of furnishing dialysis. The controls on quality of care that have been in effect since the beginning of the program will continue to apply. These regulations will also ensure access to care by providing for adequate reimbursement to isolated, essential facilities, where patients have no alternative sources of dialysis care. These regulations also provide for time-limited approval for Medicare participation of special purpose renal dialysis facilities. As a general rule we have not approved facilities such as transient or mobile units set up for emergency purposes or to serve vacationing dialysis patients in State parks and children's camps. This change in regulations will remove this limitation.

  14. Section 506 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003--limitation on charges for services furnished by Medicare participating inpatient hospitals to individuals eligible for care purchased by Indian health programs. Final rule.

    PubMed

    2007-06-01

    The Secretary of the Department of Health and Human Services (HHS) hereby issues this final rule establishing regulations required by section 506 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), (Pub. L. 108-173). Section 506 of the MMA amended section 1866 (a)(1) of the Social Security Act to add subparagraph (U) which requires hospitals that furnish inpatient hospital services payable under Medicare to participate in the contract health services program (CHS) of the Indian Health Service (IHS) operated by the IHS, Tribes, and Tribal organizations, and to participate in programs operated by urban Indian organizations that are funded by IHS (collectively referred to as I/T/Us) for any medical care purchased by those programs. Section 506 also requires such participation to be in accordance with the admission practices, payment methodology, and payment rates set forth in regulations established by the Secretary, including acceptance of no more than such payment rates as payment in full. PMID:17577967

  15. The Spillover Effects of Medicare Managed Care: Medicare Advantage and Hospital Utilization

    PubMed Central

    Baicker, Katherine; Chernew, Michael; Robbins, Jacob

    2013-01-01

    More than a quarter of Medicare beneficiaries are enrolled in Medicare Advantage, which was created in large part to improve the efficiency of health care delivery by promoting competition among private managed care plans. This paper explores the spillover effects of the Medicare Advantage program on the traditional Medicare program and other patients, taking advantage of changes in Medicare Advantage payment policy to isolate exogenous increases in Medicare Advantage enrollment and trace out the effects of greater managed care penetration on hospital utilization and spending throughout the health care system. We find that when more seniors enroll in Medicare managed care, hospital costs decline for all seniors and for commercially insured younger populations. Greater managed care penetration is not associated with fewer hospitalizations, but is associated with lower costs and shorter stays per hospitalization. These spillovers are substantial – offsetting more than 10% of increased payments to Medicare Advantage plans. PMID:24308880

  16. The spillover effects of Medicare managed care: Medicare Advantage and hospital utilization.

    PubMed

    Baicker, Katherine; Chernew, Michael E; Robbins, Jacob A

    2013-12-01

    More than a quarter of Medicare beneficiaries are enrolled in Medicare Advantage, which was created in large part to improve the efficiency of health care delivery by promoting competition among private managed care plans. This paper explores the spillover effects of the Medicare Advantage program on the traditional Medicare program and other patients, taking advantage of changes in Medicare Advantage payment policy to isolate exogenous increases in Medicare Advantage enrollment and trace out the effects of greater managed care penetration on hospital utilization and spending throughout the health care system. We find that when more seniors enroll in Medicare managed care, hospital costs decline for all seniors and for commercially insured younger populations. Greater managed care penetration is not associated with fewer hospitalizations, but is associated with lower costs and shorter stays per hospitalization. These spillovers are substantial - offsetting more than 10% of increased payments to Medicare Advantage plans.

  17. How Medicare Prescription Drug Coverage Works with a Medicare Advantage Plan or Medicare Cost Plan

    MedlinePlus

    ... Works with a Medicare Advantage Plan or Medicare Cost Plan Medicare offers prescription drug coverage for everyone ... t offer Medicare prescription drug coverage. • A Medicare Cost Plan if it doesn’t offer Medicare prescription ...

  18. Do the Medicaid and Medicare programs compete for access to health care services? A longitudinal analysis of physician fees, 1998-2004.

    PubMed

    Howard, Larry L

    2014-09-01

    As the demand for publicly funded health care continues to rise in the U.S., there is increasing pressure on state governments to ensure patient access through adjustments in provider compensation policies. This paper longitudinally examines the fees that states paid physicians for services covered by the Medicaid program over the period 1998-2004. Controlling for an extensive set of economic and health care industry characteristics, the elasticity of states' Medicaid fees, with respect to Medicare fees, is estimated to be in the range of 0.2-0.7 depending on the type of physician service examined. The findings indicate a significant degree of price competition between the Medicaid and Medicare programs for physician services that is more pronounced for cardiology and critical care, but not hospital care. The results also suggest several policy levers that work to either increase patient access or reduce total program costs through changes in fees. PMID:24682916

  19. 77 FR 17073 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-23

    ... the Children's Health Insurance Program (CHIP). This meeting is open to the public. DATES: Meeting..., and the Children's Health Insurance Program (CHIP). Enhancing the Federal government's effectiveness... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH...

  20. 77 FR 2983 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-01-20

    ... the Children's Health Insurance Program (CHIP). This meeting is open to the public. DATES: Meeting..., and the Children's Health Insurance Program (CHIP). Enhancing the Federal government's effectiveness... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH...

  1. Cumulative Expenditures under the DI, SSI, Medicare, and Medicaid Programs for a Cohort of Disabled Working-Age Adults

    PubMed Central

    Riley, Gerald F; Rupp, Kalman

    2015-01-01

    Objective To estimate cumulative DI, SSI, Medicare, and Medicaid expenditures from initial disability benefit award to death or age 65. Data Sources Administrative records for a cohort of new CY2000 DI and SSI awardees aged 18–64. Study Design Actual expenditures were obtained for 2000–2006/7. Subsequent expenditures were simulated using a regression-adjusted Markov process to assign individuals to annual disability benefit coverage states. Program expenditures were simulated conditional on assigned benefit coverage status. Estimates reflect present value of expenditures at initial award in 2000 and are expressed in constant 2012 dollars. Expenditure estimates were also updated to reflect benefit levels and characteristics of new awardees in 2012. Data Collection We matched records for a 10 percent nationally representative sample. Principal Findings Overall average cumulative expenditures are $292,401 through death or age 65, with 51.4 percent for cash benefits and 48.6 percent for health care. Expenditures are about twice the average for individuals first awarded benefits at age 18–30. Overall average expenditures increased by 10 percent when updated for a simulated 2012 cohort. Conclusions Data on cumulative expenditures, especially combined across programs, are useful for evaluating the long-term payoff of investments designed to modify entry to and exit from the disability rolls. PMID:25109322

  2. Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Short Inpatient Hospital Stays; Transition for Certain Medicare-Dependent, Small Rural Hospitals Under the Hospital Inpatient Prospective Payment System; Provider Administrative Appeals and Judicial Review. Final rule with comment period; final rule.

    PubMed

    2015-11-13

    This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2016 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this final rule with comment period updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program. Further, this document includes certain finalized policies relating to the hospital inpatient prospective payment system: Changes to the 2-midnight rule under the short inpatient hospital stay policy; and a payment transition for hospitals that lost their status as a Medicare-dependent, small rural hospital (MDH) because they are no longer in a rural area due to the implementation of the new Office of Management and Budget delineations in FY 2015 and have not reclassified from urban to rural before January 1, 2016. In addition, this document contains a final rule that finalizes certain 2015 proposals, and addresses public comments received, relating to the changes in the Medicare regulations governing provider administrative appeals and judicial review relating to appropriate claims in provider cost reports.

  3. 78 FR 308 - Medicare Program; Request for Information on Hospital and Vendor Readiness for Electronic Health...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-01-03

    ... (77 FR 53968) outlines our commitment to aligning quality measurement and reporting programs... Incentive Program as set forth in the EHR Incentive Program--Stage 2 final rule (77 FR 53968) and any... Hospital and Vendor Readiness for Electronic Health Records Hospital Inpatient Quality Data...

  4. 75 FR 81278 - Medicare Program: Solicitation of Comments Regarding Development of a Recovery Audit Contractor...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-27

    ... rules for the MA program (69 FR 46866) and prescription drug benefit program (69 FR 46632). The final regulations implementing both programs, published on January 28, 2005 (70 FR 4588 and 70 FR 4194, respectively..., the RAC contractor would come to an agreement with interested MA organizations (MAO) to conduct...

  5. Clinical Informatics Fellowship Programs: In Search of a Viable Financial Model: An open letter to the Centers for Medicare and Medicaid Services.

    PubMed

    Lehmann, C U; Longhurst, C A; Hersh, W; Mohan, V; Levy, B P; Embi, P J; Finnell, J T; Turner, A M; Martin, R; Williamson, J; Munger, B

    2015-01-01

    In the US, the new subspecialty of Clinical Informatics focuses on systems-level improvements in care delivery through the use of health information technology (HIT), data analytics, clinical decision support, data visualization and related tools. Clinical informatics is one of the first subspecialties in medicine open to physicians trained in any primary specialty. Clinical Informatics benefits patients and payers such as Medicare and Medicaid through its potential to reduce errors, increase safety, reduce costs, and improve care coordination and efficiency. Even though Clinical Informatics benefits patients and payers, because GME funding from the Centers for Medicare and Medicaid Services (CMS) has not grown at the same rate as training programs, the majority of the cost of training new Clinical Informaticians is currently paid by academic health science centers, which is unsustainable. To maintain the value of HIT investments by the government and health care organizations, we must train sufficient leaders in Clinical Informatics. In the best interest of patients, payers, and the US society, it is therefore critical to find viable financial models for Clinical Informatics fellowship programs. To support the development of adequate training programs in Clinical Informatics, we request that the Centers for Medicare and Medicaid Services (CMS) issue clarifying guidance that would allow accredited ACGME institutions to bill for clinical services delivered by fellows at the fellowship program site within their primary specialty. PMID:26171074

  6. Clinical Informatics Fellowship Programs: In Search of a Viable Financial Model: An open letter to the Centers for Medicare and Medicaid Services.

    PubMed

    Lehmann, C U; Longhurst, C A; Hersh, W; Mohan, V; Levy, B P; Embi, P J; Finnell, J T; Turner, A M; Martin, R; Williamson, J; Munger, B

    2015-01-01

    In the US, the new subspecialty of Clinical Informatics focuses on systems-level improvements in care delivery through the use of health information technology (HIT), data analytics, clinical decision support, data visualization and related tools. Clinical informatics is one of the first subspecialties in medicine open to physicians trained in any primary specialty. Clinical Informatics benefits patients and payers such as Medicare and Medicaid through its potential to reduce errors, increase safety, reduce costs, and improve care coordination and efficiency. Even though Clinical Informatics benefits patients and payers, because GME funding from the Centers for Medicare and Medicaid Services (CMS) has not grown at the same rate as training programs, the majority of the cost of training new Clinical Informaticians is currently paid by academic health science centers, which is unsustainable. To maintain the value of HIT investments by the government and health care organizations, we must train sufficient leaders in Clinical Informatics. In the best interest of patients, payers, and the US society, it is therefore critical to find viable financial models for Clinical Informatics fellowship programs. To support the development of adequate training programs in Clinical Informatics, we request that the Centers for Medicare and Medicaid Services (CMS) issue clarifying guidance that would allow accredited ACGME institutions to bill for clinical services delivered by fellows at the fellowship program site within their primary specialty.

  7. Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNFs) for FY 2016, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and Staffing Data Collection. Final Rule.

    PubMed

    2015-08-01

    This final rule updates the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2016. In addition, it specifies a SNF all-cause all-condition hospital readmission measure, as well as adopts that measure for a new SNF Value-Based Purchasing (VBP) Program, and includes a discussion of SNF VBP Program policies we are considering for future rulemaking to promote higher quality and more efficient health care for Medicare beneficiaries. Additionally, this final rule will implement a new quality reporting program for SNFs as specified in the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). It also amends the requirements that a long-term care (LTC) facility must meet to qualify to participate as a skilled nursing facility (SNF) in the Medicare program, or a nursing facility (NF) in the Medicaid program, by establishing requirements that implement the provision in the Affordable Care Act regarding the submission of staffing information based on payroll data. PMID:26242002

  8. Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNFs) for FY 2016, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and Staffing Data Collection. Final Rule.

    PubMed

    2015-08-01

    This final rule updates the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2016. In addition, it specifies a SNF all-cause all-condition hospital readmission measure, as well as adopts that measure for a new SNF Value-Based Purchasing (VBP) Program, and includes a discussion of SNF VBP Program policies we are considering for future rulemaking to promote higher quality and more efficient health care for Medicare beneficiaries. Additionally, this final rule will implement a new quality reporting program for SNFs as specified in the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). It also amends the requirements that a long-term care (LTC) facility must meet to qualify to participate as a skilled nursing facility (SNF) in the Medicare program, or a nursing facility (NF) in the Medicaid program, by establishing requirements that implement the provision in the Affordable Care Act regarding the submission of staffing information based on payroll data.

  9. 75 FR 70165 - Medicare Program; Request for Information Regarding Accountable Care Organizations and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-17

    ... (CMMI) within CMS, which is authorized to test innovative payment and service delivery models to reduce... innovative payment and delivery system models that complement the Shared Savings Program in the CMMI. In both... the Shared Savings Program and other innovative payment models that CMMI is authorized to test...

  10. 42 CFR 424.525 - Rejection of a provider or supplier's enrollment application for Medicare enrollment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... application for Medicare enrollment. 424.525 Section 424.525 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Requirements for Establishing and Maintaining Medicare Billing Privileges § 424.525 Rejection of...

  11. 42 CFR 411.204 - Medicare benefits secondary to LGHP benefits.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Medicare benefits secondary to LGHP benefits. 411.204 Section 411.204 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT...

  12. 42 CFR 411.52 - Basis for conditional Medicare payment in liability cases.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Basis for conditional Medicare payment in liability cases. 411.52 Section 411.52 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE...

  13. 76 FR 36539 - Office of the Assistant Secretary for Planning and Evaluation; Medicare Program; Meeting of the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-22

    ...This notice announces public meetings of the Technical Advisory Panel on Medicare Trustee Reports (Panel). Notice of these meetings is given under the Federal Advisory Committee Act (5 U.S.C. App. 2, section 10(a)(1) and (a)(2)). The Panel will discuss the short- term (10 year) projection methods and assumptions in projecting Medicare health spending for Parts A, B, C and D and may make......

  14. Medicare Program; FY 2016 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements. Final rule.

    PubMed

    2015-08-01

    This final rule will update the hospice payment rates and the wage index for fiscal year (FY) 2016 (October 1, 2015 through September 30, 2016), including implementing the last year of the phase-out of the wage index budget neutrality adjustment factor (BNAF). Effective on January 1, 2016, this rule also finalizes our proposals to differentiate payments for routine home care (RHC) based on the beneficiary's length of stay and implement a service intensity add-on (SIA) payment for services provided in the last 7 days of a beneficiary's life, if certain criteria are met. In addition, this rule will implement changes to the aggregate cap calculation mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), align the cap accounting year for both the inpatient cap and the hospice aggregate cap with the federal fiscal year starting in FY 2017, make changes to the hospice quality reporting program, clarify a requirement for diagnosis reporting on the hospice claim, and discuss recent hospice payment reform research and analyses. PMID:26248391

  15. Claims and Appeals (Medicare)

    MedlinePlus

    ... Change Plans Getting started with Medicare Your Medicare coverage choices When & how to sign up for Part ... Apply for Medicare online How to get drug coverage When can I join a health or drug ...

  16. What Medicare Covers

    MedlinePlus

    ... Change Plans Getting started with Medicare Your Medicare coverage choices When & how to sign up for Part ... Apply for Medicare online How to get drug coverage When can I join a health or drug ...

  17. Medicare and Medicaid programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; electronic reporting pilot; Inpatient Rehabilitation Facilities Quality Reporting Program; revision to Quality Improvement Organization regulations. Final rule with comment period.

