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Sample records for 50091-50140 medicare program

  1. 78 FR 43820 - Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-22

    ... Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare Prescription Drug...; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare Prescription Drug Benefit...-referencing errors in the Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and...

  2. 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

    ... Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit... Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year 2012 and Other... the Office of the Federal Register base the comment period closing date on the date the proposed...

  3. 78 FR 16614 - Medicare Program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-18

    ... Medicare Program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical Insurance (Part B... following the denial of a Part A inpatient hospital claim by a Medicare review contractor on the basis that... Inpatient Billing in Hospitals,'' to propose a permanent policy that would apply on a prospective basis...

  4. Reform of the Medicare program.

    PubMed

    Rubin, R N

    1988-01-01

    Financing of the Medicare program is under stress because of national economic and demographic trends. A comprehensive overview of the required changes is imperative. The American Medical Association has proposed to place Medicare funding out of the political arena and to place it under the administration of an independent commission such as the Federal Reserve Board. Further, the plan would initiate a voucher system financed by a tax on adjusted gross income during the working years invested through a new public trust fund.

  5. 78 FR 12427 - Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-22

    ...This proposed rule would implement medical loss ratio (MLR) requirements for the Medicare Advantage Program and the Medicare Prescription Drug Benefit Program under the Patient Protection and Affordable Care Act.

  6. 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.

  7. 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 ...

  8. 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

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

    PubMed

    2015-06-09

    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.

  10. 76 FR 76541 - Medicare Program; Availability of Medicare Data for Performance Measurement

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-07

    ... 42 CFR Part 401 Medicare Program; Availability of Medicare Data for Performance Measurement; Final... 401 RIN 0938-AQ17 Medicare Program; Availability of Medicare Data for Performance Measurement AGENCY... the comments were from organizations engaged in performance measurement or data aggregation that...

  11. 76 FR 33565 - Medicare Program; Availability of Medicare Data for Performance Measurement

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-08

    ... measurement errors and assessing measure reliability. Identifying appropriate peer groups of providers and... 42 CFR Part 401 Medicare Program; Availability of Medicare Data for Performance Measurement; Proposed...-AQ17 Medicare Program; Availability of Medicare Data for Performance Measurement AGENCY: Centers...

  12. Medicare hospice benefit: Early program experiences

    PubMed Central

    Davis, Feather Ann

    1988-01-01

    In this article, an overview of the Medicare hospice benefit is presented and selected preliminary findings from the Medicare hospice benefit program evaluation are provided. By mid-1987, about one-half of all community home health agency-based hospices were Medicare certified, compared with about one-fifth of all independent/freestanding hospices and one-seventh of hospital and skilled nursing facility-based hospices. Medicare beneficiary election of the hospice benefit increased from about 2,000 beneficiaries in fiscal year 1984 to about 11,000 during fiscal year 1986. Medicare reimbursed hospices an average of $1,798, $2,078 and $2,337 per patient during fiscal years 1984, 1985, and 1986, respectively. PMID:10312635

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

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... services for which Medicare payment may be made either directly or indirectly. (b) Auditing, settling and.... 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... Health Expenditures and Medicare expenditures. The Panel's discussion is expected to be very technical...

  15. 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

    ... Arrangements and as a Basis for Termination or Non- Renewal of a Medicare Contract (Sec. 422.504, Sec. 422.510... Past Contract Termination or CMS-Initiated Non-Renewal (Sec. 422.502 and Sec. 423.503) D. Improving Program Efficiencies 1. Cost Contract Plan Public Notification Requirements in Cases of Non-Renewal...

  16. 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

    ... Termination or Non- Renewal of a Medicare Contract (Sec. Sec. 422.504, 422.510, 423.505, and 423.509) 3...-Initiated Non-Renewal (Sec. Sec. 422.502 and 423.503) D. Improving Program Efficiencies 1. Cost Contract Plan Public Notification Requirements in Cases of Non-Renewal (Sec. 417.492) 2. New Benefit...

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

    PubMed

    2011-11-02

    This final rule implements 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 the Medicare Shared Savings Program. Under these provisions, providers of services and suppliers can continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, and be eligible for additional payments if they meet specified quality and savings requirements.

  18. Can health promotion programs save Medicare money?

    PubMed Central

    Goetzel, Ron Z; Shechter, David; Ozminkowski, Ronald J; Stapleton, David C; Lapin, Pauline J; McGinnis, J Michael; Gordon, Catherine R; Breslow, Lester

    2007-01-01

    The impact of an aging population on escalating US healthcare costs is influenced largely by the prevalence of chronic disease in this population. Consequently, preventing or postponing disease onset among the elderly has become a crucial public health issue. Fortunately, much of the total burden of disease is attributable to conditions that are preventable. In this paper, we address whether well-designed health promotion programs can prevent illness, reduce disability, and improve the quality of life. Furthermore, we assess evidence that these programs have the potential to reduce healthcare utilization and related expenditures for the Medicare program. We hypothesize that seniors who reduce their modifiable health risks can forestall disability, reduce healthcare utilization, and save Medicare money. We end with a discussion of a new Senior Risk Reduction Demonstration, which will be initiated by the Centers for Medicare and Medicaid Services in 2007, to test whether risk reduction programs developed in the private sector can achieve health improvements among seniors and a positive return on investment for the Medicare program. PMID:18044084

  19. 76 FR 58514 - Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-21

    ... 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... spending in the long run. The Panel's discussion is expected to be very technical in nature and will...

  20. 78 FR 25013 - Medicare Program; Requirements for the Medicare Incentive Reward Program and Provider Enrollment

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-04-29

    ... against the Medicare program under Title XVIII of the Social Security Act (the Act). Provider enrollment... defined in Sec. 424.502), corporate officers, corporate directors, and/or board members. We note that...

  1. 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...

  2. Medicare

    MedlinePlus

    ... more news See all your Medicare plan choices (TV Ad) Open to lower Medicare costs or extra benefits? (TV Ad) Open to lower costs or extra benefits? (TV Ad) Medicare & You: flu prevention Watch more videos ...

  3. 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

  4. Medicare program; application of certain appeals provisions to the Medicare prescription drug appeals process. Final rule.

    PubMed

    2009-12-09

    This final rule will implement the procedures that the Department of Health and Human Services will follow at the Administrative Law Judge and Medicare Appeals Council levels in deciding appeals brought by individuals who have enrolled in the Medicare prescription drug benefit program. In addition, it will implement the reopening procedures that will be followed at all levels of appeal.

  5. 75 FR 3742 - Medicare Program; Meeting of the Advisory Panel on Medicare Education; Cancellation of the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-01-22

    ... on Medicare Education; Cancellation of the February 3, 2010 Meeting and Announcement of the March 31... notice also announces a public meeting on March 31, 2010. The Panel advises and makes recommendations to... the Medicare program. This meeting is open to the public. DATES: Meeting Date: Wednesday, March 31...

  6. 77 FR 1877 - Medicare Program; Medicare Advantage and Prescription Drug Benefit Programs: Negotiated Pricing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-01-12

    ... adequate time be allowed to implement the changes needed to report costs based on pass- through, because...; Medicare Advantage and Prescription Drug Benefit Programs: Negotiated Pricing and Remaining Revisions... finalizes provisions regarding the reporting of gross covered retiree plan-related prescription drug costs...