    PubMed

    2012-11-15

    This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2013 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this final rule with comment period updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program, the ASC Quality Reporting (ASCQR) Program, and the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program. We are continuing the electronic reporting pilot for the Electronic Health Record (EHR) Incentive Program, and revising the various regulations governing Quality Improvement Organizations (QIOs), including the secure transmittal of electronic medical information, beneficiary complaint resolution and notification processes, and technical changes. The technical changes to the QIO regulations reflect CMS' commitment to the general principles of the President's Executive Order on Regulatory Reform, Executive Order 13563 (January 18, 2011).

  18. Solicitation of information and recommendations for developing OIG compliance program guidance for certain Medicare+Choice organizations--OIG, HHS. Notice.

    PubMed

    1998-09-22

    This Federal Register notice seeks the input and recommendations of interested parties into the OIG's development of a compliance program guidance for Medicare+Choice organizations that offer coordinated care plans (M+CO/CCPs). The OIG has previously developed compliance program guidances for hospitals, clinical laboratories and home health agencies in order to provide clear and meaningful guidance to those segments of the health care industry. In an effort to provide similar guidance to certain M+C organizations, we are soliciting comments, recommendations and other suggestions from concerned parties and organizations on how best to develop compliance program guidance and reduce fraud and abuse within M+CO/CCPs.

  19. Medicare Pays for Chronic Care Management.

    PubMed

    Sorrel, Amy Lynn

    2015-09-01

    As of January, the Centers for Medicare & Medicaid Services began paying for chronic care management of patients with two or more conditions under its Chronic Care Management program. The payment applies to patients in traditional fee-for-service and noncapitated Medicare Advantage plan arrangements. Texas Medical Association leaders caution the program has some hefty requirements. PMID:26360339

  20. Medicare Pays for Chronic Care Management.

    PubMed

    Sorrel, Amy Lynn

    2015-09-01

    As of January, the Centers for Medicare & Medicaid Services began paying for chronic care management of patients with two or more conditions under its Chronic Care Management program. The payment applies to patients in traditional fee-for-service and noncapitated Medicare Advantage plan arrangements. Texas Medical Association leaders caution the program has some hefty requirements.

  1. Medicare Special Needs Plan (SNP)

    MedlinePlus

    ... up/change plans About Medicare health plans Medicare Advantage Plans + Share widget - Select to show Subcategories Getting ... plan? About Medicare health plans , current subcategory Medicare Advantage Plans , current page Medicare Medical Savings Account (MSA) ...

  2. 75 FR 70831 - Medicare and Medicaid Programs: Changes to the Hospital and Critical Access Hospital Conditions...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-19

    ... proposed rule in the Federal Register on May 26, 2010 (75 FR 29479). In that rule, we proposed to revise..., 2003, 68 FR 47311) applies to those entities that receive Federal financial assistance from HHS... and Medicaid Programs: Changes to the Hospital and Critical Access Hospital Conditions...

  3. 75 FR 29479 - Medicare and Medicaid Programs: Proposed Changes Affecting Hospital and Critical Access Hospital...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-05-26

    ... and Medicaid Programs: Proposed Changes Affecting Hospital and Critical Access Hospital (CAH... proposed rule would revise the conditions of participation (CoPs) for both hospitals and critical access hospitals (CAHs). These revisions would allow for a new credentialing and privileging process for...

  4. 76 FR 25550 - Medicare and Medicaid Programs: Changes Affecting Hospital and Critical Access Hospital...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-05

    ... May 26, 2010 (75 FR 29479). In that rule, we proposed to revise both the hospital and CAH... and Medicaid Programs: Changes Affecting Hospital and Critical Access Hospital Conditions of...) for both hospitals and critical access hospitals (CAHs). The final rule will implement a...

  5. 77 FR 217 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-01-04

    ..., Hospital Value-Based Purchasing (VBP) Program Issues. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2011-28612 of November 30, 2011 (76 FR 74122), (hereinafter referred to as the CY 2012 OPPS/ASC final.../HospitalOutpatientPPS/HORD . In addition, the CY 2012 Statewide Average CCRs displayed in Table 11 (76...

  6. 75 FR 21329 - Medicaid Program; State Allotments for Payment of Medicare Part B Premiums for Qualifying...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-04-23

    ... Abstinence Programs Extension and Hurricane Katrina Unemployment Relief Act of 2005 (Pub. L. 109-91) was... million in FY 2002. On March 29, 1999, we published a notice in the Federal Register (64 FR 14931) to.... Therefore, on August 26, 2005, we published in the Federal Register an interim final rule (70 FR...

  7. 76 FR 5861 - Medicare, Medicaid, and Children's Health Insurance Programs; Additional Screening Requirements...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-02

    .... 108-173) NASDAQ National Association of Securities Dealers Automated Quotation System NF Nursing... nursing facilities SPIA State Program Integrity Assessment SSA Social Security Administration SSA DMF... Suppliers proposed rule published September 23, 2010 (75 FR 58204). We note that we received some...

  8. 78 FR 45231 - Medicare and Medicaid Programs; Initial Approval of Center for Improvement in Healthcare Quality...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-26

    ... surveys by State agencies. Certification by a nationally recognized accreditation program can substitute... notice in the Federal Register (78 FR 12325) announcing CIHQ's request for approval of its hospital.... 482.23(c)(4), CIHQ modified its standards to address the requirement that blood and...

  9. 77 FR 59616 - Medicare and Medicaid Programs; Approval of the American Osteopathic Association/Healthcare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-09-28

    ... Proposed Notice On May 25, 2012, we published a proposed notice in the Federal Register (77 FR 31361... Continuing CMS-Approval of Its Ambulatory Surgical Center (ASC) Accreditation Program AGENCY: Centers for... sooner as determined by CMS. AOA/HFAP's current term of approval for their ASC accreditation...

  10. 76 FR 15316 - Medicaid Program; State Allotments for Payment of Medicare Part B Premiums for Qualifying...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-21

    ... November 24, 2008 (73 FR 70893), and reflecting funding for the QI program made available under the... 3 of the ``Emergency Aid to American Survivors of the Haiti Earthquake Act'' enacted on January 27, 2010 (Haiti Earthquake Act, Pub. L. 111-127) amended section 1933(g)(2)(M) of the Social Security...

  11. 76 FR 47301 - Medicare Program; Hospice Wage Index for Fiscal Year 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-04

    ... illness. Finally, this final rule will begin implementation of a hospice quality reporting program. DATES... Dowell, (410) 786-0060 for questions regarding quality reporting for hospices and collection of... Encounters 4. Hospice Aide and Homemaker Services E. Quality Reporting for Hospices 1. Background...

  12. 76 FR 26805 - Medicare Program; Hospice Wage Index for Fiscal Year 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-09

    ... standards that included CBSAs. In the FY 2006 hospice wage index final rule (70 FR 45130), we implemented a.... Finally, this proposed rule would begin implementation of a hospice quality reporting program. DATES... CONTACT: For information regarding ``Quality Reporting for Hospices'' and ``Collection of...

  13. Medicare program; right of appeal for Medicare secondary payer determinations relating to liability insurance (including self-insurance), no-fault insurance, and workers' compensation laws and plans. Final rule.

    PubMed

    2015-02-27

    This final rule implements provisions of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (SMART Act) which require us to provide a right of appeal and an appeal process for liability insurance (including self-insurance), no-fault insurance, and workers' compensation laws or plans when Medicare pursues a Medicare Secondary Payer (MSP) recovery claim directly from the liability insurance (including self-insurance), no-fault insurance, or workers' compensation law or plan.

  14. Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2017. Final rule.

    PubMed

    2016-08-01

    This final rule will update the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2017 as required by the statute. As required by section 1886(j)(5) of the Act, this rule includes the classification and weighting factors for the IRF prospective payment system's (IRF PPS's) case-mix groups and a description of the methodologies and data used in computing the prospective payment rates for FY 2017. This final rule also revises and updates quality measures and reporting requirements under the IRF quality reporting program (QRP). PMID:27529901

  15. Medicare Program; Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies. Final rule.

    PubMed

    2015-12-30

    This final rule establishes a prior authorization program for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items that are frequently subject to unnecessary utilization. This rule defines unnecessary utilization and creates a new requirement that claims for certain DMEPOS items must have an associated provisional affirmed prior authorization decision as a condition of payment. This rule also adds the review contractor's decision regarding prior authorization of coverage of DMEPOS items to the list of actions that are not initial determinations and therefore not appealable.

  16. Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2017. Final rule.

    PubMed

    2016-08-01

    This final rule will update the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2017 as required by the statute. As required by section 1886(j)(5) of the Act, this rule includes the classification and weighting factors for the IRF prospective payment system's (IRF PPS's) case-mix groups and a description of the methodologies and data used in computing the prospective payment rates for FY 2017. This final rule also revises and updates quality measures and reporting requirements under the IRF quality reporting program (QRP).

  17. Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2016. Final rule.

    PubMed

    2015-08-01

    This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2016 as required by the statute. As required by section 1886(j)(5) of the Act, this rule includes the classification and weighting factors for the IRF PPS's case-mix groups and a description of the methodologies and data used in computing the prospective payment rates for FY 2016. This final rule also finalizes policy changes, including the adoption of an IRF-specific market basket that reflects the cost structures of only IRF providers, a 1-year phase-in of the revised wage index changes, a 3-year phase-out of the rural adjustment for certain IRFs, and revisions and updates to the quality reporting program (QRP).

  18. Medicare program; inpatient rehabilitation facility prospective payment system for federal fiscal year 2014. Final rule.

    PubMed

    2013-08-01

    This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2014 (for discharges occurring on or after October 1, 2013 and on or before September 30, 2014) as required by the statute. This final rule also revised the list of diagnosis codes that may be counted toward an IRF's "60 percent rule'' compliance calculation to determine "presumptive compliance,'' update the IRF facility-level adjustment factors using an enhanced estimation methodology, revise sections of the Inpatient Rehabilitation Facility-Patient Assessment Instrument, revise requirements for acute care hospitals that have IRF units, clarify the IRF regulation text regarding limitation of review, update references to previously changed sections in the regulations text, and revise and update quality measures and reporting requirements under the IRF quality reporting program.

  19. Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2016. Final rule.

    PubMed

    2015-08-01

    This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2016 as required by the statute. As required by section 1886(j)(5) of the Act, this rule includes the classification and weighting factors for the IRF PPS's case-mix groups and a description of the methodologies and data used in computing the prospective payment rates for FY 2016. This final rule also finalizes policy changes, including the adoption of an IRF-specific market basket that reflects the cost structures of only IRF providers, a 1-year phase-in of the revised wage index changes, a 3-year phase-out of the rural adjustment for certain IRFs, and revisions and updates to the quality reporting program (QRP). PMID:26248390

  20. Medicare Care Choices Model Enables Concurrent Palliative and Curative Care.

    PubMed

    2015-01-01

    On July 20, 2015, the federal Centers for Medicare & Medicaid Services (CMS) announced hospices that have been selected to participate in the Medicare Care Choices Model. Fewer than half of the Medicare beneficiaries use hospice care for which they are eligible. Current Medicare regulations preclude concurrent palliative and curative care. Under the Medicare Choices Model, dually eligible Medicare beneficiaries may elect to receive supportive care services typically provided by hospice while continuing to receive curative services. This report describes how CMS has expanded the model from an originally anticipated 30 Medicare-certified hospices to over 140 Medicare-certified hospices and extended the duration of the model from 3 to 5 years. Medicare-certified hospice programs that will participate in the model are listed.

  1. Savings estimate for a Medicare insured group.

    PubMed

    Birnbaum, H; Holland, S K; Lenhart, G; Reilly, H L; Hoffman, K; Pardo, D P

    1991-01-01

    Estimates of the savings potential of a managed-care program for a Medicare retiree population in Michigan under a hypothetical Medicare insured group (MIG) are presented in this article. In return for receiving an experience-rated capitation payment, a MIG would administer all Medicare and employer complementary benefits for its enrollees. A study of the financial and operational feasibility of implementing a MIG for retirees of a national corporation involving an analysis of 1986 claims data finds that selected managed-care initiatives implemented by a MIG would generate an annual savings of 3.8 percent of total (Medicare plus complementary) expenditures. Although savings are less than the 5 percent to be retained by Medicare, this finding illustrates the potential for savings from managed-care initiatives to Medicare generally and to MIGs elsewhere, where savings may be greater if constraints are less restrictive.

  2. Trends in Medicare Health Maintenance Organization Enrollment: 1986-93

    PubMed Central

    McMillan, Alma

    1993-01-01

    This study examines Medicare health maintenance organization (HMO) enrollment under the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 (Public Law 97-248) from 1986 to 1993. It shows that there was moderate growth in the number of Medicare beneficiaries participating in the TEFRA risk program, reaching 1 in 20 beneficiaries in 1993. Medicare HMO enrollment is heavily concentrated in a few large plans, resulting in heavy concentrations geographically. California and Florida accounted for over one-third of Medicare HMO enrollees. One-half of the States have no Medicare HMO enrollment and one-fifth of the States have fewer than 15,000 Medicare HMO enrollees. PMID:10133705

  3. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Policy Changes and Fiscal Year 2016 Rates; Revisions of Quality Reporting Requirements for Specific Providers, Including Changes Related to the Electronic Health Record Incentive Program; Extensions of the Medicare-Dependent, Small Rural Hospital Program and the Low-Volume Payment Adjustment for Hospitals. Final rule; interim final rule with comment period.

    PubMed

    2015-08-17

    We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2016. Some of these changes implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act), the Pathway for Sustainable Growth Reform(SGR) Act of 2013, the Protecting Access to Medicare Act of 2014, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Medicare Access and CHIP Reauthorization Act of 2015, and other legislation. We also are addressing the update of the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2016.As an interim final rule with comment period, we are implementing the statutory extensions of the Medicare dependent,small rural hospital (MDH)Program and changes to the payment adjustment for low-volume hospitals under the IPPS.We also are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2016 and implementing certain statutory changes to the LTCH PPS under the Affordable Care Act and the Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013 and the Protecting Access to Medicare Act of 2014.In addition, we are establishing new requirements or revising existing requirements for quality reporting by specific providers (acute care hospitals,PPS-exempt cancer hospitals, and LTCHs) that are participating in Medicare, including related provisions for eligible hospitals and critical access hospitals participating in the Medicare Electronic Health Record (EHR)Incentive Program. We also are updating policies relating to the

  4. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Policy Changes and Fiscal Year 2016 Rates; Revisions of Quality Reporting Requirements for Specific Providers, Including Changes Related to the Electronic Health Record Incentive Program; Extensions of the Medicare-Dependent, Small Rural Hospital Program and the Low-Volume Payment Adjustment for Hospitals. Final rule; interim final rule with comment period.

    PubMed

    2015-08-17

    We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2016. Some of these changes implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act), the Pathway for Sustainable Growth Reform(SGR) Act of 2013, the Protecting Access to Medicare Act of 2014, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Medicare Access and CHIP Reauthorization Act of 2015, and other legislation. We also are addressing the update of the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2016.As an interim final rule with comment period, we are implementing the statutory extensions of the Medicare dependent,small rural hospital (MDH)Program and changes to the payment adjustment for low-volume hospitals under the IPPS.We also are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2016 and implementing certain statutory changes to the LTCH PPS under the Affordable Care Act and the Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013 and the Protecting Access to Medicare Act of 2014.In addition, we are establishing new requirements or revising existing requirements for quality reporting by specific providers (acute care hospitals,PPS-exempt cancer hospitals, and LTCHs) that are participating in Medicare, including related provisions for eligible hospitals and critical access hospitals participating in the Medicare Electronic Health Record (EHR)Incentive Program. We also are updating policies relating to the

  5. 78 FR 9057 - Medicare Program; Request for Information on the Use of Clinical Quality Measures (CQMs) Reported...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-07

    ... Physician Fee Schedule (PFS) final rule with comment period (77 FR 69306).). ] The claims-based reporting... Medicare PFS final rule with comment period (77 FR 69178). Generally, the registry qualification process... period (77 FR 69185).) 3. PQRS Reporting Options Using the Registry-Based Reporting Mechanism Since...