  7. 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

    ... Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Parts 417, 422, and 423..., No. 224 / Monday, November 22, 2010 / Proposed Rules#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES...: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-4144-P...

  8. 42 CFR 421.316 - Limitation on Medicare integrity program contractor liability.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Limitation on Medicare integrity program contractor... HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Medicare Integrity Program Contractors § 421.316 Limitation on Medicare integrity program contractor liability. (a) A MIP contractor, a...

  9. 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.

  10. 76 FR 59136 - Medicare and Medicaid Programs; Application by Community Health Accreditation Program for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-23

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare and Medicaid Programs; Application by... Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-2377-PN, P.O. Box... following address only: Centers for Medicare & Medicaid Services, Department of Health and Human Services...

  11. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Bid Pricing Data Release; Medicare Advantage and Part D Medical Loss Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model; Medicare Shared Savings Program Requirements. Final rule.

    PubMed

    2016-11-15

    This major final rule addresses changes to the physician fee schedule and other Medicare Part B payment policies, such as changes to the Value Modifier, to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. This final rule also includes changes related to the Medicare Shared Savings Program, requirements for Medicare Advantage Provider Networks, and provides for the release of certain pricing data from Medicare Advantage bids and of data from medical loss ratio reports submitted by Medicare health and drug plans. In addition, this final rule expands the Medicare Diabetes Prevention Program model.

  12. 78 FR 71619 - Medicare and Medicaid Programs; Continued Approval of American Osteopathic Association/Healthcare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-11-29

    ... standards to include staff qualification requirements for rehabilitation therapy services. To meet the... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare and Medicaid Programs; Continued... Hospital Accreditation Program AGENCY: Centers for Medicare & Medicaid Services, HHS. ACTION: Final notice...

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

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 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 SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Medicare Integrity...

  14. 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.

  15. Medicare program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical Insurance (Part B). Notice of CMS ruling.

    PubMed

    2013-03-18

    This notice announces a CMS Ruling that establishes a policy that revises the current policy on Part B billing following the denial of a Part A inpatient hospital claim by a Medicare review contractor on the basis that the inpatient admission was determined not reasonable and necessary. This revised policy is intended as an interim measure until CMS can finalize a policy to address the issues raised by the Administrative Law Judge and Medicare Appeals Council decisions going forward. To that end, elsewhere in this issue of the Federal Register, we published a proposed rule entitled, "Medicare Program; Part B Inpatient Billing in Hospitals,'' to propose a permanent policy that would apply on a prospective basis.

  16. 75 FR 76471 - Medicare Program; Renewal of the Medicare Evidence Development & Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-08

    ..., patient advocacy, the economics of health care, medical ethics and other related professions such as... functions on a committee basis. The MEDCAC--(1) Hears public testimony; (2) reviews medical literature... Federal Domestic Assistance Program No. 93.774, Medicare--Supplementary Medical Insurance Program). Dated...

  17. 42 CFR 423.2315 - Medicare Coverage Gap Discount Program Agreement.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG... NDCs for pharmacy claims processing. (9) Enter into and have in effect, under terms and conditions...

  18. 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

    ... rehabilitation, physical therapy, occupational therapy, audiology, or speech pathology services, the services are... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare and Medicaid Programs; Approval of the Joint Commission for Deeming Authority for Psychiatric Hospitals AGENCY: Centers for Medicare & Medicaid...

  19. 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

    ... Medicare or Medicaid programs or Children's Health Insurance Program (CHIP); revalidating their Medicare... Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment..., Medicaid, and Children's Health Insurance Program (CHIP) provider enrollment processes. Specifically,...

  20. Identifying the Transgender Population in the Medicare Program

    PubMed Central

    Proctor, Kimberly; Haffer, Samuel C.; Ewald, Erin; Hodge, Carla; James, Cara V.

    2016-01-01

    Abstract Purpose: To identify and describe the transgender population in the Medicare program using administrative data. Methods: Using a combination of International Classification of Diseases ninth edition (ICD-9) codes relating to transsexualism and gender identity disorder, we analyzed 100% of the 2013 Centers for Medicare & Medicaid Services (CMS) Medicare Fee-For-Service (FFS) “final action” claims from both institutional and noninstitutional providers (∼1 billion claims) to identify individuals who may be transgender Medicare beneficiaries. To confirm, we developed and applied a multistage validation process. Results: Four thousand ninety-eight transgender beneficiaries were identified, of which ∼90% had confirmatory diagnoses, billing codes, or evidence of a hormone prescription. In general, the racial, ethnic, and geographic distribution of the Medicare transgender population tends to reflect the broader Medicare population. However, age, original entitlement status, and disease burden of the transgender population appear substantially different. Conclusions: Using a variety of claims information, ranging from claims history to additional diagnoses, billing modifiers, and hormone prescriptions, we demonstrate that administrative data provide a valuable resource for identifying a lower bound of the Medicare transgender population. In addition, we provide a baseline description of the diversity and disease burden of the population and a framework for future research. PMID:28861539

  1. 76 FR 39006 - Medicare Program; Hospital Inpatient Value-Based Purchasing Program; Correction

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-05

    ... Program; Hospital Inpatient Value-Based Purchasing Program; Correction AGENCY: Centers for Medicare...) entitled ``Medicare Program; Hospital Inpatient Value-Based Purchasing Program.'' DATES: Effective Date... the new combined section ``II. A Overview of the January 7, 2011 Hospital Inpatient VBP Program...

  2. 42 CFR 424.530 - Denial of enrollment in the Medicare program.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Denial of enrollment in the Medicare program. 424.530 Section 424.530 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND... Establishing and Maintaining Medicare Billing Privileges § 424.530 Denial of enrollment in the Medicare program...

  3. 42 CFR 424.530 - Denial of enrollment in the Medicare program.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Denial of enrollment in the Medicare program. 424.530 Section 424.530 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND... Establishing and Maintaining Medicare Billing Privileges § 424.530 Denial of enrollment in the Medicare program...

  4. 42 CFR 421.302 - Eligibility requirements for Medicare integrity program contractors.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Eligibility requirements for Medicare integrity program contractors. 421.302 Section 421.302 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE...

  5. 76 FR 28040 - Medicare and Medicaid Programs; Application by the Joint Commission for Continued Deeming...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-13

    ... HUMAN SERVICES Centers for Medicare and Medicaid Services Medicare and Medicaid Programs; Application by... Medicare and Medicaid Services (CMS), HHS. ACTION: Proposed Notice. SUMMARY: This proposed notice with... participate in the Medicare or Medicaid programs. Section 1865(a)(3)(A) of the Social Security Act requires...

  6. 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

    ... 42 CFR Parts 402 and 403 Medicare, Medicaid, Children's Health Insurance Programs; Transparency..., Children's Health Insurance Programs; Transparency Reports and Reporting of Physician Ownership or... medical supplies covered by Medicare, Medicaid or the Children's Health Insurance Program (CHIP) to...

  7. 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...-specific spending target derived from claims, based on expected Medicare FFS utilization for each of the.... Under this 3-year demonstration, IAH providers will continue to bill and be paid standard Medicare FFS...