  6. 76 FR 10600 - Medicare Program; Public Meeting in Calendar Year 2011 for New Clinical Laboratory Tests Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-25

    ... Year 2011 for New Clinical Laboratory Tests Payment Determinations AGENCY: Centers for Medicare... following years. We refer readers to Sec. 414.508(b). For each new clinical laboratory test code, a... public on the appropriate basis for establishing payment amounts for a specified list of new...

  7. 78 FR 31560 - Medicare Program; Public Meeting in Calendar Year 2013 for New Clinical Laboratory Test Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-24

    ... clinical diagnostic laboratory tests under Part B of title XVIII of the Social Security Act (the Act) that..., 2001 notice (66 FR 58743) to implement section 531(b) of BIPA. Section 942(b) of the Medicare... payment amount for each such code, an explanation of the reasons for each determination, the data on...

  8. Effect of an Innovative Medicare Managed Care Program on the Quality of Care for Nursing Home Residents

    ERIC Educational Resources Information Center

    Kane, Robert L.; Flood, Shannon; Bershadsky, Boris; Keckhafer, Gail

    2004-01-01

    Purpose: We sought to assess the quality of care provided by an innovative Medicare+Choice HMO targeted specifically at nursing home residents and employing nurse practitioners to provide additional primary care over and above that provided by physicians. The underlying premise of the Evercare approach is that the additional primary care will…

  9. 76 FR 13515 - Medicare Program; Revisions to the Reductions and Increases to Hospitals' FTE Resident Caps for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-14

    ... investment of time and audit resources. There are approximately 1,100 teaching hospitals and more than 300 of... Medicare and Medicaid Extenders Act of 2010 relating to the treatment of teaching hospitals that are... order to account for the higher indirect patient care costs of teaching hospitals relative...

  10. 75 FR 58411 - Medicare Program; Town Hall Meeting on the Physician Compare Web Site, October 27, 2010

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-09-24

    ... Physician Compare Web Site, October 27, 2010 AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS... 2010, ``Public Reporting of Performance Information'' requires CMS to establish a Physician Compare Web site by January 1, 2011. This notice announces a Town Hall meeting to discuss the Physician Compare...

  11. 76 FR 9503 - Medicare and Medicaid Programs; Requirements for Long-Term Care (LTC) Facilities; Notice of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-18

    ...) facility must meet in order to qualify to participate as a skilled nursing facility (SNF) in the Medicare..., individuals serving as administrators of a SNF or NF provide written notification of the impending closure and... both state that a SNF/NF must care for its residents in such a manner and in such an environment...

  12. 76 FR 7569 - Office of the Assistant Secretary for Planning and Evaluation; Medicare Program; Meeting of the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-10

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND... long- term rate of change in health spending and may make recommendations to the Medicare Trustees on how the Trustees might more accurately estimate health spending in the long run. The...

  13. 75 FR 76468 - Office of the Assistant Secretary for Planning and Evaluation; Medicare Program; Meeting of the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-08

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND... long- term rate of change in health spending and may make recommendations to the Medicare Trustees on how the Trustees might more accurately estimate health spending in the long run. The...

  14. 75 FR 70925 - Office of the Assistant Secretary for Planning and Evaluation; Medicare Program; Meeting of the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-19

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND... long- term rate of change in health spending and may make recommendations to the Medicare Trustees on how the Trustees might more accurately estimate health spending in the long run. The...

  15. 75 FR 8971 - Medicare Program; Public Meetings in Calendar Year 2010 for All New Public Requests for Revisions...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-02-26

    ... Year 2010 for All New Public Requests for Revisions to the Healthcare Common Procedure Coding System (HCPCS) Coding and Payment Determinations AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS... Procedure Coding System (HCPCS) public meetings to be held in calendar year 2010 to discuss our...

  16. Paradigm shifts in Medicare reform.

    PubMed

    Jones, S B; Etheredge, L

    1996-04-01

    Reforms passed by Congress and vetoed by the president during the past year would have accelerated initiatives already transforming Medicare. Operating in a rapidly changing insurance marketplace, Medicare is shifting from a social insurance model toward a private individual insurance model-expanding the number and type of alternative health plans it offers-and growing numbers of beneficiaries are enrolling in these plans. Such reforms, especially if bolstered by legislative reforms that are likely to resurface after the November elections, will rewrite the social contract enacted more than 30 years ago. They require fundamental shifts in ways of thinking about the federal government's responsibilities; the Medicare program's management; relations between the Medicare program and doctors, hospitals, and other health care providers; and the role of beneficiaries in the Medicare program. The likely deferral of further legislative attempts to reform Medicare affords an opportunity to step back and consider these ongoing changes. It is not easy to describe paradigm shifts accurately, but there are advantages to trying. First, conceptual comparisons can allow public discussion to go beyond budget scorekeeping and media soundbites to consider how different the Medicare program will be if it evolves in the new ways being proposed. Second, a conceptual framework can assist health policy analysts to target what to watch for in tracking changes, to assess the tradeoffs involved, and to advise about the needs for refining legislation. This paper includes examples of what to watch for in tracking the implemented changes. The paradigm shifts are summarized below, then described individually in terms of directions of change along a number of continuums. Note that complete paradigm shifts, from one end of a continuum to the other, are seldom completely realized nor even far advanced. But Medicare's ongoing reforms, accelerated by legislative proposals, seem likely predecessors of

  17. The financial status of Medicare.

    PubMed Central

    Foster, R S

    1998-01-01

    Medicare is the largest health care program in the country, providing medical care to 38 million aged and disabled Americans. Concerns over rapid cost increases and the imminent insolvency of the Medicare Hospital Insurance trust fund led to enactment of sweeping Medicare legislation as part of the Balanced Budget Act of 1997. Preliminary estimates indicate that this legislation will result in program savings of $150 billion in the first five years and will postpone the depletion of the Hospital Insurance fund from the year 2001 until about 2010. While the Balanced Budget Act significantly reduces Hospital Insurance expenditure in the long range, serious deficits are still expected when the "baby boom" generation reaches retirement. The Medicare Supplementary Medical Insurance trust fund is automatically in financial balance, but policy makers remain concerned about continuing rapid cost increases. A new National Bipartisan Commission on the Future of Medicare will attempt to determine effective solutions to these long-range problems. Images p110-a p111-a p111-b PMID:9719810

  18. Use of Medicare's Diabetes Self-Management Training Benefit

    ERIC Educational Resources Information Center

    Strawbridge, Larisa M.; Lloyd, Jennifer T.; Meadow, Ann; Riley, Gerald F.; Howell, Benjamin L.

    2015-01-01

    Medicare began reimbursing for outpatient diabetes self-management training (DSMT) in 2000; however, little is known about program utilization. Individuals diagnosed with diabetes in 2010 were identified from a 20% random selection of the Medicare fee-for-service population (N = 110,064). Medicare administrative and claims files were used to…

  19. 42 CFR 414.21 - Medicare payment basis.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Medicare payment basis. 414.21 Section 414.21 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Physicians and...

  20. 42 CFR 417.456 - Refunds to Medicare enrollees.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Refunds to Medicare enrollees. 417.456 Section 417.456 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH...

  1. 42 CFR 405.1100 - Medicare Appeals Council review: General.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Medicare Appeals Council review: General. 405.1100 Section 405.1100 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED...

  2. 42 CFR 417.452 - Liability of Medicare enrollees.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Liability of Medicare enrollees. 417.452 Section 417.452 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS,...

  3. 78 FR 11189 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-October Through December 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-15

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND...-Approved Carotid Sarah J. McClain... (410) 786-2294 Stent Facilities. VIII American College of JoAnna... oversight of private health insurance. Administration and oversight of these programs involves the...

  4. What Is Medicare?

    MedlinePlus

    ... gov Medicare forms Advance directives & long-term care Electronic prescribing Electronic Health Records (EHRs) Download claims with Medicare’s Blue ... health plan offered by a private company that contracts with Medicare to provide you with all your ...

  5. Medicare Advantage Plans

    MedlinePlus

    ... gov Medicare forms Advance directives & long-term care Electronic prescribing Electronic Health Records (EHRs) Download claims with Medicare’s Blue ... health plan offered by a private company that contracts with Medicare to provide you with all your ...

  6. Medicare risk contracting: determinants of market entry.

    PubMed

    Porell, F W; Wallack, S S

    1990-01-01

    The Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 made it more attractive for health maintenance organizations (HMOs) and other competitive medical plans to enter into risk contracts with Medicare. Since the start of the TEFRA program in April 1985, more than 160 HMOs have had risk contracts with Medicare under the program. An investigation of factors associated with TEFRA risk-market entry at the end of 1986 revealed that high adjusted average per capita cost payment levels, prior Medicare cost-contract experience, and prior Federal qualification were the most important factors distinguishing market entrants from nonentrants. PMID:10113567

  7. 42 CFR 424.520 - Effective date of Medicare billing privileges.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Effective date of Medicare billing privileges. 424.520 Section 424.520 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Requirements...

  8. Medicare on life support: will it survive?

    PubMed

    Fronstin, P; Copeland, C

    1997-09-01

    This Issue Brief discusses Medicare reform. The Balanced Budget Act of 1997 reduces spending in the Medicare program by $115 billion between 1998 and 2002. Most of the reduction in spending comes from reducing payments to providers, and most of the savings (36 percent) occur in 2002. By 2007, the Part A trust fund is expected to be insolvent, four years before the baby-boom generation reaches the current Medicare eligibility age of 65. Congress is likely to revisit Medicare reform in the near future. A number of reforms received a significant amount of attention during the Medicare reform debate, but were not included in the final legislation. The Senate-passed legislation would have increased the Medicare eligibility age from 65 to 67, imposed means testing on Medicare Part B, and imposed a Part B home health copayment of $5. While these provisions were not included in the Balanced Budget Act of 1997, they may be the focal point of future Medicare reform. Many changes to the Medicare program are likely to significantly affect employment-based health plans for both active and retired workers. Raising the Medicare eligibility age would undoubtedly affect both workers and retirees. Unless workers are willing to work until age 67, their likelihood of becoming uninsured would increase. In 1995, 15.8 percent of retirees ages 55-64 were uninsured, compared with 11.5 percent of workers in the same age group. Early retirees might also find themselves unable to afford health insurance in the private market. An Employee Benefit Research Institute/Gallup poll indicates a direct link between the availability of retiree health benefits and a worker's decision to retire early. In 1993, 61 percent of workers reported that they would not retire before becoming eligible for Medicare if their employer did not provide retiree health benefits. If workers responded to an increase in the retirement age by working longer, employment-based health plans would probably experience an

  9. Medicare and Medicaid Programs; CY 2016 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements. Final rule.

    PubMed

    2015-11-01

    This final rule will update Home Health Prospective Payment System (HH PPS) rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor under the Medicare prospective payment system for home health agencies (HHAs), effective for episodes ending on or after January 1, 2016. As required by the Affordable Care Act, this rule implements the 3rd year of the 4-year phase-in of the rebasing adjustments to the HH PPS payment rates. This rule updates the HH PPS case-mix weights using the most current, complete data available at the time of rulemaking and provides a clarification regarding the use of the "initial encounter'' seventh character applicable to certain ICD-10-CM code categories. This final rule will also finalize reductions to the national, standardized 60-day episode payment rate in CY 2016, CY 2017, and CY 2018 of 0.97 percent in each year to account for estimated case-mix growth unrelated to increases in patient acuity (nominal case-mix growth) between CY 2012 and CY 2014. In addition, this rule implements a HH value-based purchasing (HHVBP) model, beginning January 1, 2016, in which all Medicare-certified HHAs in selected states will be required to participate. Finally, this rule finalizes minor changes to the home health quality reporting program and minor technical regulations text changes.

  10. Medicare program; revisions to payment policies under the physician fee schedule for calendar year 2005. Final rule with comment period.

    PubMed

    2004-11-15

    This final rule refines the resource-based practice expense relative value units (RVUs) and makes other changes to Medicare Part B payment policy. These policy changes concern: supplemental survey data for practice expense; updated geographic practice cost indices for physician work and practice expense; updated malpractice RVUs; revised requirements for supervision of therapy assistants; revised payment rules for low osmolar contrast media; changes to payment policies for physicians and practitioners managing dialysis patients; clarification of care plan oversight requirements; revised requirements for supervision of diagnostic psychological testing services; clarifications to the policies affecting therapy services; revised requirements for assignment of Medicare claims; addition to the list of telehealth services; and, several coding issues. We are making these changes to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. This final rule also addresses the following provisions of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Pub. L. 108-17) (MMA): coverage of an initial preventive physical examination; coverage of cardiovascular (CV) screening blood tests; coverage of diabetes screening tests; incentive payment improvements for physicians in shortage areas; payment for covered outpatient drugs and biologicals; payment for renal dialysis services; coverage of routine costs associated with certain clinical trials of category A devices as defined by the Food and Drug Administration; hospice consultation service; indexing the Part B deductible to inflation; extension of coverage of intravenous immune globulin (IVIG) for the treatment in the home of primary immune deficiency diseases; revisions to reassignment provisions; and, payment for diagnostic mammograms, physicians' services associated with drug administration services and coverage of religious nonmedical health

  11. Medicare Payment Systems: A Look Back and a Look Forward.

    PubMed

    Schaum, Kathleen Dianne

    2013-12-01

    Medicare is the major payer for patients with chronic wounds. Over the past 50 years, the Medicare payment systems have undergone numerous changes. At the beginning of the Medicare program, providers were paid based on fee-for-service. In 1997, many of the Medicare payment systems were converted to prospective payment systems (PPSs). Currently, Medicare is conducting many demonstration payment programs to provide the best quality outcomes, at the lowest total cost of care (not necessarily the lowest cost product or procedure), and with patient satisfaction. While the demonstration payment programs are being tested, providers may receive parallel Medicare payments: payment through current PPS and through the demonstration payment program. Wound care providers and manufacturers need to prepare now for the future payment systems. PMID:24761334

  12. Medicare Payment Systems: A Look Back and a Look Forward

    PubMed Central

    Schaum, Kathleen Dianne

    2013-01-01

    Medicare is the major payer for patients with chronic wounds. Over the past 50 years, the Medicare payment systems have undergone numerous changes. At the beginning of the Medicare program, providers were paid based on fee-for-service. In 1997, many of the Medicare payment systems were converted to prospective payment systems (PPSs). Currently, Medicare is conducting many demonstration payment programs to provide the best quality outcomes, at the lowest total cost of care (not necessarily the lowest cost product or procedure), and with patient satisfaction. While the demonstration payment programs are being tested, providers may receive parallel Medicare payments: payment through current PPS and through the demonstration payment program. Wound care providers and manufacturers need to prepare now for the future payment systems. PMID:24761334

  13. Medicare and Medicaid programs: hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting programs; Hospital Value-Based Purchasing Program; organ procurement organizations; quality improvement organizations; Electronic Health Records (EHR) Incentive Program; provider reimbursement determinations and appeals. Final rule with comment period and final rules.

    PubMed

    2013-12-10

    : This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2014 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this final rule with comment period updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program, the ASC Quality Reporting (ASCQR) Program, and the Hospital Value-Based Purchasing (VBP) Program. In the final rules in this document, we are finalizing changes to the conditions for coverage (CfCs) for organ procurement organizations (OPOs); revisions to the Quality Improvement Organization (QIO) regulations; changes to the Medicare fee-for-service Electronic Health Record (EHR) Incentive Program; and changes relating to provider reimbursement determinations and appeals.

  14. Medicare, Medicaid, and Children's Health Insurance Programs; additional screening requirements, application fees, temporary enrollment moratoria, payment suspensions and compliance plans for providers and suppliers. Final rule with comment period.

    PubMed

    2011-02-01

    This final rule with comment period will implement provisions of the ACA that establish: Procedures under which screening is conducted for providers of medical or other services and suppliers in the Medicare program, providers in the Medicaid program, and providers in the Children's Health Insurance Program (CHIP); an application fee imposed on institutional providers and suppliers; temporary moratoria that may be imposed if necessary to prevent or combat fraud, waste, and abuse under the Medicare and Medicaid programs, and CHIP; guidance for States regarding termination of providers from Medicaid and CHIP if terminated by Medicare or another Medicaid State plan or CHIP; guidance regarding the termination of providers and suppliers from Medicare if terminated by a Medicaid State agency; and requirements for suspension of payments pending credible allegations of fraud in the Medicare and Medicaid programs. This final rule with comment period also discusses our earlier solicitation of comments regarding provisions of the ACA that require providers of medical or other items or services or suppliers within a particular industry sector or category to establish compliance programs. We have identified specific provisions surrounding our implementation of fingerprinting for certain providers and suppliers for which we may make changes if warranted by the public comments received. We expect to publish our response to those comments, including any possible changes to the rule made as a result of them, as soon as possible following the end of the comment period. Furthermore, we clarify that we are finalizing the adoption of fingerprinting pursuant to the terms and conditions set forth herein.

  15. New York's Medicare Marketplace: examining new York's Medicare advantage plan landscape in light of payment reform.

    PubMed

    Goggin-Callahaan, Doug; Baker, Joe; Bennett, Rachel; Clerk, Michell; Hersey, Eric; Riccardi, Fred; Torbattejad, May; Xu, Denise

    2013-01-01

    The Patient Protection and Affordable Care Act (ACA) provided for cost savings in the Medicare program, in part to underwrite coverage expansion to Medicare beneficiaries, to finance new coverage for those not eligible for Medicare, and to strengthen Medicare's financial outlook. One cost-saving measure, a reformulation and reduction in payments to private health insurance plans that provide Medicare benefits through the Medicare Advantage (MA) program, had a sound policy basis but was criticized, particularly by opponents o fthe ACA, as a measure that would lead to increased costs, reductions in benefits, and diminished plan choices to Medicare beneficiaries enrolled in MA plans. Despite dire predictions to this effect, a review of a sample of MA plan offerings in New York State in 2012 shows that Medicare beneficiaries enrolled in such plans did not experience significant benefit reductions or increased costs. While the number of plan offerings decreased, the reduction was mostly caused by the elimination of duplicative plan choices in 2011. Although the MA plan executives we interviewed indicated that further reductions in plan reimbursement in future years-tempered by potential bonus payments for meeting quality and performance metrics-could impact plan costs and benefits, they believed plans will employ a number of strategies to remain in the market and maintain benefciary benefits and cost structures. However, government regulators and consumer advocates will need to examine MA plan offerings in the coming years to determine the efect ofplan reaction to the ACA payments on beneficiaries'costs for coverage and access

  16. Centers for Medicare & Medicaid Services

    MedlinePlus

    ... Websites Visit other Centers for Medicare and Medicaid Services & Health and Human Services Websites section Expand Medicare.gov Link to the ... helpful links for all Centers for Medicare & Medicaid Services websites section Expand Web Policies & Important Links Privacy ...

  17. Medicare program; revision to accrual basis of accounting policy. Health Care Financing Administration (HCFA), HHS. Final rule.

    PubMed

    1999-09-27

    Medicare policy provides that payroll taxes that a provider becomes obligated to remit to governmental agencies are included in allowable costs only in the cost reporting period in which payment (upon which the payroll taxes are based) is actually made to an employee. Therefore, for payroll accrued in 1 year but not paid until the next year, the associated payroll taxes are not an allowable cost until the next year. This final rule provides for an exception when payment would be made to the employee in the current year but for the fact the regularly scheduled payment date is after the end of the year. In that case, the rule requires allowance in the current year of accrued taxes on payroll that is accrued through the end of the year but not paid until the beginning of the next year, thus allowing accrued taxes on end-of-the year payroll in the same year that the accrual of the payroll itself is allowed. The effect of this rule is not on the allowability of cost but rather only on the timing of payment; that is, the cost of payroll taxes on end-of-the-year payroll is allowable in the current period rather than in the following period. PMID:11010708

  18. Medicare program; replacement of reasonable charge methodology by fee schedules for parenteral and enteral nutrients, equipment, and supplies. Final rule.

    PubMed

    2001-08-28

    This final rule implements fee schedules for payment of parenteral and enteral nutrition (PEN) items and services furnished under the prosthetic device benefit, defined in section 1861(s)(8) of the Social Security Act. The authority for establishing these fee schedules is provided by the Balanced Budget Act of 1997, which amended the Social Security Act at section 1842(s). Section 1842(s) of the Social Security Act specifies that statewide or other area wide fee schedules may be implemented for the following items and services still subject to the reasonable charge payment methodology: medical supplies; home dialysis supplies and equipment; therapeutic shoes; parenteral and enteral nutrients, equipment, and supplies; electromyogram devices; salivation devices; blood products; and transfusion medicine. This final rule describes changes made to the proposed fee schedule payment methodology for these items and services and provides that the fee schedules for PEN items and services are effective for all covered items and services furnished on or after January 1, 2002. Fee schedules will not be implemented for electromyogram devices and salivation devices at this time since these items are not covered by Medicare. In addition, fee schedules will not be implemented for medical supplies, home dialysis supplies and equipment, therapeutic shoes, blood products, and transfusion medicine at this time since the data required to establish these fee schedules are inadequate.

  19. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2017 Rates; Quality Reporting Requirements for Specific Providers; Graduate Medical Education; Hospital Notification Procedures Applicable to Beneficiaries Receiving Observation Services; Technical Changes Relating to Costs to Organizations and Medicare Cost Reports; Finalization of Interim Final Rules With Comment Period on LTCH PPS Payments for Severe Wounds, Modifications of Limitations on Redesignation by the Medicare Geographic Classification Review Board, and Extensions of Payments to MDHs and Low-Volume Hospitals. Final rule.

    PubMed

    2016-08-22

    We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2017. Some of these changes will implement certain statutory provisions contained in the Pathway for Sustainable Growth Reform Act of 2013, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Notice of Observation Treatment and Implications for Care Eligibility Act of 2015, and other legislation. We also are providing the estimated market basket update to apply to the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2017. We are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2017. In addition, we are making changes relating to direct graduate medical education (GME) and indirect medical education payments; establishing new requirements or revising existing requirements for quality reporting by specific Medicare providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities), including related provisions for eligible hospitals and critical access hospitals (CAHs) participating in the Electronic Health Record Incentive Program; updating policies relating to the Hospital Value-Based Purchasing Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition Reduction Program; implementing statutory provisions that require hospitals and CAHs to furnish notification to Medicare beneficiaries, including Medicare Advantage enrollees, when the beneficiaries receive outpatient observation services for more than 24 hours; announcing the implementation of the Frontier Community Health Integration Project Demonstration; and

  20. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2017 Rates; Quality Reporting Requirements for Specific Providers; Graduate Medical Education; Hospital Notification Procedures Applicable to Beneficiaries Receiving Observation Services; Technical Changes Relating to Costs to Organizations and Medicare Cost Reports; Finalization of Interim Final Rules With Comment Period on LTCH PPS Payments for Severe Wounds, Modifications of Limitations on Redesignation by the Medicare Geographic Classification Review Board, and Extensions of Payments to MDHs and Low-Volume Hospitals. Final rule.

    PubMed

    2016-08-22

    We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2017. Some of these changes will implement certain statutory provisions contained in the Pathway for Sustainable Growth Reform Act of 2013, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Notice of Observation Treatment and Implications for Care Eligibility Act of 2015, and other legislation. We also are providing the estimated market basket update to apply to the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2017. We are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2017. In addition, we are making changes relating to direct graduate medical education (GME) and indirect medical education payments; establishing new requirements or revising existing requirements for quality reporting by specific Medicare providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities), including related provisions for eligible hospitals and critical access hospitals (CAHs) participating in the Electronic Health Record Incentive Program; updating policies relating to the Hospital Value-Based Purchasing Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition Reduction Program; implementing statutory provisions that require hospitals and CAHs to furnish notification to Medicare beneficiaries, including Medicare Advantage enrollees, when the beneficiaries receive outpatient observation services for more than 24 hours; announcing the implementation of the Frontier Community Health Integration Project Demonstration; and

  1. Beneficiary complaints, provider numbers and carrier shopping: Medicare contractor operations.

    PubMed

    Kusserow, R P

    1991-11-01

    The number of Medicare claims processed annually will double in the next 10 years, making it imperative that contractors review claims accurately and ensure that payments are made only for medically necessary, high-quality care. Effective identification and prosecution of fraud and abuse in the Medicare program will depend on a cooperative effort between Medicare contractors, the Health Care Financing Administration, and the Office of Inspector General.

  2. Potential Consequences of Reforming Medicare into a Competitive Bidding System

    PubMed Central

    Song, Zirui; Cutler, David M.; Chernew, Michael E.

    2012-01-01

    The idea of a premium support (or voucher) system for Medicare has generated substantial debate. Under premium support, Medicare beneficiaries choose among health plans that compete in a market-based bidding system. In some models, the Traditional Medicare (TM) program is abandoned entirely in favor of private health plans. In other models, such as the Ryan-Wyden plan, TM becomes one option among many. PMID:22851110

  3. Medicare and Medicaid managed care: a tale of two trajectories.

    PubMed

    Hurley, Robert E; Retchin, Sheldon M

    2006-01-01

    Two decades of efforts to promote managed care models in Medicare and Medicaid have resulted in vastly different experiences as measured by enrollment, plan participation, and ability to achieve the goals of public policy-makers. The Medicare Modernization Act of 2003 introduced a major transformation to engage and retain private health plans. It is useful for plan administrators to consider why the trajectories for the programs have been so divergent and to assess prospects for success in the Medicare Advantage initiative.

  4. Trends in Medicare Part D Medication Therapy Management Eligibility Criteria

    PubMed Central

    Wang, Junling; Shih, Ya-Chen Tina; Qin, Yolanda; Young, Theo; Thomas, Zachary; Spivey, Christina A.; Solomon, David K.; Chisholm-Burns, Marie

    2015-01-01

    Background To increase the enrollment rate of medication therapy management (MTM) programs in Medicare Part D plans, the US Centers for Medicare & Medicaid Services (CMS) lowered the allowable eligibility thresholds based on the number of chronic diseases and Part D drugs for Medicare Part D plans for 2010 and after. However, an increase in MTM enrollment rates has not been realized. Objectives To describe trends in MTM eligibility thresholds used by Medicare Part D plans and to identify patterns that may hinder enrollment in MTM programs. Methods This study analyzed data extracted from the Medicare Part D MTM Programs Fact Sheets (2008–2014). The annual percentages of utilizing each threshold value of the number of chronic diseases and Part D drugs, as well as other aspects of MTM enrollment practices, were analyzed among Medicare MTM programs that were established by Medicare Part D plans. Results For 2010 and after, increased proportions of Medicare Part D plans set their eligibility thresholds at the maximum numbers allowable. For example, in 2008, 48.7% of Medicare Part D plans (N = 347:712) opened MTM enrollment to Medicare beneficiaries with only 2 chronic disease states (specific diseases varied between plans), whereas the other half restricted enrollment to patients with a minimum of 3 to 5 chronic disease states. After 2010, only approximately 20% of plans opened their MTM enrollment to patients with 2 chronic disease states, with the remaining 80% restricting enrollment to patients with 3 or more chronic diseases. Conclusion The policy change by CMS for 2010 and after is associated with increased proportions of plans setting their MTM eligibility thresholds at the maximum numbers allowable. Changes to the eligibility thresholds by Medicare Part D plans might have acted as a barrier for increased MTM enrollment. Thus, CMS may need to identify alternative strategies to increase MTM enrollment in Medicare plans. PMID:26380030

  5. The Experience of Rural Independent Pharmacies with Medicare Part D: Reports from the Field

    ERIC Educational Resources Information Center

    Radford, Andrea; Slifkin, Rebecca; Fraser, Roslyn; Mason, Michelle; Mueller, Keith

    2007-01-01

    Context: The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) created prescription drug coverage for Medicare beneficiaries through a new Part D program, the single largest addition to Medicare since its creation in 1965. Prior to program implementation in January 2006, concerns had been voiced as to how independent…

  6. Understanding the Impacts of the Medicare Modernization Act: Concerns of Congressional Staff

    ERIC Educational Resources Information Center

    Mueller, Keith J.; Coburn, Andrew F.; MacKinney, A. Clinton; McBride, Timothy D.; Slifkin, Rebecca T.; Wakefield, Mary K.

    2005-01-01

    Sweeping changes to the Medicare program embodied in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), including a new prescription drug benefit, changes in payment policies, and reform of the Medicare managed-care program, have major implications for rural health care. The most efficient mechanism for research to…

  7. 42 CFR 417.448 - Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Medicare enrollees of risk HMOs or CMPs. 417.448 Section 417.448 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE... Disenrollment under Medicare Contract § 417.448 Restriction on payments for services received by...

  8. 42 CFR 424.16 - Timing of certification for individual admitted to a hospital before entitlement to Medicare...

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... a hospital before entitlement to Medicare benefits. 424.16 Section 424.16 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Certification and Plan Requirements § 424.16 Timing of certification...

  9. 42 CFR 426.516 - Role of Medicare Managed Care Organizations (MCOs) and State agencies in the NCD review process.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Role of Medicare Managed Care Organizations (MCOs... MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM REVIEW... of Medicare Managed Care Organizations (MCOs) and State agencies in the NCD review process....

  10. Public/Private Partnerships for Prescription Drug Coverage: Policy Formulation and Outcomes in Quebec's Universal Drug Insurance Program, with Comparisons to the Medicare Prescription Drug Program in the United States

    PubMed Central

    Pomey, Marie-Pascale; Forest, Pierre-Gerlier; Palley, Howard A; Martin, Elisabeth

    2007-01-01

    In January 1997, the government of Quebec, Canada, implemented a public/private prescription drug program that covered the entire population of the province. Under this program, the public sector collaborates with private insurers to protect all Quebecers from the high cost of drugs. This article outlines the principal features and history of the Quebec plan and draws parallels between the factors that led to its emergence and those that led to the passage of the Medicare Prescription Drug, Improvement and Modernization Act (MMA) in the United States. It also discusses the challenges and similarities of both programs and analyzes Quebec's ten years of experience to identify adjustments that may help U.S. policymakers optimize the MMA. PMID:17718665

  11. Medicare and state health care programs: fraud and abuse, civil money penalties and intermediate sanctions for certain violations by health maintenance organizations and competitive medical plans--HHS. Final rule.

    PubMed

    1994-07-15

    This final rule implements sections 9312(c)(2), 9312(f), and 9434(b) of Public Law 99-509, section 7 of Public Law 100-93, section 4014 of Public Law 100-203, sections 224 and 411(k)(12) of Public Law 100-360, and section 6411(d)(3) of Public Law 101-239. These provisions broaden the Secretary's authority to impose intermediate sanctions and civil money penalties on health maintenance organizations (HMOs), competitive medical plans, and other prepaid health plans contracting under Medicare or Medicaid that (1) substantially fail to provide an enrolled individual with required medically necessary items and services; (2) engage in certain marketing, enrollment, reporting, or claims payment abuses; or (3) in the case of Medicare risk-contracting plans, employ or contract with, either directly or indirectly, an individual or entity excluded from participation in Medicare. The provisions also condition Federal financial participation in certain State payments on the State's exclusion of certain prohibited entities from participation in HMO contracts and waiver programs. This final rule is intended to significantly enhance the protections for Medicare beneficiaries and Medicaid recipients enrolled in a HMO, competitive medical plan, or other contracting organization under titles XVIII and XIX of the Social Security Act. PMID:10136015

  12. Medicare program; end-stage renal disease prospective payment system and quality incentive program; ambulance fee schedule; durable medical equipment; and competitive acquisition of certain durable medical equipment prosthetics, orthotics and supplies. Final rule.