  8. 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

    ... Programs SSA Social Security Administration SSI Supplemental Security Income TMR Targeted Medication Review... 1851 through 1859 of the Social Security Act (the Act) which established the current MA program (known...

  9. Measuring Beneficiary Knowledge of the Medicare Program: A Psychometric Analysis

    PubMed Central

    Bann, Carla M.; Terrell, Sherry A.; McCormack, Lauren A.; Berkman, Nancy D.

    2003-01-01

    Reliable measures of Medicare beneficiaries' program knowledge are necessary for credible program monitoring, evaluation, and public accountability. This study developed and evaluated the psychometric properties of two possible measures of beneficiary knowledge. One measure was based on self-reported knowledge, the other was a true/false quiz which requires beneficiaries to demonstrate their knowledge. We used data from the 1998 and 1999 Medicare Current Beneficiary Survey (MCBS) to evaluate the reliability and construct validity of the indices. Overall, based on both content considerations and the psychometric analyses, the true/false quiz proved to be the more accurate and useful measure of beneficiaries' knowledge. PMID:14628404

  10. 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

  11. 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.

  12. 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

    ... Medicare Fraud and Abuse, and Establishment of a Program to Collect Suggestions for Improving Medicare... 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...

  13. Medicare Program: Changes to the Medicare Claims and Entitlement, Medicare Advantage Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures. Final rule.

    PubMed

    2017-01-17

    This final rule revises the procedures that the Department of Health and Human Services (HHS) follows at the Administrative Law Judge (ALJ) level for appeals of payment and coverage determinations for items and services furnished to Medicare beneficiaries, enrollees in Medicare Advantage (MA) and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as well as appeals of Medicare beneficiary enrollment and entitlement determinations, and certain Medicare premium appeals. In addition, this final rule revises procedures that the Department of Health and Human Services follows at the Centers for Medicare & Medicaid Services (CMS) and the Medicare Appeals Council (Council) levels of appeal for certain matters affecting the ALJ level.

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

    PubMed

    2014-12-05

    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.

  15. Use of Medicare summary notice inserts to generate interest in the Medicare stop smoking program.

    PubMed

    Maglione, Margaret; Larson, Carrie; Giannotti, Tierney; Lapin, Pauline

    2007-01-01

    Evaluations of outreach strategies that effectively and efficiently reach the senior population often go unreported. The Medicare Stop Smoking Program (MSSP) was a seven-state demonstration project funded by the Centers for Medicare and Medicaid Services. The 1-year recruitment plan for MSSP included a multifaceted paid media campaign; however, enrollment was slower than anticipated. The purpose of this substudy was to test the effects of including envelope-sized advertisement inserts with Medicare Summary Notices (MSNs) as a supplemental recruitment strategy. Information obtained from enrollees on where they had learned about the program as well as overall enrollment rates were analyzed and compared with the time periods during which the inserts were included in MSN mailings. Average call volume to the enrollment center increased by 65.7% in Alabama, the pilot state, and by more than 200% in the subsequent demonstration states. Despite the introduction of the MSN inserts late in the recruitment period, 32.2 % of the 7354 total enrollees stated that they learned about the project through the inserts. This recruitment method is highly recommended as a cost-effective way to reach the senior population.

  16. 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.

  17. 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

    ... Listing of Program Issuances--January Through March 2013 AGENCY: Centers for Medicare & Medicaid Services... through March 2013, relating to the Medicare and Medicaid programs and other programs administered by CMS...

  18. 76 FR 19527 - Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-07

    ... Schedule MS-DRGs Medicare Severity-Diagnosis Related Groups MSP Minimum Savings Percentage MSR Minimum... term care, children's, and cancer hospitals.) Section 1899(h)(3) of the Act defines the term...

  19. 78 FR 17677 - Medicare and Medicaid Programs: Application From the American Osteopathic Association/Healthcare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-22

    ... Program; No. 93.773 Medicare--Hospital Insurance Program; and No. 93.774, Medicare--Supplementary Medical...-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...

  20. 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...

  1. Medicare program; Medicare Advantage and prescription drug benefit programs: negotiated pricing and remaining revisions. Final rule with comment period.

    PubMed

    2009-01-12

    This rule contains final regulations governing the Medicare Advantage (MA) program (Part C) and prescription drug benefit program (Part D), and interim final regulations governing certain aspects of the Retiree Drug Subsidy (RDS) Program, and reflecting new statutory definitions relating to Special Needs Plans under Part C. The final regulations revising the Part C and Part D regulations include provisions regarding medical savings account (MSA) plans, cost-sharing for dual eligible enrollees in the MA program, the prescription drug payment and novation processes in the Part D program, and the enrollment and appeals processes for both programs. This final rule with comment period also responds to public comments on the May 16, 2008 proposed rule and takes into account statutory revisions contained in the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA).

  2. Medicare program; establishing additional Medicare durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) supplier enrollment safeguards. Final rule.

    PubMed

    2010-08-27

    This final rule will clarify, expand, and add to the existing enrollment requirements that Durable Medical Equipment and Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers must meet to establish and maintain billing privileges in the Medicare program.

  3. 42 CFR 460.168 - Reinstatement in other Medicare and Medicaid programs.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 4 2012-10-01 2012-10-01 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 other...

  4. 75 FR 70165 - Medicare Program; Request for Information Regarding Accountable Care Organizations and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-17

    ... Information Regarding Accountable Care Organizations and the Medicare Shared Saving Program AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Request for information. SUMMARY: This document... accountable care organizations (ACOs) participating in the Medicare program under section 3021 or 3022 of the...

  5. 78 FR 47935 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-06

    ... Medicare cost report data available; a decision that was supported by numerous commenters. We do not agree... 42 CFR Parts 413 and 424 Medicare Program; Prospective Payment System and Consolidated Billing for... & Medicaid Services 42 CFR Parts 413 and 424 RIN 0938-AR65 Medicare Program; Prospective Payment System and...

  6. 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

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Section 3113: The Treatment of... participate in the Treatment of Certain Complex Diagnostic Laboratory Tests Demonstration. The Demonstration... Treatment of Certain Complex Diagnostic Laboratory Tests Demonstration. The authorizing legislation...

  7. 76 FR 33306 - Medicare Program; Pioneer Accountable Care Organization Model, Request for Applications; Correction

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-08

    ... Care Organization Model: Request for Applications.'' FOR FURTHER INFORMATION CONTACT: Maria Alexander... http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care-models/pioneer-aco... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Pioneer Accountable...

  8. 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 permits...

  9. 77 FR 64755 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 2; Corrections

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-10-23

    ... Medicare and Medicaid Programs; Electronic Health Record Incentive Program--Stage 2; Corrections AGENCY... Medicaid Programs; Electronic Health Record Incentive Program--Stage 2'' which appeared in the September 4... Programs; Electronic Health Record Incentive Program--Stage 2'' there were a number of technical errors and...

  10. 78 FR 65660 - Medicare Program; Solicitation of Five Nominations to the Advisory Panel on Hospital Outpatient...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-11-01

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Solicitation of Five... Department of Health and Human Services and the Administrator of the Centers for Medicare & Medicaid Services... The Secretary of the Department of Health and Human Services (the Secretary) is required by...

  11. 76 FR 1366 - Medicare Program; Amendment to Payment Policies Under the Physician Fee Schedule and Other...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-01-10

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part 410 RIN 0938-AP79 Medicare Program; Amendment to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2011 AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Final rule. SUMMARY: This...

  12. 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

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services RIN 0938-AR47 Medicaid Program; State Allotments... for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice sets forth the... 2011 through December 31, 2010 to $165 million. Section 110 of the Medicare and Medicaid Extenders Act...

  13. 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

    ... program, the scope of covered services, and the conditions for Medicare payment for hospice care... the Community Health Accreditation Program for Continued Approval of Its Hospice Accreditation Program... Accreditation Program (CHAP) for continued recognition as a national accrediting organization for hospices...

  14. Medicare program; revised civil money penalties, assessments, exclusions, and related appeals procedures. Final rule.

    PubMed

    2007-07-20

    This final rule establishes the procedures for imposing exclusions for certain violations of the Medicare program and is based on the procedures that the Office of Inspector General has published for civil money penalties, assessments, and exclusions under their delegated authority. Implementation of this final rule protects beneficiaries from persons (that is, health care providers and entities) found in noncompliance with Medicare regulations, and otherwise improves the safeguard provisions under the Medicare statute. This final rule also establishes procedures that enable a person targeted for exclusion from the Medicare program to request the Centers for Medicare & Medicaid Services to act on its behalf to recommend to the Inspector General that the exclusion from Medicare be waived due to hardship that would be placed on Medicare beneficiaries as a result of the person's exclusion.

  15. 75 FR 8374 - Medicare Program; Meeting of the Practicing Physicians Advisory Council, March 8, 2010; Correction

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-02-24

    ... Physicians Advisory Council, March 8, 2010; Correction AGENCY: Centers for Medicare & Medicaid Services (CMS... Program; Meeting of the Practicing Physicians Advisory Council, March 8, 2010.'' FOR FURTHER INFORMATION...

  16. 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

    ..., respectively, for Medicare Part A and Part B appeals. Section 940 of the Medicare Prescription Drug... are to be adjusted, as of January 2005, by the percentage increase in the medical care component of the consumer price index (CPI) for all urban consumers (U.S. city average) for July 2003 to July of...

  17. 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

    ..., respectively, for Medicare Part A and Part B appeals. Section 940 of the Medicare Prescription Drug... the consumer price index for all urban consumers (U.S. city average) for July 2003 to July of the year... (Prescription Drug Plan) Appeals The annually adjusted AIC threshold amounts for ALJ hearings and...

  18. Medicare program: changes to the Medicare claims appeal procedures. Interim final rule with comment period.

    PubMed

    2005-03-08

    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 under sections 1869 and 1879 of the Social Security Act (the Act). Section 521 of the Medicare, Medicaid, and SCHIP Benefits Act of 2000 (BIPA) amended section 1869 of the Act to provide for significant changes to the Medicare claims appeal procedures. This interim final rule responds to comments on the November 15, 2002 proposed rule regarding changes to these appeal procedures, establishes the implementing regulations, and explains how the new procedures will be implemented. It also sets forth provisions that are needed to implement the new statutory requirements enacted in Title IX of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).

  19. 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...

  20. 76 FR 41260 - Supplemental Funding for the Senior Medicare Patrol (SMP) Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-13

    ... HUMAN SERVICES Administration on Aging Supplemental Funding for the Senior Medicare Patrol (SMP) Program... provide supplemental grant funds for the support of the Senior Medicare Patrol (SMP) program. The goal of...: Supplemental funding to provide expanded support for the SMP program network. C. Amount of the Award: $178,000...

  1. 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…

  2. 77 FR 40951 - Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-11

    ... replaced the basic case-mix adjusted composite payment system and the methodologies for the reimbursement... 42 CFR Parts 413 and 417 Medicare Program; End-Stage Renal Disease Prospective Payment System... Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program, and Bad Debt...

  3. 78 FR 14689 - Medicare Program; Extension of the Payment Adjustment for Low-volume Hospitals and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-07

    ...; Extension of the Payment Adjustment for Low- volume Hospitals and the Medicare-dependent Hospital (MDH) Program Under the Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals for.... SUMMARY: This notice announces changes to the payment adjustment for low-volume hospitals and to the...

  4. 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...

  5. 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...

  6. 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

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare and Medicaid Programs; Application from...: Centers for Medicare and Medicaid Services, HHS. ACTION: Proposed notice. SUMMARY: This proposed notice... accrediting organization for rural health clinics (RHCs) that wish to participate in the Medicare or Medicaid...

  7. 76 FR 15105 - Medicare and Medicaid Programs; Civil Money Penalties for Nursing Homes

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-18

    ... Services 42 CFR Part 488 Medicare and Medicaid Programs; Civil Money Penalties for Nursing Homes; Final... and Medicaid Programs; Civil Money Penalties for Nursing Homes AGENCY: Centers for Medicare & Medicaid... nursing homes are not in compliance with Federal participation requirements in accordance with section...

  8. 74 FR 49921 - Medicare Programs; End-Stage Renal Disease Prospective Payment System

    Federal Register 2010, 2011, 2012, 2013, 2014

    2009-09-29

    ... Programs; End-Stage Renal Disease Prospective Payment System; Town Hall Meeting on End-Stage Renal Disease... & Medicaid Services 42 CFR Parts 410, 413 and 414 RIN 0938-AP57 Medicare Programs; End-Stage Renal Disease...) for Medicare outpatient end-stage renal disease (ESRD) dialysis facilities beginning January 1,...

  9. 78 FR 59704 - Medicare, Medicaid, and CLIA Programs; Clinical Laboratory Improvement Amendments of 1988...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-27

    ... requirements of the Clinical Laboratory Improvement Amendments of 1988 (CLIA) for a period of 6 years. DATES... CLIA is a user-fee funded program. The registration fee paid by laboratories is intended to cover the... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare, Medicaid, and CLIA Programs; Clinical...

  10. 76 FR 24213 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-29

    ... 42 CFR Part 412 Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2012; Changes in Size and Square Footage of Inpatient Rehabilitation Units and... Services 42 CFR Part 412 RIN 0938-AQ28 Medicare Program; Inpatient Rehabilitation Facility...

  11. 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...

  12. Results of the Medicare Health Support disease-management pilot program.

    PubMed

    McCall, Nancy; Cromwell, Jerry

    2011-11-03

    In the Medicare Modernization Act of 2003, Congress required the Centers for Medicare and Medicaid Services to test the commercial disease-management model in the Medicare fee-for-service program. The Medicare Health Support Pilot Program was a large, randomized study of eight commercial programs for disease management that used nurse-based call centers. We randomly assigned patients with heart failure, diabetes, or both to the intervention or to usual care (control) and compared them with the use of a difference-in-differences method to evaluate the effects of the commercial programs on the quality of clinical care, acute care utilization, and Medicare expenditures for Medicare fee-for-service beneficiaries. The study included 242,417 patients (163,107 in the intervention group and 79,310 in the control group). The eight commercial disease-management programs did not reduce hospital admissions or emergency room visits, as compared with usual care. We observed only 14 significant improvements in process-of-care measures out of 40 comparisons. These modest improvements came at substantial cost to the Medicare program in fees paid to the disease-management companies ($400 million), with no demonstrable savings in Medicare expenditures. In this large study, commercial disease-management programs using nurse-based call centers achieved only modest improvements in quality-of-care measures, with no demonstrable reduction in the utilization of acute care or the costs of care.