    PubMed

    2011-11-10

    This final rule updates and makes certain revisions to the End-Stage Renal Disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2012. We are also finalizing the interim final rule with comment period published on April 6, 2011, regarding the transition budget-neutrality adjustment under the ESRD PPS,. This final rule also sets forth requirements for the ESRD quality incentive program (QIP) for payment years (PYs) 2013 and 2014. In addition, this final rule revises the ambulance fee schedule regulations to conform to statutory changes. This final rule also revises the definition of durable medical equipment (DME) by adding a 3-year minimum lifetime requirement (MLR) that must be met by an item or device in order to be considered durable for the purpose of classifying the item under the Medicare benefit category for DME. Finally, this final rule implements certain provisions of section 154 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) related to the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) Competitive Acquisition Program and responds to comments received on an interim final rule published January 16, 2009, that implemented these provisions of MIPPA effective April 18, 2009. (See the Table of Contents for a listing of the specific issues addressed in this final rule.)

  13. Analysis Of Medicare Advantage HMOs compared with traditional Medicare shows lower use of many services during 2003-09.

    PubMed

    Landon, Bruce E; Zaslavsky, Alan M; Saunders, Robert C; Pawlson, L Gregory; Newhouse, Joseph P; Ayanian, John Z

    2012-12-01

    Enrollment in Medicare Advantage, the managed care program for Medicare beneficiaries, has grown rapidly, from 4.6 million enrollees in 2003 to 12.8 million by 2012, or 27 percent of all current Medicare beneficiaries. We analyzed utilization patterns of enrollees in Medicare Advantage health maintenance organization (HMO) plans compared to matched samples of people in traditional Medicare during 2003-09, to ascertain whether the HMO enrollees demonstrated different levels of use of services, which can be a hallmark of more integrated care. We found that utilization rates in some major categories, including emergency departments and ambulatory surgery or procedures, generally were 20-30 percent lower in Medicare Advantage HMOs in all years. Medicare Advantage HMO enrollees initially had lower rates of ambulatory visits and hospitalizations, although these rates converged by 2008; they also received about 10 percent fewer hip or knee replacements. In contrast, HMO enrollees underwent more coronary bypass surgery than patients in traditional Medicare. These findings suggest that overall, Medicare Advantage HMO enrollees might use fewer services and be experiencing more appropriate use of services than enrollees in traditional Medicare.

  14. Medicare Payment Reform: Aligning Incentives for Better Care.

    PubMed

    Anderson, Gerard F; Davis, Karen; Guterman, Stuart

    2015-06-01

    The Affordable Care Act (ACA) has provided the Medicare program with an array of tools to improve the quality of care that beneficiaries receive and to increase the efficiency with which that care is provided. Notably, the ACA has created the Center for Medicare and Medicaid Innovation, which is developing and testing promising new models to improve the quality of care provided to Medicare beneficiaries while reducing spending. These new models are part of an effort by the U.S. Department of Health and Human Services to increase the proportion of traditional Medicare payments tied to quality or value to 85 percent by 2016 and 90 percent by 2018. This issue brief, one in a series on Medicare's past, present, and future, explores the evolution of Medicare payment policy, the potential of value-based payment to improve care for beneficiaries and achieve savings, and strategies for accelerating its adoption. PMID:26151988

  15. Medicare Payment Reform: Aligning Incentives for Better Care.

    PubMed

    Anderson, Gerard F; Davis, Karen; Guterman, Stuart

    2015-06-01

    The Affordable Care Act (ACA) has provided the Medicare program with an array of tools to improve the quality of care that beneficiaries receive and to increase the efficiency with which that care is provided. Notably, the ACA has created the Center for Medicare and Medicaid Innovation, which is developing and testing promising new models to improve the quality of care provided to Medicare beneficiaries while reducing spending. These new models are part of an effort by the U.S. Department of Health and Human Services to increase the proportion of traditional Medicare payments tied to quality or value to 85 percent by 2016 and 90 percent by 2018. This issue brief, one in a series on Medicare's past, present, and future, explores the evolution of Medicare payment policy, the potential of value-based payment to improve care for beneficiaries and achieve savings, and strategies for accelerating its adoption.

  16. Medicare Advantage update: benefits, enrollment, and payments after the ACA.

    PubMed

    Linehan, Kathryn

    2013-07-19

    In 2012, the Medicare program paid private health plans $136 billion to cover about 13 million beneficiaries who received Part A and B benefits through the Medicare Advantage (MA) program rather than traditional fee-for-service (FFS) Medicare. Private plans have been a part of the program since the 1970s. Debate about the policy goals--Should they cost less per beneficiary than FFS Medicare? Should they be available to all beneficiaries? Should they be able to offer additional benefits?--has long accompanied Medicare's private plan option.This debate is reflected in the history of Medicare payment policy,and policy decisions over the years have affected plans' willingness to participate and beneficiaries' enrollment at different periods of the program. Recently, evidence that the Medicare program was paying more per beneficiary in MA relative to what would have been spent under FFS Medicare prompted policymakers to reduce MA payments in the Patient Protection and Affordable Care Act of 2010 (ACA). So far, plans continue to participate in MA and enrollment continues to grow, but payment reductions in 2012 through 2014 have been partially offset by payments made to plans through the quality bonus payment demonstration.This brief contains recent data on plan enrollment, availability, and benefits and discusses MA plan payment policy, including changes to MA payment made in the ACA and their actual and projected effects.

  17. Medicare and participating physicians: physician election of "participation" status under Medicare.

    PubMed

    Blehart, B

    1985-07-01

    The purpose of this paper is to assist physicians in making Medicare participation decisions for the coming period of October 1, 1985, to September 30, 1986. This paper will describe the participation program, its operation, and the potential advantages and disadvantages of a participation election. The paper concludes that, while it may be advantageous for some physicians to be identified as "participating" in Medicare, this is an individual decision that should only be made upon a careful examination of many factors.

  18. 42 CFR 1003.105 - Exclusion from participation in Medicare, Medicaid and all Federal health care programs.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... and all Federal health care programs. 1003.105 Section 1003.105 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES CIVIL MONEY PENALTIES... health care programs. (a)(1) Except as set forth in paragraph (b) of this section, the following...

  19. 42 CFR 1003.105 - Exclusion from participation in Medicare, Medicaid and all Federal health care programs.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... and all Federal health care programs. 1003.105 Section 1003.105 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES CIVIL MONEY PENALTIES... health care programs. (a)(1) Except as set forth in paragraph (b) of this section, the following...

  20. 42 CFR 1003.105 - Exclusion from participation in Medicare, Medicaid and all Federal health care programs.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... and all Federal health care programs. 1003.105 Section 1003.105 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES CIVIL MONEY PENALTIES... health care programs. (a)(1) Except as set forth in paragraph (b) of this section, the following...

  1. 42 CFR 1003.105 - Exclusion from participation in Medicare, Medicaid and all Federal health care programs.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... and all Federal health care programs. 1003.105 Section 1003.105 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES CIVIL MONEY PENALTIES... health care programs. (a)(1) Except as set forth in paragraph (b) of this section, the following...

  2. 42 CFR 1003.105 - Exclusion from participation in Medicare, Medicaid and all Federal health care programs.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... and all Federal health care programs. 1003.105 Section 1003.105 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES CIVIL MONEY PENALTIES... health care programs. (a)(1) Except as set forth in paragraph (b) of this section, the following...

  3. 78 FR 57857 - Medicare and Medicaid Programs; Application from the Compliance Team for Initial CMS-Approval of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-20

    ... the Compliance Team for Initial CMS-Approval of its Rural Health Clinic Accreditation Program AGENCY... acknowledges the receipt of an application from the Compliance Team for initial recognition as a national... Compliance Team's request for initial CMS approval of its RHC accreditation program. This notice...

  4. 42 CFR 460.94 - Required services for Medicare participants.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE Services § 460.94 Required services for Medicare participants. (a)...

  5. 42 CFR 460.180 - Medicare payment to PACE organizations.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Payment § 460.180 Medicare payment to PACE organizations. (a) Principle...

  6. 42 CFR 460.180 - Medicare payment to PACE organizations.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Payment § 460.180 Medicare payment to PACE organizations. (a) Principle...

  7. 42 CFR 460.94 - Required services for Medicare participants.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE Services § 460.94 Required services for Medicare participants. (a)...

  8. 42 CFR 460.94 - Required services for Medicare participants.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE Services § 460.94 Required services for Medicare participants. (a)...

  9. 42 CFR 460.180 - Medicare payment to PACE organizations.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Payment § 460.180 Medicare payment to PACE organizations. (a) Principle...

  10. 42 CFR 460.94 - Required services for Medicare participants.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE Services § 460.94 Required services for Medicare participants. (a)...

  11. Medicare and Rural Health

    MedlinePlus

    ... Health Gateway Evidence-based Toolkits Rural Health Models & Innovations Supporting Rural Community Health Tools for Success Am ... in rural areas. Center for Medicare and Medicaid Innovation (CMMI) – CMMI, also known as the CMS Innovation ...

  12. Pharmacy utilization and the Medicare Modernization Act.

    PubMed

    Maio, Vittorio; Pizzi, Laura; Roumm, Adam R; Clarke, Janice; Goldfarb, Neil I; Nash, David B; Chess, David

    2005-01-01

    To control expenditures and use medications appropriately, the Medicare drug coverage program has established pharmacy utilization management (PUM) measures. This article assesses the effects of these strategies on the care of seniors. The literature suggests that although caps on drug benefits lower pharmaceutical costs, they may also increase the use of other health care services and hurt health outcomes. Our review raises concerns regarding the potential unintended effects of the Medicare drug program's PUM policies for beneficiaries. Therefore, the economic and clinical impact of PUM measures on seniors should be studied further to help policymakers design better drug benefit plans. PMID:15787955

  13. Medicare and Medicaid programs; modifications to the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program for 2014 and other changes to EHR Incentive Program; and health information technology: revision to the certified EHR technology definition and EHR certification changes related to standards. Final rule.

    PubMed

    2014-09-01

    This final rule changes the meaningful use stage timeline and the definition of certified electronic health record technology (CEHRT) to allow options in the use of CEHRT for the EHR reporting period in 2014. It also sets the requirements for reporting on meaningful use objectives and measures as well as clinical quality measure (CQM) reporting in 2014 for providers who use one of the CEHRT options finalized in this rule for their EHR reporting period in 2014. In addition, it finalizes revisions to the Medicare and Medicaid EHR Incentive Programs to adopt an alternate measure for the Stage 2 meaningful use objective for hospitals to provide structured electronic laboratory results to ambulatory providers; to correct the regulation text for the measures associated with the objective for hospitals to provide patients the ability to view online, download, and transmit information about a hospital admission; and to set a case number threshold exemption for CQM reporting applicable for eligible hospitals and critical access hospitals (CAHs) beginning with FY 2013. Finally, this rule finalizes the provisionally adopted replacement of the Data Element Catalog (DEC) and the Quality Reporting Document Architecture (QRDA) Category III standards with updated versions of these standards.

  14. 42 CFR 417.454 - Charges to Medicare enrollees.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... inpatient hospital care. If a Medicare enrollee who is an inpatient of a hospital requests immediate QIO... enrollee for any inpatient care costs incured before noon of the first working day after the QIO issues its... (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH...

  15. Educating Older Adults About Medicare: The Role of Cognitive Variables

    ERIC Educational Resources Information Center

    Bayen, Ute J.; McCormack, Lauren A.; Bann, Carla M.

    2005-01-01

    A survey was conducted on 3,738 beneficiaries about their knowledge of the Medicare program as well as their reading habits, reading comprehension ability, and metamemory. Factor analysis yielded a reading and a metamemory factor. These factors explained variance in knowledge about Medicare above and beyond the variance explained by formal…

  16. 42 CFR 412.108 - Special treatment: Medicare-dependent, small rural hospitals.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... hospitals. 412.108 Section 412.108 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES... § 412.108 Special treatment: Medicare-dependent, small rural hospitals. (a) Criteria for...

  17. Medicare. Indirect Medical Education Payments Are Too High. GAO Report to Congressional Committees.

    ERIC Educational Resources Information Center

    Zimmerman, Michael; And Others

    A report to the Congressional Committees examines the variation in Medicare costs and payments among teaching and nonteaching hospitals and identifies factors explaining the variation. Three chapters are as follows: (1) introduction (i.e., the Medicare Program, Medicare payments for inpatient hospital services, objectives, scope, and methodology);…

  18. Diagnosis-Based Risk Adjustment for Medicare Prescription Drug Plan Payments

    PubMed Central

    Robst, John; Levy, Jesse M.; Ingber, Melvin J.

    2007-01-01

    The 2003 Medicare Prescription Drug, Improvement, and Modernization Act (MMA) created Medicare Part D, a voluntary prescription drug benefit program. The benefit is a government subsidized prescription drug benefit within Medicare. This article focuses on the development of the prescription drug risk-adjustment model used to adjust payments to reflect the health status of plan enrollees. PMID:17722748

  19. 42 CFR 420.405 - Rewards for information relating to Medicare fraud and abuse.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Rewards for information relating to Medicare fraud... Rewards for Information Relating to Medicare Fraud and Abuse, and Establishment of a Program to Collect... Rewards for information relating to Medicare fraud and abuse. (a) General rule. CMS pays a monetary...

  20. 42 CFR 420.405 - Rewards for information relating to Medicare fraud and abuse.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Rewards for information relating to Medicare fraud... Information Relating to Medicare Fraud and Abuse, and Establishment of a Program to Collect Suggestions for... information relating to Medicare fraud and abuse. (a) General rule. CMS pays a monetary reward for...

  1. 42 CFR 405.377 - Withholding Medicare payments to recover Medicaid overpayments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Withholding Medicare payments to recover Medicaid overpayments. 405.377 Section 405.377 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED...

  2. 42 CFR 405.425 - Effects of opting-out of Medicare.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Effects of opting-out of Medicare. 405.425 Section 405.425 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED Private Contracts §...

  3. 42 CFR 405.410 - Conditions for properly opting-out of Medicare.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Conditions for properly opting-out of Medicare. 405.410 Section 405.410 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED Private...

  4. 42 CFR 418.405 - Effect of coinsurance liability on Medicare payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Effect of coinsurance liability on Medicare payment. 418.405 Section 418.405 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HOSPICE CARE Coinsurance § 418.405 Effect...

  5. 42 CFR 417.528 - Payment when Medicare is not primary payer.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Payment when Medicare is not primary payer. 417.528 Section 417.528 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS,...

  6. 42 CFR 406.15 - Special provisions applicable to Medicare qualified government employment.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... government employment. 406.15 Section 406.15 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM HOSPITAL INSURANCE ELIGIBILITY AND ENTITLEMENT... government employment. (a) Definition. As used in this section, Medicare-qualified government...

  7. 77 FR 31359 - Medicare and Medicaid Programs; Announcement of the Re-Approval of the Joint Commission as an...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-25

    ...This notice announces the application of the Joint Commission for re-approval as an accreditation organization for clinical laboratories under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) program for all specialty and subspecialty areas under CLIA. We have determined that the Joint Commission meets or exceeds the applicable CLIA requirements. We are announcing the re-approval......

  8. HOW MUCH FAVORABLE SELECTION IS LEFT IN MEDICARE ADVANTAGE?

    PubMed Central

    PRICE, MARY; MCWILLIAMS, J. MICHAEL; HSU, JOHN; MCGUIRE, THOMAS G.

    2015-01-01

    The health economics literature contains two models of selection, one with endogenous plan characteristics to attract good risks and one with fixed plan characteristics; neither model contains a regulator. Medicare Advantage, a principal example of selection in the literature, is, however, subject to anti-selection regulations. Because selection causes economic inefficiency and because the historically favorable selection into Medicare Advantage plans increased government cost, the effectiveness of the anti-selection regulations is an important policy question, especially since the Medicare Advantage program has grown to comprise 30 percent of Medicare beneficiaries. Moreover, similar anti-selection regulations are being used in health insurance exchanges for those under 65. Contrary to earlier work, we show that the strengthened anti-selection regulations that Medicare introduced starting in 2004 markedly reduced government overpayment attributable to favorable selection in Medicare Advantage. At least some of the remaining selection is plausibly related to fixed plan characteristics of Traditional Medicare versus Medicare Advantage rather than changed selection strategies by Medicare Advantage plans. PMID:26389127

  9. Valuing neurosurgery services: part II. The interdependence of Current Procedural Terminology and federal Medicare payment policy.