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

    PubMed

    2009-12-09

    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.

  14. 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.

  15. 78 FR 74825 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-10

    ... December 10, 2013 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services... Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Hospital Value-Based Purchasing Program; Organ Procurement Organizations; Quality Improvement Organizations; Electronic...

  16. The interaction of partial public insurance programs and residual private insurance markets: evidence from the US Medicare program.

    PubMed

    Finkelstein, Amy

    2004-01-01

    A ubiquitous form of government intervention in insurance markets is to provide compulsory, but partial, public insurance coverage and to allow voluntary purchases of supplementary private insurance. This paper investigates the effects of such programs on insurance coverage for the risks not covered by the public program, using the example of the US Medicare program. I find that Medicare does not have substantial effects-in either direction-on coverage in residual private insurance markets. In particular, there is no evidence that Medicare is associated with reductions in private insurance coverage for prescription drug expenditures, an expenditure risk not covered by Medicare. Medicare is, however, associated with a shift in the source of prescription drug coverage, from employer-provided coverage to Medicare HMOs.

  17. Statistical uncertainty in the Medicare shared savings program.

    PubMed

    DeLia, Derek; Hoover, Donald; Cantor, Joel C

    2012-01-01

    Analyze statistical risks facing CMS and Accountable Care Organizations (ACOs) under the Medicare Shared Savings Program (MSSP). We calculate the probability that shared savings formulas lead to inappropriate payment, payment denial, and/or financial penalties, assuming that ACOs generate real savings in Medicare spending ranging from 0-10%. We also calculate expected payments from CMS to ACOs under these scenarios. The probability of an incorrect outcome is heavily dependent on ACO enrollment size. For example, in the MSSP two-sided model, an ACO with 5,000 enrollees that keeps spending constant faces a 0.24 probability of being inappropriately rewarded for savings and a 0.26 probability of paying an undeserved penalty for increased spending. For an ACO with 50,000 enrollees, both of these probabilities of incorrect outcomes are equal to 0.02. The probability of inappropriate payment denial declines as real ACO savings increase. Still, for ACOs with 5,000 patients, the probability of denial is at least 0.15 even when true savings are 5-7%. Depending on ACO size and the real ACO savings rate, expected ACO payments vary from $115,000 to $35.3 million. Our analysis indicates there may be greater statistical uncertainty in the MSSP than previously recognized. CMS and ACOs will have to consider this uncertainty in their financial, administrative, and care management planning. We also suggest analytic strategies that can be used to refine ACO payment formulas in the longer term to ensure that the MSSP (and other ACO initiatives that will be influenced by it) work as efficiently as possible.

  18. 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 the...

  19. 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 the...

  20. 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 the...

  1. 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 the...

  2. 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 the...

  3. 77 FR 23722 - Medicare Program; Extension of Certain Wage Index Reclassifications and Special Exceptions for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-04-20

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Extension of Certain Wage... Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice announces changes to wage indices and hospital... exception wage indices through March 31, 2012 for the hospital inpatient prospective payment systems...

  4. 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...

  5. 76 FR 74067 - Medicare Program; Announcement of a New Application Deadline for the Advance Payment Model

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-30

    ....innovations.cms.gov/initiatives/aco/advance-payment/index.html . FOR FURTHER INFORMATION CONTACT: Dan Farmer... undertaken by the Center for Medicare and Medicaid Innovation (Innovation Center). The Advance Payment Model is an Innovation Center initiative designed for participants in the Medicare Shared Savings Program...

  6. 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

    ... undertaken by the Center for Medicare and Medicaid Innovation (Innovation Center). The Advance Payment Model is an Innovation Center initiative designed for participants in the Medicare Shared Savings Program... the application process. In November 30, 2011 Federal Register (76 FR 74067), we published a second...

  7. 75 FR 43531 - Medicare and Medicaid Programs; Application by Det Norske Veritas Healthcare for Deeming...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-26

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare and Medicaid Programs; Application by Det Norske Veritas Healthcare for Deeming Authority for Critical Access Hospitals (CAHs) AGENCY... notice with comment period acknowledges the receipt of an application from Det Norske Veritas Healthcare...

  8. 42 CFR 424.535 - Revocation of enrollment and billing privileges in the Medicare program.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Revocation of enrollment and billing privileges in... Requirements for Establishing and Maintaining Medicare Billing Privileges § 424.535 Revocation of enrollment and billing privileges in the Medicare program. (a) Reasons for revocation. CMS may revoke a...

  9. 76 FR 70227 - Medicare Program; End-Stage Renal Disease Prospective Payment System and Quality Incentive...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-10

    ... November 10, 2011 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services... HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 413 and 414 RIN 0938-AQ27... Incentive Program (QIP) for PY 2013 and PY 2014 1. PY 2013 ESRD QIP Requirements a. Performance Measures for...

  10. 75 FR 38026 - Medicare Program; Identification of Backward Compatible Version of Adopted Standard for E...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-01

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part 423 RIN 0938-AP49 Medicare Program... comments by facsimile (FAX) transmission. You may submit comments in one of four ways (please choose only one of the ways listed): 1. Electronically. You may submit electronic comments on this regulation to...

  11. 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

    ... under the Medicare statute. This meeting will focus on selected genetic tests for cancer diagnosis (for cancers of unknown primary site and for cervical cytology findings of uncertain clinical significance... PowerPoint presentation materials and writings that will be used in support of an oral presentation is 5...

  12. 76 FR 62415 - Medicare Program; Establishment of the Medicare Economic Index Technical Advisory Panel and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-07

    ... convening of a technical advisory panel to review all aspects of the Medicare Economic Index (MEI... the MEI accurately and appropriately meets its intended statutory purpose. We also solicited comments... Law 92-463, Federal Advisory Committee Act, to conduct a technical review of the MEI. II. Charter...

  13. 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

    ... to the Amount in Controversy Threshold Amounts for Calendar Year 2011 AGENCY: Centers for Medicare... July of the preceding year involved and rounded to the nearest multiple of $10. B. Calendar Year 2011... judicial review will rise to $1,300 for the 2011 calendar year. These updated amounts are based on the...

  14. 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

    ... to the Amount in Controversy Threshold Amounts for Calendar Year 2013 AGENCY: Centers for Medicare... for requests for ALJ hearings and judicial review filed on or after January 1, 2013. The calendar year... nearest multiple of $10. B. Calendar Year 2013 The AIC threshold amount for ALJ hearing requests...

  15. 75 FR 68790 - Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual Deductible...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-09

    ... over) and disabled (under age 65) beneficiaries enrolled in Part B of the Medicare Supplementary... cost of Part B for each disabled enrollee (under age 65). The Part B deductible to be paid by enrollees... applicable for 2011 are $230.70 for enrollees age 65 and over and $266.30 for disabled enrollees under age 65...