    PubMed

    Bean, James R

    2002-04-15

    Current Procedural Terminology (CPT) policies for coding of medical procedures and services are adopted by the American Medical Association CPT editorial panel. Since institution of the Medicare Fee Schedule in 1992, the Medicare budget neutrality rule has strongly influenced CPT policies for the coding of additions or modifications. The Centers for Medicare and Medicaid Services Medicare program policies, particularly payment limits, influence code modification strategies and CPT editorial panel processes. PMID:16212303

  10. Medicare Australia and the professional services review scheme.

    PubMed

    Bird, Sara

    2008-09-01

    Medicare Australia's Practitioner Review Program and the Professional Services Review (PSR) Scheme aim to protect the integrity of Medicare and pharmaceutical benefits programs by protecting patients and the community from the risks associated with 'inappropriate practice' and also protecting the Commonwealth Government from having to meet the cost of services provided as a result of inappropriate practice. This article outlines the operation of the Practitioner Review Program and PSR.

  11. Clinical and Economic Impact of a Digital, Remotely-Delivered Intensive Behavioral Counseling Program on Medicare Beneficiaries at Risk for Diabetes and Cardiovascular Disease

    PubMed Central

    Chen, Fang; Su, Wenqing; Becker, Shawn H.; Payne, Mike; Peters, Anne L.; Dall, Timothy M.

    2016-01-01

    Background Type 2 diabetes and cardiovascular disease impose substantial clinical and economic burdens for seniors (age 65 and above) and the Medicare program. Intensive Behavioral Counseling (IBC) interventions like the National Diabetes Prevention Program (NDPP), have demonstrated effectiveness in reducing excess body weight and lowering or delaying morbidity onset. This paper estimated the potential health implications and medical savings of a digital version of IBC modeled after the NDPP. Methods and Findings Participants in this digital IBC intervention, the Omada program, include 1,121 overweight or obese seniors with additional risk factors for diabetes or heart disease. Weight changes were objectively measured via participant use of a networked weight scale. Participants averaged 6.8% reduction in body weight within 26 weeks, and 89% of participants completed 9 or more of the 16 core phase lessons. We used a Markov-based microsimulation model to simulate the impact of weight loss on future health states and medical expenditures over 10 years. Cumulative per capita medical expenditure savings over 3, 5 and 10 years ranged from $1,720 to 1,770 (3 years), $3,840 to $4,240 (5 years) and $11,550 to $14,200 (10 years). The range reflects assumptions of weight re-gain similar to that seen in the DPP clinical trial (lower bound) or minimal weight re-gain aligned with age-adjusted national averages (upper bound). The estimated net economic benefit after IBC costs is $10,250 to $12,840 cumulative over 10 years. Simulation outcomes suggest reduced incidence of diabetes by 27–41% for participants with prediabetes, and stroke by approximately 15% over 5 years. Conclusions A digital, remotely-delivered IBC program can help seniors at risk for diabetes and cardiovascular disease achieve significant weight loss, reduces risk for diabetes and cardiovascular disease, and achieve meaningful medical cost savings. These findings affirm recommendations for IBC coverage by the

  12. Medicare and Medicaid programs; physicians' referrals to health care entities with which they have financial relationships. Health Care Financing Administration (HCFA), HHS. Final rule with comment period.

    PubMed

    2001-01-01

    This final rule with 90-day comment period (Phase I of this rulemaking) incorporates into regulations the provisions in paragraphs (a), (b), and (h) of section 1877 of the Social Security Act (the Act). Under section 1877, if a physician or a member of a physician's immediate family has a financial relationship with a health care entity, the physician may not make referrals to that entity for the furnishing of designated health services (DHS) under the Medicare program, unless an exception applies. The following services are DHS: clinical laboratory services; physical therapy services; occupational therapy services; radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services; radiation therapy services and supplies; durable medical equipment and supplies; parenteral and enteral nutrients, equipment, and supplies; prosthetics, orthotics, and prosthetic devices and supplies; home health services; outpatient prescription drugs; and inpatient and outpatient hospital services. In addition, section 1877 of the Act provides that an entity may not present or cause to be presented a Medicare claim or bill to any individual, third party payer, or other entity for DHS furnished under a prohibited referral, nor may we make payment for a designated health service furnished under a prohibited referral. Paragraph (a) of section 1877 of the Act includes the general prohibition. Paragraph (b) of the Act includes exceptions that pertain to both ownership and compensation relationships, including an in-office ancillary services exception. Paragraph (h) includes definitions that are used throughout section 1877 of the Act, including the group practice definition and the definitions for each of the DHS. We intend to publish a second final rule with comment period (Phase II of this rulemaking) shortly addressing, to the extent necessary, the remaining sections of the Act. Phase II of this rulemaking will address comments

  13. Assessing Medicare Part D Claim Completeness Using Medication Self-reports: The Role of Veteran Status and Generic Drug Discount Programs

    PubMed Central

    Zhou, Lei; Stearns, Sally C.; Thudium, Emily M.; Alburikan, Khalid A.; Rodgers, Jo Ellen

    2015-01-01

    Objective Medicare Part D claims are commonly used for research, but missing claims could compromise their validity. This study assessed two possible causes of missing claims: veteran status and Generic Drug Discount Programs (GDDP). Methods We merged medication self-reports from telephone interviews in the Atherosclerosis Risk in Communities Study (ARIC) with Part D claims for six medications (three were commonly in GDDP in 2009). Merged records (4,468) were available for 2,905 ARIC participants enrolled in Part D. Multinomial logit regression provided estimates of the association of concordance (self-report & Part D, self-report only, or Part D only) with veteran and GDDP status, controlling for participant socio-demographics. Results Sample participants were 74±5 years of age, 68% white and 63% female; 19% were male veterans. Compared to females, male veterans were 11% (95% CI: 7%–16%) less likely to have matched medications in self-report & Part D and 11% (95% CI: 7%–16%) more likely to have self-report only. Records for GDDP versus non-GDDP medications were 4% (95% CI: 1%–7%) more likely to be in self-report & Part D and 3% (95% CI: 1%–5%) less likely to be in Part D only, with no difference in self-report only. Conclusions Part D claims were more likely to be missing for veterans, but claims for medications commonly available through GDDP were more likely to match with self-reports. While researchers should be aware of the possibility of missing claims, GDDP status was associated with a higher rather than lower likelihood of claims being complete in 2009. PMID:25793271

  14. Medicare drug coverage and moral hazard.

    PubMed

    Pauly, Mark V

    2004-01-01

    This paper explores the effect of more extensive drug coverage in Medicare on the use of and spending for prescription drugs and considers whether any additional use is likely to represent satisfaction of previously unmet needs or whether it represents yet more overuse. Reasonable estimates of the effect on spending strongly suggest that the spending increase will be small and that some of it will go to beneficiaries who do not face high financial barriers at present. Thus, from the viewpoint of improvements in health, national spending on drugs, or pharmaceutical firm revenues, effects are small. The effects of such programs on Medicare's fiscal future are much more important. PMID:15002634

  15. Medicare finances: findings of the 2007 Trustees report.

    PubMed

    Van de Water, Paul N

    2007-04-01

    Each year Medicare's Board of Trustees issues a report that describes the financial condition of the Medicare program in the near term and over the next 75 years. Similar to recent trustees reports, the 2007 report projects that Medicare's Hospital Insurance Trust Fund will be depleted in 2019, at which time scheduled income will cover 79 percent of expenditures. For the first time, the trustees have issued a "Medicare funding warning," which means that more than 45 percent of Medicare will be financed by general (non-dedicated) revenues within the next seven years. Looking at these projections, some observers contend that Medicare must be fundamentally restructured in order to put the program--and the overall federal budget--on a sound fiscal course. Others point out that Medicare spending has grown at about the same rate as spending for private health insurance and argue that it is impossible to limit spending on Medicare without also slowing the growth of private health care costs or abandoning equal access to care for the aged and disabled.

  16. Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services. Final rule.

    PubMed

    2015-11-24

    This final rule implements a new Medicare Part A and B payment model under section 1115A of the Social Security Act, called the Comprehensive Care for Joint Replacement (CJR) model, in which acute care hospitals in certain selected geographic areas will receive retrospective bundled payments for episodes of care for lower extremity joint replacement (LEJR) or reattachment of a lower extremity. All related care within 90 days of hospital discharge from the joint replacement procedure will be included in the episode of care. We believe this model will further our goals in improving the efficiency and quality of care for Medicare beneficiaries with these common medical procedures. PMID:26606762

  17. Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services. Final rule.

    PubMed

    2015-11-24

    This final rule implements a new Medicare Part A and B payment model under section 1115A of the Social Security Act, called the Comprehensive Care for Joint Replacement (CJR) model, in which acute care hospitals in certain selected geographic areas will receive retrospective bundled payments for episodes of care for lower extremity joint replacement (LEJR) or reattachment of a lower extremity. All related care within 90 days of hospital discharge from the joint replacement procedure will be included in the episode of care. We believe this model will further our goals in improving the efficiency and quality of care for Medicare beneficiaries with these common medical procedures.

  18. Medicare Preventive and Screening Services

    MedlinePlus

    ... covered? Search Medicare.gov for covered items Preventive & screening services How often is it covered? Medicare Part B (Medical Insurance) covers: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone ...

  19. Medicare and Medicaid programs; Home Health Prospective Payment System rate update for CY 2014, home health quality reporting requirements, and cost allocation of home health survey expenses. Final rule.

    PubMed

    2013-12-01

    This final rule will update the Home Health Prospective Payment System (HH PPS) rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, the low-utilization payment adjustment (LUPA) add-on, and the non-routine medical supply (NRS) conversion factor under the Medicare prospective payment system for home health agencies (HHAs), effective January 1, 2014. As required by the Affordable Care Act, this rule establishes rebasing adjustments, with a 4-year phase-in, to the national, standardized 60-day episode payment rates; the national per-visit rates; and the NRS conversion factor. In addition, this final rule will remove 170 diagnosis codes from assignment to diagnosis groups within the HH PPS Grouper, effective January 1, 2014. Finally, this rule will establish home health quality reporting requirements for CY 2014 payment and subsequent years and will clarify that a state Medicaid program must provide that, in certifying HHAs, the state's designated survey agency carry out certain other responsibilities that already apply to surveys of nursing facilities and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID), including sharing in the cost of HHA surveys. For that portion of costs attributable to Medicare and Medicaid, we will assign 50 percent to Medicare and 50 percent to Medicaid, the standard method that CMS and states use in the allocation of expenses related to surveys of nursing homes. PMID:24294635

  20. Medicare and Medicaid programs; Home Health Prospective Payment System rate update for CY 2014, home health quality reporting requirements, and cost allocation of home health survey expenses. Final rule.

    PubMed

    2013-12-01

    This final rule will update the Home Health Prospective Payment System (HH PPS) rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, the low-utilization payment adjustment (LUPA) add-on, and the non-routine medical supply (NRS) conversion factor under the Medicare prospective payment system for home health agencies (HHAs), effective January 1, 2014. As required by the Affordable Care Act, this rule establishes rebasing adjustments, with a 4-year phase-in, to the national, standardized 60-day episode payment rates; the national per-visit rates; and the NRS conversion factor. In addition, this final rule will remove 170 diagnosis codes from assignment to diagnosis groups within the HH PPS Grouper, effective January 1, 2014. Finally, this rule will establish home health quality reporting requirements for CY 2014 payment and subsequent years and will clarify that a state Medicaid program must provide that, in certifying HHAs, the state's designated survey agency carry out certain other responsibilities that already apply to surveys of nursing facilities and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID), including sharing in the cost of HHA surveys. For that portion of costs attributable to Medicare and Medicaid, we will assign 50 percent to Medicare and 50 percent to Medicaid, the standard method that CMS and states use in the allocation of expenses related to surveys of nursing homes.

  1. Medicare Interim Payment System's Impact on Medicare Home Health Utilization

    PubMed Central

    Liu, Korbin; Long, Sharon K.; Dowling, Krista

    2003-01-01

    The Medicare home health interim payment system (IPS) implemented in fiscal year 1998 provided very strong incentives for home health agencies (HHAs) to reduce the number of visits provided to each Medicare user and to avoid those beneficiaries whose Medicare plan of care was likely to exceed the average beneficiary cost limit. We analyzed multiple years of data from the Medicare Current Beneficiary Survey (MCBS) to examine how the IPS affected subgroups of the Medicare population by health and socioeconomic characteristics. We found that the IPS strongly reduced overall utilization, but that few subgroups were disproportionately affected. PMID:14997695

  2. Medicare, managed care, and vision services to the elderly.

    PubMed

    Soroka, M

    1995-06-01

    Proportionately, fewer Medicare patients are enrolled in HMOs than in fee-for-service programs. Despite the advantages of selecting the HMO option, only 2.9 million beneficiaries are enrolled. Integrating Medicare into health care reform will be a major challenge to this administration. There is general recognition that it will be difficult to control health costs if people at least 65 years of age remain outside the system. With renewed marketing programs directed toward the elderly, we can expect further increases in Medicare HMO enrollment.

  3. Kaiser-Permanente's Medicare Plus Project: A Successful Medicare Prospective Payment Demonstration

    PubMed Central

    Greenlick, Merwyn R.; Lamb, Sara J.; Carpenter, Theodore M.; Fischer, Thomas S.; Marks, Sylvia D.; Cooper, William J.

    1983-01-01

    The Medicare Plus project of the Oregon Region Kaiser-Permanente Medical Care Program was designed as a model for prospective payment to Increase Health Maintenance Organization (HMO) participation in the Medicare program. The project demonstrated that it is possible to design a prospective payment system that costs the Medicare program less than services purchased in the community from fee-for-service providers; would provide appropriate payment to the HMO; and in addition, creates a “savings” to return to beneficiaries in the form of comprehensive benefits to motivate them to enroll in the HMO. Medicare Plus was highly successful in recruiting 5,500 new and 1,800 conversion members into the demonstration, through use of a media campaign, a recruitment brochure, and a telephone information center. Members recruited were a representative age and geographic cross section of the senior citizen population in the Portland, Oregon metropolitan area. Utilization of inpatient services by Medicare Plus members in the first full year (1981) was 1679 days per thousand members and decreased to 1607 in the second full year (1982). New members made an average of eight visits per year to ambulatory care facilities. PMID:10310002

  4. Medical costs of CKD in the Medicare population.

    PubMed

    Honeycutt, Amanda A; Segel, Joel E; Zhuo, Xiaohui; Hoerger, Thomas J; Imai, Kumiko; Williams, Desmond

    2013-09-01

    Estimates of the medical costs associated with different stages of CKD are needed to assess the economic benefits of interventions that slow the progression of kidney disease. We combined laboratory data from the National Health and Nutrition Examination Survey with expenditure data from Medicare claims to estimate the Medicare program's annual costs that were attributable to CKD stage 1-4. The Medicare costs for persons who have stage 1 kidney disease were not significantly different from zero. Per person annual Medicare expenses attributable to CKD were $1700 for stage 2, $3500 for stage 3, and $12,700 for stage 4, adjusted to 2010 dollars. Our findings suggest that the medical costs attributable to CKD are substantial among Medicare beneficiaries, even during the early stages; moreover, costs increase as disease severity worsens. These cost estimates may facilitate the assessment of the net economic benefits of interventions that prevent or slow the progression of CKD.