  16. 75 FR 4095 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-01-26

    ... Evidence Development and Coverage Advisory Committee, March 24, 2010 AGENCY: Centers for Medicare..., March 24, 2010. The Committee generally provides advice and recommendations concerning the adequacy of...)). DATES: Meeting date: Wednesday, March 24, 2010 from 7:30 a.m. until 4:30 p.m., eastern daylight time (e...

  17. 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.

  18. Medicare program; aggregation of Medicare claims for administrative appeals--HCFA. Final rule.

    PubMed

    1994-03-16

    Medicare beneficiaries and, under certain circumstances, providers, physicians and other entities furnishing health care services may appeal adverse determinations regarding certain claims for benefits payable under part A and part B of Medicare. For administrative appeals at the carrier or intermediary hearing level or administrative law judge (ALJ) level and for any subsequent judicial review, the amount remaining in dispute must meet or exceed threshold amounts set by statute. Section 1869(b)(2) of the Social Security Act permits claims to be aggregated to reach the ALJ hearing threshold amounts. This final rule establishes a system of aggregation under which individual appellants have one set of requirements for aggregating claims and two or more appellants have a different set of requirements for aggregating claims.

  19. Medicare and state health care programs; fraud and abuse: OIG civil money penalties under the Medicare prescription drug discount card program. Interim final rule with comment period.

    PubMed

    2004-05-19

    In accordance with section 1860D-31 of the Social Security Act, this rule sets forth the OIG's new authority for imposing civil money penalties (CMPs) against endorsed sponsors under the Medicare prescription drug discount card program that knowingly engage in false or misleading marketing practices; overcharge program enrollees; or misuse transitional assistance funds.

  20. Medicare and state health care programs; fraud and abuse: OIG civil money penalties under the Medicare prescription drug discount card program. Final rule.

    PubMed

    2004-12-14

    In accordance with section 1860D-31 of the Social Security Act, this rule finalizes OIG's new authority for imposing civil money penalties (CMPs) against endorsed sponsors under the Medicare prescription drug discount card program that knowingly engage in false or misleading marketing practices; overcharge program enrollees; or misuse transitional assistance funds.

  1. 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.

  2. Cost of Smoking to the Medicare Program, 1993

    PubMed Central

    Zhang, Xiulan; Miller, Leonard; Max, Wendy; Rice, Dorothy P.

    1999-01-01

    Medicare expenditures attributable to smoking in 1993 were estimated using a multivariate model that related expenditures to smoking history, health status, and the propensity to have had a smoking-related disease, controlling for sociodemographics, economic variables, and other risk factors. Smoking-attributable Medicare expenditures are presented separately for each State and by type of expenditure. Nationally, smoking accounted for 9.4 percent of Medicare expenditures—$14.2 billion, with considerable variation among States. Smoking accounted for 11.4 percent of Medicare expenditures for hospital care, 11.3 percent of nursing home care, 5.9 percent of home health care, and 5.6 percent of ambulatory care. PMID:11482121

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

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-02-16

    ...), HHS. ACTION: Proposed rule. SUMMARY: This proposed rule would require providers and suppliers... approximately 47 million enrolled beneficiaries. Providers and suppliers furnishing Medicare items and services... ``person'' as a provider of services, supplier, Medicaid managed care organization (MCO) (as defined...

  4. Adverse selection in the Medicare prescription drug program.

    PubMed

    Riley, Gerald F; Levy, Jesse M; Montgomery, Melissa A

    2009-01-01

    The Medicare Part D drug benefit created choices for beneficiaries among many prescription drug plans with varying levels of coverage. As a result, Medicare enrollees with high prescription drug costs have strong incentives to enroll in Part D, especially in plans with more comprehensive coverage. To measure this potential problem of "adverse selection," which could threaten plans' finances, we compared baseline characteristics among groups of beneficiaries with various drug coverage arrangements in 2006. We found some significant differences. For example, enrollees in stand-alone prescription drug plans, especially in plans offering benefits in the coverage gap, or "doughnut hole," had higher baseline drug costs and worse health than enrollees in Medicare Advantage prescription drug plans. Although risk-adjusted payments and other measures have been put in place to account for selection, these patterns could adversely affect future Medicare costs and should be watched carefully.

  5. 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)...

  6. 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

  7. 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

    ...-AR53 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Proposed Fiscal Year 2014 Rates; Quality Reporting Requirements for Specific Providers; Hospital Conditions of Participation; Corrections AGENCY...

  8. 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.

  9. Medicare program; home health agencies; financial security requirements--HCFA. Proposed rule.

    PubMed

    1985-11-25

    These proposed regulations would implement sections 930(n) and (p) of the Omnibus Reconciliation Act of 1980 (Pub. L. 96-499). Section 930(n) authorizes the Secretary to require home health agencies (HHAs) participating in Medicare to meet conditions, including bonding or establishment of escrow accounts, to ensure the financial security of the Medicare trust fund. Section 930(p) excludes from Medicare reimbursement any costs incurred by an HHA in connection with bonding or establishing an escrow account. It also excludes interest payments made by an HHA that are charged on amounts borrowed to repay Medicare overpayments. The intent of these additional requirements is to assure the availability of funds to repay overpayments, and thereby ensure the financial security of the Medicare program.

  10. 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

    ... Health and Human Services Centers for Medicare & Medicaid Services Medicare and Medicaid Programs..., No. 242 / Friday, December 17, 2010 / Notices#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers... regulations under the authority granted to the Secretary of the Department of Health and Human Services...

  11. Understanding medicare

    MedlinePlus

    ... coverage (part D). Centers for Medicare and Medicare Services web site. www.medicare.gov/part-d/index.html . ... What Medicare covers. Centers for Medicare and Medicare Services web site. www.medicare.gov/what-medicare-covers/index. ...

  12. Impact Of The YMCA Of The USA Diabetes Prevention Program On Medicare Spending And Utilization.

    PubMed

    Alva, Maria L; Hoerger, Thomas J; Jeyaraman, Ravikumar; Amico, Peter; Rojas-Smith, Lucia

    2017-03-01

    The YMCA of the USA received a Health Care Innovation Award from the Centers for Medicare and Medicaid Services to provide a diabetes prevention program to Medicare beneficiaries with prediabetes in seventeen regional networks of participating YMCAs nationwide. The goal of the program is to help participants lose weight and increase physical activity. We tested whether the program reduced medical spending and utilization in the Medicare population. Using claims data to compute total medical costs for fee-for-service Medicare participants and a matched comparison group of nonparticipants, we found that the overall weighted average savings per member per quarter during the first three years of the intervention period was $278. Total decreases in inpatient admissions and emergency department (ED) visits were significant, with nine fewer inpatient stays and nine fewer ED visits per 1,000 participants per quarter. These results justify continued support of the model.

  13. 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

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Calculation of national beneficiary copayment 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...

  14. 42 CFR 419.41 - Calculation of national beneficiary copayment amounts and national Medicare program payment amounts.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Calculation of national beneficiary copayment 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...

  15. Medicare Shared Savings Program: public reporting and shared savings distributions.

    PubMed

    Schulz, John; DeCamp, Matthew; Berkowitz, Scott A

    2015-08-01

    To determine if Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) are meeting public reporting requirements related to shared savings plans, to quantitate the composition of shared savings distribution plans, and to investigate whether early ACO success is associated with specific plan or ACO characteristics. Cross-sectional study. ACO descriptive characteristics and distribution plan details were abstracted from official ACO websites for all 338 active MSSP ACOs launched through January 2014. Publicly available MSSP results from 2012 and 2013 start date ACOs were used to investigate associations with successful shared savings generation. Of current MSSP ACOs, 313 of 338 (93%) maintain a website, 284 of 338 (84%) provided at least a general statement about shared savings distributions, and 176 of 338 (52%) reported detailed allocation percentages to ACO participants. On average, ACOs reporting detailed allocations planned to give 63% (range = 0%-100%; SD = 26.3) to their primary care providers (PCPs), specialists, and/or hospitals, and 33% (range = 0%-100%; SD = 25.6) to infrastructure. ACOs including a hospital planned to give a larger average percentage to participating entities than those without (69% vs 58%; P = .01). ACOs planning to give > 50% to their PCPs and specialists were more likely to have generated savings (P = .001), as were ACOs composed of > 10 participating entities (P = .004). Just over one-half of MSSP ACOs report detailed shared savings distribution plans online, and these plans vary widely. There appears to be no single shared savings distribution plan determinate of ACO success. Continued investigation of predictors for generating savings is needed to inform future shared savings models.

  16. Changes in Postacute Care in the Medicare Shared Savings Program.

    PubMed

    McWilliams, J Michael; Gilstrap, Lauren G; Stevenson, David G; Chernew, Michael E; Huskamp, Haiden A; Grabowski, David C

    2017-04-01

    Postacute care is thought to be a major source of wasteful spending. The extent to which accountable care organizations (ACOs) can limit postacute care spending has implications for the importance and design of other payment models that include postacute care. To assess changes in postacute care spending and use of postacute care associated with provider participation as ACOs in the Medicare Shared Savings Program (MSSP) and the pathways by which they occurred. With the use of fee-for-service Medicare claims from a random 20% sample of beneficiaries with 25 544 650 patient-years, 8 395 426 hospital admissions, and 1 595 352 stays in skilled nursing facilities (SNFs) from January 1, 2009, to December 31, 2014, difference-in-difference comparisons of beneficiaries served by ACOs with beneficiaries served by local non-ACO health care professionals (control group) were performed before vs after entry into the MSSP. Differential changes were estimated separately for cohorts of ACOs entering the MSSP in 2012, 2013, and 2014. Patient attribution to an ACO in the MSSP. Postacute spending, discharge to a facility, length of SNF stays, readmissions, use of highly rated SNFs, and mortality, adjusted for patient characteristics. For the 2012 cohort of 114 ACOs, participation in the MSSP was associated with an overall reduction in postacute spending (differential change in 2014 for ACOs vs control group, -$106 per beneficiary [95% CI, -$176 to -$35], or -9.0% of the precontract unadjusted mean of $1172; P = .003) that was driven by differential reductions in acute inpatient care, discharges to facilities rather than home (-0.6 percentage points [95% CI, -1.1 to 0.0], or -2.7% of the unadjusted precontract mean of 22.6%; P = .03), and length of SNF stays (-0.60 days per stay [95% CI, -0.99 to -0.22], or -2.2% of the precontract unadjusted mean of 27.07 days; P = .002). Reductions in use of SNFs and length of stay were largely due to within-hospital or

  17. 42 CFR 460.168 - Reinstatement in other Medicare and Medicaid programs.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Participant Enrollment and Disenrollment § 460.168... Medicare and Medicaid programs after disenrollment, the PACE organization must do the following: (a) Make...

  18. 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...

  19. Measuring Coding Intensity in the Medicare Advantage Program

    PubMed Central

    Kronick, Richard; Welch, W. Pete

    2014-01-01

    Background In 2004, Medicare implemented a system of paying Medicare Advantage (MA) plans that gave them greater incentive than fee-for-service (FFS) providers to report diagnoses. Data Risk scores for all Medicare beneficiaries 2004–2013 and Medicare Current Beneficiary Survey (MCBS) data, 2006–2011. Measures Change in average risk score for all enrollees and for stayers (beneficiaries who were in either FFS or MA for two consecutive years). Prevalence rates by Hierarchical Condition Category (HCC). Results Each year the average MA risk score increased faster than the average FFS score. Using the risk adjustment model in place in 2004, the average MA score as a ratio of the average FFS score would have increased from 90% in 2004 to 109% in 2013. Using the model partially implemented in 2014, the ratio would have increased from 88% to 102%. The increase in relative MA scores appears to largely reflect changes in diagnostic coding, not real increases in the morbidity of MA enrollees. In survey-based data for 2006–2011, the MA-FFS ratio of risk scores remained roughly constant at 96%. Intensity of coding varies widely by contract, with some contracts coding very similarly to FFS and others coding much more intensely than the MA average. Underpinning this relative growth in scores is particularly rapid relative growth in a subset of HCCs. Discussion Medicare has taken significant steps to mitigate the effects of coding intensity in MA, including implementing a 3.4% coding intensity adjustment in 2010 and revising the risk adjustment model in 2013 and 2014. Given the continuous relative increase in the average MA risk score, further policy changes will likely be necessary. PMID:25068076

  20. Measuring coding intensity in the Medicare Advantage program.

    PubMed

    Kronick, Richard; Welch, W Pete

    2014-01-01

    In 2004, Medicare implemented a system of paying Medicare Advantage (MA) plans that gave them greater incentive than fee-for-service (FFS) providers to report diagnoses. Risk scores for all Medicare beneficiaries 2004-2013 and Medicare Current Beneficiary Survey (MCBS) data, 2006-2011. Change in average risk score for all enrollees and for stayers (beneficiaries who were in either FFS or MA for two consecutive years). Prevalence rates by Hierarchical Condition Category (HCC). Each year the average MA risk score increased faster than the average FFS score. Using the risk adjustment model in place in 2004, the average MA score as a ratio of the average FFS score would have increased from 90% in 2004 to 109% in 2013. Using the model partially implemented in 2014, the ratio would have increased from 88% to 102%. The increase in relative MA scores appears to largely reflect changes in diagnostic coding, not real increases in the morbidity of MA enrollees. In survey-based data for 2006-2011, the MA-FFS ratio of risk scores remained roughly constant at 96%. Intensity of coding varies widely by contract, with some contracts coding very similarly to FFS and others coding much more intensely than the MA average. Underpinning this relative growth in scores is particularly rapid relative growth in a subset of HCCs. Medicare has taken significant steps to mitigate the effects of coding intensity in MA, including implementing a 3.4% coding intensity adjustment in 2010 and revising the risk adjustment model in 2013 and 2014. Given the continuous relative increase in the average MA risk score, further policy changes will likely be necessary.

  1. Understanding the landscape of MTM programs for Medicare. Part D: Results from a study for the Centers for Medicare & Medicaid services.