  5. Medicare as insurance innovator: the case of hospice.

    PubMed

    Taylor, Donald H

    2013-09-01

    The stylized fact is that while private insurance has tended to innovate on the benefit design side of the insurance contract, Medicare has lead innovation on the payment side. Traditional or Fee-For-Service Medicare has produced many innovations in the payment for health care services, such as Prospective Payment for hospitals, Diagnostic-Related Groups to categorize care, and the Resource-Based Relative Value System used by the program to pay physicians, while private insurance has produced a series of benefit design innovations. This story misses one important example of Medicare benefit innovation: the creation of the Medicare hospice benefit. A key question is whether Medicare can again lead a system-wide benefit design effort to improve upon current hospice and palliative care policy.

  6. Vertical integration strategies: revenue effects in hospital and Medicare markets.

    PubMed

    Cody, M

    1996-01-01

    The purpose of this study was to evaluate the revenue effects of seven vertically integrated strategies on California hospitals. The strategies investigated were managed care contracts, physician affiliations, ambulatory care, ambulatory surgery, home health services, inpatient rehabilitation, and skilled nursing care. The study population included 242 not-for-profit hospitals in continuous operation from 1983 to 1990. Many hospitals developed vertically integrated programs in the 1980s as inpatient utilization fell in response to the Medicare Prospective Payment program. Net revenue rose on average by $2,080 from 1983 to 1990, but fell by $2,421 from the Medicare program. On the whole, the more physicians affiliated with a hospital, the higher the net revenue. However, in the Medicare population, the number of managed care contracts was significant. The pre-hospital strategies generated significant revenue, while the post-hospital strategies did not. In the Medicare program, inpatient rehabilitation significantly reduced revenue.

  7. Medicare's enduring struggle to define "reasonable and necessary" care.

    PubMed

    Neumann, Peter J; Chambers, James D

    2012-11-01

    Medicare legislation mandates that the program not pay for items and services that are not "reasonable and necessary" - terms that are open to interpretation and easily politicized. In today's fiscal environment, "reasonable and necessary" warrants a closer look. PMID:23113832

  8. Urban-Rural Differences in the Effect of a Medicare Health Promotion and Disease Self-Management Program on Physical Function and Health Care Expenditures

    ERIC Educational Resources Information Center

    Meng, Hongdao; Wamsley, Brenda; Liebel, Diane; Dixon, Denise; Eggert, Gerald; Van Nostrand, Joan

    2009-01-01

    Purpose: To evaluate the impact of a multicomponent health promotion and disease self-management intervention on physical function and health care expenditures among Medicare beneficiaries. To determine if these outcomes vary by urban or rural residence. Design and Methods: We analyzed data from a 22-month randomized controlled trial of a health…

  9. Medicare Prescription Drug Coverage

    MedlinePlus

    ... people also have to pay an additional monthly cost. Private companies provide Medicare prescription drug coverage. You choose the drug plan you like best. Whether or not you should sign up depends on how good your current coverage is. You need to sign up as ...

  10. Medicare, Medicaid, and Children's Health Insurance Programs: Announcement of the Implementation and Extension of Temporary Moratoria on Enrollment of Part B Non-Emergency Ground Ambulance Suppliers and Home Health Agencies in Designated Geographic Locations and Lifting of the Temporary Moratoria on Enrollment of Part B Emergency Ground Ambulance Suppliers in All Geographic Locations. Extension, implementation, and lifting of temporary moratoria.

    PubMed

    2016-08-01

    This document announces the extension of temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance suppliers and Medicare home health agencies (HHAs), subunits, and branch locations in specific locations within designated metropolitan areas in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey to prevent and combat fraud, waste, and abuse. It also announces the implementation of temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance suppliers and Medicare HHAs, subunits, and branch locations in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey on a statewide basis. In addition, it announces the lifting of the moratoria on all Part B emergency ground ambulance suppliers. These moratoria, and the changes described in this document, also apply to the enrollment of HHAs and non-emergency ground ambulance suppliers in Medicaid and the Children's Health Insurance Program. PMID:27487581

  11. Medicare, Medicaid, and Children's Health Insurance Programs: Announcement of the Implementation and Extension of Temporary Moratoria on Enrollment of Part B Non-Emergency Ground Ambulance Suppliers and Home Health Agencies in Designated Geographic Locations and Lifting of the Temporary Moratoria on Enrollment of Part B Emergency Ground Ambulance Suppliers in All Geographic Locations. Extension, implementation, and lifting of temporary moratoria.

    PubMed

    2016-08-01

    This document announces the extension of temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance suppliers and Medicare home health agencies (HHAs), subunits, and branch locations in specific locations within designated metropolitan areas in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey to prevent and combat fraud, waste, and abuse. It also announces the implementation of temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance suppliers and Medicare HHAs, subunits, and branch locations in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey on a statewide basis. In addition, it announces the lifting of the moratoria on all Part B emergency ground ambulance suppliers. These moratoria, and the changes described in this document, also apply to the enrollment of HHAs and non-emergency ground ambulance suppliers in Medicaid and the Children's Health Insurance Program.

  12. Medicare program; participation in CHAMPUS and CHAMPVA, hospital admissions for veterans, discharge rights notice, and hospital responsibility for emergency care--HCFA and OIG. Interim final rule with comment period.

    PubMed

    1994-06-22

    We are revising requirements for Medicare participating hospitals by adding the following: A hospital must provide inpatient hospital services to individuals who have health coverage provided by either the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) or the Civilian Health and Medical Program of the Veterans Administration (CHAMPVA), subject to limitations provided by regulations that require the hospital to collect the beneficiary's cost-share and accept payment from the CHAMPUS/CHAMPVA programs as payment in full. A hospital must provide inpatient hospital services to military veterans (subject to the limitations provided in 38 CFR 17.50 ff.) and accept payment from the Department of Veterans Affairs as payment in full. A hospital must give each Medicare beneficiary (or his or her representative) at or about the time of admission, a written statement of his or her rights concerning discharge from the hospital. A hospital (including a rural primary care hospital) with an emergency department must provide, upon request and within the capabilities of the hospital or rural primary care hospital, an appropriate medical screening examination, stabilizing treatment and/or an appropriate transfer to another medical facility to any individual with an emergency medical condition, regardless of the individual's eligibility for Medicare. The statute provides for the termination of a provider's agreement for violation of any of these provisions. These revisions implement sections 9121 and 9122 of the Consolidated Omnibus Budget Reconciliation Act of 1985 (as amended by section 4009 of the Omnibus Budget Reconciliation Act of 1987), section 233 of the Veteran's Benefit Improvement and Health Care Authorization Act of 1986, sections 9305(b)(1) and 9307 of the Omnibus Budget Reconciliation Act of 1986, sections 6003(g)(3)(D)(xiv), 6018 and 6211 of the Omnibus Budget Reconciliation Act of 1989, and sections 4008(b), 4027(a), and 4027(k)(3) of the

  13. Medicare program; participation in CHAMPUS and CHAMPVA, hospital admissions for veterans, discharge rights notice, and hospital responsibility for emergency care--HCFA and OIG. Interim final rule with comment period.

    PubMed

    1994-06-22

    We are revising requirements for Medicare participating hospitals by adding the following: A hospital must provide inpatient hospital services to individuals who have health coverage provided by either the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) or the Civilian Health and Medical Program of the Veterans Administration (CHAMPVA), subject to limitations provided by regulations that require the hospital to collect the beneficiary's cost-share and accept payment from the CHAMPUS/CHAMPVA programs as payment in full. A hospital must provide inpatient hospital services to military veterans (subject to the limitations provided in 38 CFR 17.50 ff.) and accept payment from the Department of Veterans Affairs as payment in full. A hospital must give each Medicare beneficiary (or his or her representative) at or about the time of admission, a written statement of his or her rights concerning discharge from the hospital. A hospital (including a rural primary care hospital) with an emergency department must provide, upon request and within the capabilities of the hospital or rural primary care hospital, an appropriate medical screening examination, stabilizing treatment and/or an appropriate transfer to another medical facility to any individual with an emergency medical condition, regardless of the individual's eligibility for Medicare. The statute provides for the termination of a provider's agreement for violation of any of these provisions. These revisions implement sections 9121 and 9122 of the Consolidated Omnibus Budget Reconciliation Act of 1985 (as amended by section 4009 of the Omnibus Budget Reconciliation Act of 1987), section 233 of the Veteran's Benefit Improvement and Health Care Authorization Act of 1986, sections 9305(b)(1) and 9307 of the Omnibus Budget Reconciliation Act of 1986, sections 6003(g)(3)(D)(xiv), 6018 and 6211 of the Omnibus Budget Reconciliation Act of 1989, and sections 4008(b), 4027(a), and 4027(k)(3) of the

  14. Pharmaceuticals: Medicare Modernization Act--2005. End of Year Issue Brief.

    PubMed

    Seay, Melicia

    2005-12-31

    The enactment of the landmark Medicare Modernization Act of 2003 (MMA) marked the first structural change to Medicare since its inception in 1965. The MMA established the Medicare prescription drug benefit with an intermediate Medicare-approved drug discount card program to be implemented six months after enactment and full implementation in January 2006. The MMA marks the first time the federal government would be providing access to prescription drugs for seniors. Though the merits and cost of the MMA continue to be debated, the impending change to how seniors and the low-income access prescription drugs is on the horizon. Historically, state lawmakers believed it was appropriate to provide assistance to the elderly and, in some states, the disabled and indigent, for the purchase of much needed prescription drugs. Since 1975, states have been creating, terminating and redesigning state pharmaceutical assistance programs (SPAPs) that either provides a prescription drug subsidy, discount card program or full benefit design. Currently, 33 states operate pharmaceutical assistance programs that provide coverage for seniors. Now, due to the MMA, the states' role as provider of prescription drug benefits to seniors is being re-evaluated. The MMA is intended to save costs for the states. Medicare beneficiaries, the bulk of enrollees in state pharmaceutical assistance programs, will now access prescription drugs through the new Medicare prescription drug benefit. The MMA mandates a state to federal government cost shift when the financial burden of those who are eligible for both Medicaid and Medicare (dual eligibles) switch to receiving prescription drug coverage through Medicare, with Medicaid only being an option for drugs not covered by Medicare. Employers, many of which have been cutting prescription drug benefits to retirees because of rising health care costs, will now receive subsidies from the federal government to continue providing prescription drug benefits to

  15. Patents, Innovation, and the Welfare Effects of Medicare Part D*

    PubMed Central

    Gailey, Adam; Lakdawalla, Darius; Sood, Neeraj

    2013-01-01

    Purpose To evaluate the efficiency consequences of the Medicare Part D program. Methods We develop and empirically calibrate a simple theoretical model to examine the static and dynamic welfare effects of Medicare Part D. Findings We show that Medicare Part D can simultaneously reduce static deadweight loss from monopoly pricing of drugs and improve incentives for innovation. We estimate that even after excluding the insurance value of the program, the welfare gain of Medicare Part D roughly equals its social costs. The program generates $5.11 billion of annual static deadweight loss reduction, and at least $3.0 billion of annual value from extra innovation. Implications Medicare Part D and other public prescription drug programs can be welfare-improving, even for risk-neutral and purely self-interested consumers. Furthermore, negotiation for lower branded drug prices may further increase the social return to the program. Originality This study demonstrates that pure efficiency motives, which do not even surface in the policy debate over Medicare Part D, can nearly justify the program on their own merits. PMID:20575239

  16. Serving rural Medicare risk enrollees: HMOs' decisions, experiences, and future plans.

    PubMed

    Casey, M

    1998-01-01

    This article identifies factors that influence health maintenance organizations' (HMOs) decisions about offering a Medicare risk product in rural areas; describes HMOs' recent experiences serving rural Medicare risk enrollees; and assesses the potential impact of Medicare program changes on the future willingness of HMOs to offer a Medicare risk product in rural areas. Data for the analysis were collected through interviews with a national sample of 27 HMOs. The results underscore the importance of adjusted average per capita cost (AAPCC) rates in HMOs' decisions to offer Medicare risk products in rural areas, but also indicate that other factors influence these decisions. PMID:10387427

  17. Medicare overpayments to private plans, 1985-2012: shifting seniors to private plans has already cost Medicare US$282.6 billion.

    PubMed

    Hellander, Ida; Himmelstein, David U; Woolhandler, Steffie

    2013-01-01

    Previous research has documented Medicare overpayments to the private Medicare Advantage (MA) plans that compete with traditional fee-for-service Medicare. This research has assessed individual categories of overpayment for, at most, a few years. However, no study has calculated the total overpayments to private plans since the program's inception. Prior to 2004, selective enrollment of healthier seniors was the major source of excess payments. We estimate this has added US$41 billion to Medicare's costs since 1985. Medicare adopted a risk-adjustment scheme in 2004, but this has not curbed private plans' ability to game the payment system. This has added US$122.5 billion to Medicare's costs since 2004. Congress mandated increased payment to private plans in the 2003 Medicare Modernization Act, which was mitigated, to a degree, by the subsequent Affordable Care Act. In total, we find that Medicare has overpaid private insurers by US$282.6 billion since 1985. Risk adjustment does not work in for-profit MA plans, which have a financial incentive, the data, and the ingenuity to game whatever system Medicare devises. It is time to end Medicare's costly experiment with privatization. The U.S. needs to adopt a single-payer national health insurance program with effective methods for controlling costs.

  18. Does Medicare Advantage Cost Less Than Traditional Medicare?

    PubMed

    Biles, Brian; Casillas, Giselle; Guterman, Stuart

    2016-01-01

    The costs of providing benefits to enrollees in private Medicare Advantage (MA) plans are slightly less, on average, than what traditional Medicare spends per beneficiary in the same county. However, MA plans that are able to keep their costs comparatively low are concen­trated in a fairly small number of U.S. counties. In the 25 counties where the cost differences between MA plans and traditional Medicare are largest, MA plans spent a total of $5.2 billion less than what traditional Medicare would have been expected to spend on the same benefi­ciaries, with health maintenance organizations (HMOs) accounting for all of that difference. In the rest of the country, MA plans spent $4.8 billion above the expected costs under tradi­tional Medicare. Broad determinations about the relative efficiency of MA plans and traditional Medicare can therefore be misleading, as they fail to take into account local conditions and individual plans' performance.

  19. Medicare advantage plans at a crossroads--yet again.

    PubMed

    Berenson, Robert A; Dowd, Bryan E

    2009-01-01

    Since risk-taking, private health insurance plans were introduced into Medicare twenty-five years ago, policymakers have disagreed on these plans' fundamental purposes. Articulated objectives, which include improving quality, reducing government spending, providing additional benefits (without expanding the entitlement), increasing choices for beneficiaries, and providing benchmark competition for traditional Medicare, are plausible but sometimes conflicting. The program's history demonstrates continuous shifts in emphasis on these objectives. We enumerate the differing advantages of public and private plans in Medicare and argue that policymakers should focus their efforts on leveling the public-private playing field, thereby dealing forthrightly with the reality of growing fiscal problems.

  20. Fee-for-service Medicare in a competitive market environment.

    PubMed

    Dowd, Bryan E; Coulam, Robert F; Feldman, Roger; Pizer, Steven D

    Since its inception, the Medicare Program has allowed for the participation of private health plans, but the relationship of private plans to the government-sponsored fee-for-service (FFS) plan has been the subject of debate. Increased payments to private plans, the introduction of regional preferred provider organizations (PPOs), and a mandated demonstration of price competition that includes FFS Medicare reflect an ongoing attempt to define the role of private plans. The purpose of this article is to explore the roles of private plans and FFS Medicare and to attempt to identify the advantages and disadvantages of each.

  1. Setting Physicians' Prices in FFS Medicare: An Economic Perspective

    PubMed Central

    Dowd, Bryan; Feldman, Roger; Nyman, John; Town, Bob

    2006-01-01

    Recent policy discussions by the Medicare Payment Advisory Commission (MedPAC) regarding physician prices in the traditional fee-for-service (FFS) Medicare Program reflect movement toward a market pricing model. Earlier objectives such as sustainable levels of spending have given way to concerns over the relationship between fees and actual costs, access to care, and the importance of demand and supply in local markets. An important objective in other policy settings is economically efficient distribution of services. We explain the meaning of economic efficiency for Medicare physician prices and explore difficulties one might encounter in pursuing economic efficiency, as well as the cost of not pursuing it. PMID:17427848

  2. DOES MEDICARE SAVE LIVES?*

    PubMed Central

    Card, David; Dobkin, Carlos; Maestas, Nicole

    2009-01-01

    Health insurance characteristics shift at age 65 as most people become eligible for Medicare. We measure the impacts of these changes on patients who are admitted to hospitals through emergency departments for conditions with similar admission rates on weekdays and weekends. The age profiles of admissions and comorbidities for these patients are smooth at age 65, suggesting that the severity of illness is similar on either side of the Medicare threshold. In contrast, the number of procedures performed in hospitals and total list charges exhibit small but statistically significant discontinuities, implying that patients over 65 receive more services. We estimate a nearly 1-percentage-point drop in 7-day mortality for patients at age 65, equivalent to a 20% reduction in deaths for this severely ill patient group. The mortality gap persists for at least 9 months after admission. PMID:19920880

  3. Designing health insurance information for the Medicare beneficiary: a policy synthesis.

    PubMed Central

    Davidson, B N

    1988-01-01

    Can Medicare beneficiaries make rational and informed decisions about their coverage under the Medicare program? Recent policy developments in the Medicare program have been based on the theory of competition in medical care. One of the key assumptions of the competitive model is the free flow of adequate information, enabling the consumer to make an informed choice from among the various sellers of a particular product. Options for Medicare beneficiaries in supplementing their basic Medicare coverage include the purchase of private supplementary insurance policies or enrollment in a Medicare HMO. These consumers, in a complex health insurance market, have only limited information available to them because many health plans do not make adequate comparable product information available. Moreover, since the introduction of the Medicare HMO option, the long-range plan for management of the Medicare budget has become based on the large-scale voluntary enrollment of beneficiaries into capitated health plans. The policy instrument that has been used to improve beneficiary decisions on how to supplement Medicare coverage is the informational or educational program. This synthesis presents findings regarding the relative effectiveness of different types of health insurance information programs for the Medicare beneficiary in an effort to promote practical use of the most effective types of information. PMID:3060450

  4. Population-based disease management under fee-for-service Medicare.

    PubMed

    Foote, Sandra M

    2003-01-01

    Medicare policymakers are considering testing population-based disease management (PDM) programs under fee-for-service (FFS) Medicare as a way to improve health and cost outcomes for selected subgroups of chronically ill beneficiaries. This paper provides a brief overview of how PDM programs are evolving in the private sector and describes how they differ from other approaches already being tested in Medicare disease management demonstrations. It also discusses some key opportunities and issues to be considered in adapting PDM programs for testing in the FFS Medicare context.

  5. 2015: Rural Medicare Advantage Enrollment Update.

    PubMed

    Finegan, Chance; Ullrich, Fred; Mueller, Keith

    2015-07-01

    Key Findings. (1) Rural enrollment in Medicare Advantage (MA) and other prepaid plans increased by 6.8 percent between March 2014 and March 2015 to 2.1 million members, or 21.2 percent of all rural residents eligible for Medicare. This compares to a national enrollment in MA and other prepaid plans of 31.1 percent (16.7 million) of enrollees. (2) Rural enrollment in Health Maintenance Organization (HMO) plans (including point-of-service, or POS, plans), Preferred Provider Organization (PP0) plans, and other pre-paid plans (including Medicare Cost and Program of All-Inclusive Care for the Elderly Plans) all increased by 5-13 percent. (3) Enrollment in private fee-for-service (PFFS) plans continued to decline (decreasing nationally by 15.8 percent and 12.1 percent in rural counties over the period March 2014-2015). Only eight states showed an increase in PFFS plan enrollment. Five states experienced decreases of 50 percent or more. (4) The five states with the highest percentages of rural beneficiaries enrolled in a Medicare Advantage plan are Minnesota (51.8 percent), Hawaii (39.4 percent), Pennsylvania (36.2 percent), Wisconsin (35.5 percent), and New York (31.5 percent).

  6. 2015: Rural Medicare Advantage Enrollment Update.

    PubMed

    Finegan, Chance; Ullrich, Fred; Mueller, Keith

    2015-07-01

    Key Findings. (1) Rural enrollment in Medicare Advantage (MA) and other prepaid plans increased by 6.8 percent between March 2014 and March 2015 to 2.1 million members, or 21.2 percent of all rural residents eligible for Medicare. This compares to a national enrollment in MA and other prepaid plans of 31.1 percent (16.7 million) of enrollees. (2) Rural enrollment in Health Maintenance Organization (HMO) plans (including point-of-service, or POS, plans), Preferred Provider Organization (PP0) plans, and other pre-paid plans (including Medicare Cost and Program of All-Inclusive Care for the Elderly Plans) all increased by 5-13 percent. (3) Enrollment in private fee-for-service (PFFS) plans continued to decline (decreasing nationally by 15.8 percent and 12.1 percent in rural counties over the period March 2014-2015). Only eight states showed an increase in PFFS plan enrollment. Five states experienced decreases of 50 percent or more. (4) The five states with the highest percentages of rural beneficiaries enrolled in a Medicare Advantage plan are Minnesota (51.8 percent), Hawaii (39.4 percent), Pennsylvania (36.2 percent), Wisconsin (35.5 percent), and New York (31.5 percent). PMID:26793818

  7. Can Food Stamps help to reduce Medicare spending on diabetes?

    PubMed

    Nicholas, Lauren Hersch

    2011-01-01

    Diabetes is rapidly escalating amongst low-income, older adults at great cost to the Medicare program. We use longitudinal survey data from the Health and Retirement Study linked to administrative Medicare records and biomarker data to assess the relationship between Food Stamp receipt and diabetes health outcomes. We find no significant difference in Medicare spending, outpatient utilization, diabetes hospitalizations and blood sugar (HbA1c) levels between recipients and income-eligible non-recipients after controlling for a detailed set of covariates including individual fixed effects and measures of diabetes treatment compliance. As one-third of elderly Food Stamp recipients are currently diabetic, greater coordination between the Food Stamp, Medicare, and Medicaid programs may improve health outcomes for this group. PMID:21112260

  8. Making sense of the change in how Medicare Advantage plans are paid.

    PubMed

    Gold, Marsha

    2013-05-01

    The Affordable Care Act has altered payment policy for private Medicare Advantage (MA) plans, with the goal of lowering costs closer to the level in traditional Medicare. Using newly available information on 2009 MA plan costs, this analysis com­pares plans' estimates of per capita costs for providing Parts A and B benefits to their enrollees, on a risk-adjusted basis, against what government data show to be the same costs for traditional Medicare program beneficiaries residing in the same county. It finds that on average, risk-adjusted MA plan costs were 4 percent higher than traditional Medicare costs (104%). Among plan types, only HMOs had lower average costs than traditional Medicare. Among local PPOs and private fee-for service plans, over 75 percent had costs exceeding those in traditional Medicare. The wide variation seen in MA plan costs relative to traditional Medicare suggests there is room for greater efficiency in care delivery.

  9. 42 CFR 405.211 - Procedures for Medicare contractors in making coverage decisions for a non-experimental...

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Procedures for Medicare contractors in making coverage decisions for a non-experimental/investigational (Category B) device. 405.211 Section 405.211 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE...

  10. 42 CFR 426.416 - Role of Medicare Managed Care Organizations (MCOs) and State agencies in the LCD review.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Role of Medicare Managed Care Organizations (MCOs) and State agencies in the LCD review. 426.416 Section 426.416 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM REVIEW OF...

  11. Health information technology: revisions to the 2014 edition electronic health record certification criteria; and Medicare and Medicaid programs; revisions to the Electronic Health Record Incentive Program. Interim final rule with comment period.

    PubMed

    2012-12-01

    The Department of Health and Human Services (HHS) is issuing this interim final rule with comment period to replace the Data Element Catalog (DEC) standard and the Quality Reporting Document Architecture (QRDA) Category III standard adopted in the final rule published on September 4, 2012 in the Federal Register with updated versions of those standards. This interim final rule with comment period also revises the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs by adding an alternative measure for the Stage 2 meaningful use (MU) objective for hospitals to provide structured electronic laboratory results to ambulatory providers, correcting the regulation text for the measures associated with the objective for hospitals to provide patients the ability to view online, download, and transmit information about a hospital admission, and making the case number threshold exemption for clinical quality measure (CQM) reporting applicable for eligible hospitals and critical access hospitals (CAHs) beginning with FY 2013. This rule also provides notice of CMS's intention to issue technical corrections to the electronic specifications for CQMs released on October 25, 2012. PMID:23227573

  12. A Political History of Medicare and Prescription Drug Coverage

    PubMed Central

    Oliver, Thomas R; Lee, Philip R; Lipton, Helene L

    2004-01-01

    This article examines the history of efforts to add prescription drug coverage to the Medicare program. It identifies several important patterns in policymaking over four decades. First, prescription drug coverage has usually been tied to the fate of broader proposals for Medicare reform. Second, action has been hampered by divided government, federal budget deficits, and ideological conflict between those seeking to expand the traditional Medicare program and those preferring a greater role for private health care companies. Third, the provisions of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 reflect earlier missed opportunities. Policymakers concluded from past episodes that participation in the new program should be voluntary, with Medicare beneficiaries and taxpayers sharing the costs. They ignored lessons from past episodes, however, about the need to match expanded benefits with adequate mechanisms for cost containment. Based on several new circumstances in 2003, the article demonstrates why there was a historic opportunity to add a Medicare prescription drug benefit and identify challenges to implementing an effective policy. PMID:15225331

  13. Medicare Part D in 2008: rising prices and growing confusion.

    PubMed

    Flaer, Paul J; Younis, Mustafa Z; Hussain, Ali Al Sayed; Malow, Robert M

    2008-01-01

    Medicare Part D, implemented in January 2006, has failed in the promise of inexpensive medications for all recipients, including those US citizens aged 65 years or older and the disabled. Conceived as a privatization program for a prescription drug benefit tied to Medicare, the program has brought increased costs to middle- and upper-class seniors. Seniors who are continuing users of expensive brand name or specialty drugs face significantly higher prices. Medicare D recipients must deal with capitation payments, deductibles, subsidies, drug substitutions, and extensive coverage gaps or "donut holes" in which they must pay 100 percent of their medication costs. For low-income and indigent patients, especially those with chronic diseases like HIV or cancer, the Medicare Part D program seemed beneficial. However, for such patients, there is likely to be a growing realization that the old system of receiving medications at public hospitals was less expensive than prescription coverage under Medicare Part D. At Miami's public hospital, Jackson Memorial Medical Center, low-income and indigent patients pay $5 per medication whether it is a generic, brand name, or specialty drug. Return to the public hospital pharmacy system from the neighborhood pharmacy and Medicare Part D plan can mean significant savings to low-income or indigent patients. PMID:21110483

  14. Medicare and Caregivers: Illness and Hospitilization

    MedlinePlus

    ... version of this page please turn Javascript on. Medicare and Caregivers Illness and Hospitalization Facing a chronic ... and give you Medicare-covered services. When Does Medicare Cover Hospital Care? If a person needs to ...

  15. Medicare program; inpatient psychiatric facilities prospective payment system--update for rate year beginning July 1, 2011 (RY 2012). Final rule.

    PubMed

    2011-05-01

    This final rule updates the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs) for discharges occurring during the rate year (RY) beginning July 1, 2011 through September 30, 2012. The final rule also changes the IPF prospective payment system (PPS) payment rate update period to a RY that coincides with a fiscal year (FY). In addition, the rule implements policy changes affecting the IPF PPS teaching adjustment. It also rebases and revises the Rehabilitation, Psychiatric, and Long-Term Care (RPL) market basket, and makes some clarifications and corrections to terminology and regulations text. PMID:21548399

  16. Medicare program; end-stage renal disease prospective payment system, quality incentive program, and durable medical equipment, prosthetics, orthotics, and supplies.

    PubMed

    2013-12-01

    This rule updates and makes revisions to the End-Stage Renal Disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2014. This rule also sets forth requirements for the ESRD quality incentive program (QIP), including for payment year (PY) 2016 and beyond. In addition, this rule clarifies the grandfathering provision related to the 3-year minimum lifetime requirement (MLR) for Durable Medical Equipment (DME), and provides clarification of the definition of routinely purchased DME. This rule also implements budget-neutral fee schedules for splints and casts, and intraocular lenses (IOLs) inserted in a physician's office. Finally, this rule makes a few technical amendments and corrections to existing regulations related to payment for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items and services.

  17. Improving the design of competitive bidding in Medicare Advantage.

    PubMed

    Cawley, John H; Whitford, Andrew B

    2007-04-01

    In 2003, Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act, which required that in 2006 the Centers for Medicare and Medicaid Services (CMS) implement a system of competitive bids to set payments for the Medicare Advantage program. Managed care plans now bid for the right to enroll Medicare beneficiaries. Data from the first year of bidding suggest that imperfect competition is limiting the success of the bidding system. This article offers suggestions to improve this system based on findings from auction theory and previous government-run auctions. In particular, CMS can benefit by adjusting its system of competitive bids in four ways: credibly committing to regulations governing bidding; limiting the scope for collusion, entry deterrence, and predatory behavior among bidders; adjusting how benchmark reimbursement rates are set; and accounting for asymmetric information among bidders.

  18. Medicare depreciation; useful life guidelines--HCFA. Proposed rule.

    PubMed

    1982-09-30

    We are proposing to amend Medicare regulations to clarify which useful life guidelines providers of health care services may use to determine the useful life of a depreciable asset for Medicare reimbursement purposes. Current regulations state that providers must utilize HHS useful life guidelines or, if none have been published by HHS, the American Hospital Association (AHA) useful life guidelines of 1973 or IRS guidelines. We are proposing to eliminate the reference to IRS guidelines because those previously acceptable for Medicare purposes are outdated and have been made obsolete by the IRS or by statutory change. We would also delete the specific reference to the 1973 AHA guidelines. In addition, we intend this amendment to clarify that certain tax legislation on accelerated depreciation, recently passed by Congress, does not apply to the Medicare program.

  19. Improving the design of competitive bidding in Medicare Advantage.

    PubMed

    Cawley, John H; Whitford, Andrew B

    2007-04-01

    In 2003, Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act, which required that in 2006 the Centers for Medicare and Medicaid Services (CMS) implement a system of competitive bids to set payments for the Medicare Advantage program. Managed care plans now bid for the right to enroll Medicare beneficiaries. Data from the first year of bidding suggest that imperfect competition is limiting the success of the bidding system. This article offers suggestions to improve this system based on findings from auction theory and previous government-run auctions. In particular, CMS can benefit by adjusting its system of competitive bids in four ways: credibly committing to regulations governing bidding; limiting the scope for collusion, entry deterrence, and predatory behavior among bidders; adjusting how benchmark reimbursement rates are set; and accounting for asymmetric information among bidders. PMID:17463410

  20. The cost of cancer-related physician services to Medicare.

    PubMed

    Maroongroge, Sean; Kim, Simon P; Mougalian, Sarah; Johung, Kimberly; Decker, Roy H; Soulos, Pamela R; Long, Jessica B; Gross, Cary P; Yu, James B

    2015-06-01

    Although physician services represent a substantial portion of cancer care costs, little is known about trends in the costs of physician cancer services in the fee-for-service Medicare program. We analyzed aggregated data from all Part B Medicare claims for physician and supplier services attributed to cancer patients from 1999 to 2012 to characterize how billing and payments have changed over time for the most common cancer types. Billing and expenditure data are from the Medicare Statistical Supplement, and age-adjusted incidence data are from SEER. Physician services for cancer patients grew from $7.6 billion in 1999 to $12.3 billion in 2012 (60 percent increase). Reimbursements for physician and supplier services for cancer treatment in Medicare Part B beneficiaries steadily grew from 1999 to 2005 and then plateaued through 2012, led by a decrease in reimbursements for prostate cancer care. These trends may reflect shifts toward hospital-based care or changes in aggressiveness of care.