    PubMed

    Shoemaker, Sarah J; Hassol, Andrea

    2011-01-01

    To describe the features of medication therapy management (MTM) programs, including eligibility criteria, enrollment, services, and reimbursement, and to describe the criteria used to evaluate MTM programs and assess the evidence of relevance to Medicare. Descriptive, exploratory, nonexperimental study. United States between July 2007 and June 2008. 60 key informants from 46 different organizations and case studies with 28 representatives from four MTM programs. Literature review, key informant interviews, and evaluation of case studies. MTM program features and evidence of effectiveness. MTM programs used a variety of practice models. Medicare MTM programs used different eligibility criteria than MTM programs sponsored by Medicaid or other payers. MTM programs that required patients to opt-in had less success in enrolling participants than those using opt-out. Most MTM programs conducted annual medication reviews. Most non-Medicare MTM programs provided face-to-face interventions, whereas Medicare MTM programs relied more on telephone or mail; no research tested the effectiveness of different modes. Almost all MTM programs used pharmacists to provide services. Little research on Medicare MTM programs was available. Costs were commonly measured in the MTM literature, although results were inconsistent. A few studies demonstrated significant improvements in intermediate outcomes (e.g., low-density lipoprotein cholesterol), while less studies demonstrated an impact on serious sequelae (e.g., emergency department visits). Medicare MTM programs were still evolving when this study was conducted, and we found limited evidence to determine which beneficiaries would benefit most from MTM, which features achieved the desired outcomes, and which outcomes should be measured to compare MTM program performance.

  2. 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.

  3. 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

    ... Medicare-dependent, small rural hospital MedPAC Medicare Payment Advisory Commission MedPAR Medicare... Methodology for Medicare DSH under Section 3133 of the Affordable Care Act F. Medicare-Dependent, Small...

  4. Lessons for the new CMS innovation center from the Medicare health support program.

    PubMed

    Barr, Michael S; Foote, Sandra M; Krakauer, Randall; Mattingly, Patrick H

    2010-07-01

    The Patient Protection and Affordable Care Act establishes a new Center for Medicare and Medicaid Innovation in the Centers for Medicare and Medicaid Services (CMS). The center is intended to enhance the CMS's role in promoting much-needed improvements in payment and service delivery. Lessons from the Medicare Health Support Program, a chronic care pilot program that ran between 2005 and 2008, illustrate the value of drawing on experience in planning for the center and future pilot programs. The lessons include the importance of strong leadership; collaboration and flexibility to foster innovation; receptivity of beneficiaries to care management; and the need for timely data on patients' status. The lessons also highlight pitfalls to be avoided in planning future pilot programs, such as flawed strategies for selecting populations to target when testing payment and service delivery reforms.

  5. 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.

  6. Medicare Competitive Bidding Program Realized Price Savings For Durable Medical Equipment Purchases.

    PubMed

    Newman, David; Barrette, Eric; McGraves-Lloyd, Katharine

    2017-08-01

    From the inception of the Medicare program there have been questions regarding whether and how to pay for durable medical equipment, prosthetics, orthotics, and supplies. In 2011 the Centers for Medicare and Medicaid Services (CMS) implemented a competitive bidding program to reduce spending on durable medical equipment and similar items. Previously, CMS had used prices in an administrative fee schedule to reimburse for these items. We compared prices from Round 1 of the Medicare competitive bidding program, which were established for the periods 2011-13 and 2014-16, to prices paid by national commercial insurers for the same types of items in 2011-14. Our results suggest that the initial years of the program produced prices comparable to those obtained, on average, by large commercial insurers-sophisticated purchasers that presumably were able to negotiate prices with suppliers of durable medical equipment and similar items. Project HOPE—The People-to-People Health Foundation, Inc.

  7. 77 FR 68209 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-15

    ... Electronic Health Record (EHR) Incentive Program, and revising the various regulations governing Quality... November 15, 2012 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services... Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Electronic...

  8. 76 FR 74121 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-30

    .... Statutory History of Hospital Outpatient Quality Reporting (Hospital OQR) Program 3. Technical Specification... Beneficiaries (5) Effects on Other Providers (6) Effects on the Medicare and Medicaid Programs (7) Alternatives...) Estimated Effects of This Final Rule With Comment Period on Beneficiaries (4) Alternatives Considered c...

  9. 76 FR 42169 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-18

    ... Quality Reporting Program Updates and ASC Quality Reporting A. Background 1. Overview 2. Statutory History... Other Providers (6) Estimated Effects on the Medicare and Medicaid Programs (7) Alternative Considered b... Beneficiaries (4) Alternatives Considered c. Accounting Statements and Tables d. Effect of Proposed Requirements...

  10. 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

    ... Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY... Rehabilitation and Respiratory Care Services; Medicaid Program: Accreditation for Providers of Inpatient... ``Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

  11. Medical Students' Attitudes on Physician Fraud and Abuse in the Medicare and Medicaid Programs.

    ERIC Educational Resources Information Center

    Keenan, Constance E.; And Others

    1985-01-01

    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 the problem of fraud and abuse in these programs is reported. Explanations for fraud and abuse focused on physicians' attitudes and motivations. (Author/MLW)

  12. 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

  13. Medicare Part D Community Outreach Train-the-Trainer Program for Pharmacy Faculty

    PubMed Central

    Cutler, Timothy W.; Corelli, Robin L.; Smith, Amanda R.; Lipton, Helene L.

    2009-01-01

    Objectives To assess the train-the-trainer component of an initiative (Partners in D) to train pharmacy students to facilitate patient enrollment in the best Medicare Part D prescription drug plan (Part D). Methods Faculty members from 6 California colleges or schools of pharmacy were taught how to train pharmacy students about Medicare Part D and how to conduct outreach events targeting underserved patient populations. A preintervention and postintervention survey instrument was administered to determine participants' (1) knowledge of the Part D program; (2) skill using the Medicare Prescription Drug Plan Finder tool; and (3) confidence in their ability to train pharmacy students. Implementation of the Partners in D curriculum in faculty members' colleges or schools of pharmacy was also determined. Results Participants' knowledge of Part D, mastery of the Plan Finder, and confidence in teaching the material to pharmacy students all significantly improved. Within 8 weeks following the program, 5 of 6 colleges or schools of pharmacy adopted Partners in D coursework and initiated teaching the Partners-in-D curriculum. Four months afterwards, 21 outreach events reaching 186 Medicare beneficiaries had been completed. Conclusions The train-the-trainer component of the Partners in D program is practical and effective, and merits serious consideration as a national model for educating patients about Medicare Part D. PMID:19564996

  14. Medicare program; revisions to the Medicare Advantage and prescription drug benefit programs: clarification of compensation plans. Interim final rule with comment period.

    PubMed

    2008-11-14

    This interim final rule with comment period (IFC) revises the regulations governing the Medicare Advantage (MA) program (Part C), and prescription drug benefit program (Part D). This IFC sets forth new requirements governing the marketing of Part C and Part D plans which by statute must be in place at a date specified by the Secretary, but no later than November 15, 2008. The new marketing requirements, which set forth new limits on the compensation that can be paid to agents or brokers with respect to Part C and Part D plans, are based on authority under provisions in the Medicare Improvements for Patients and Providers Act (MIPPA) that became law on July 15, 2008.

  15. 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.

  16. 75 FR 44313 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-28

    ...This final rule implements the provisions of the American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111-5) that provide incentive payments to eligible professionals (EPs), eligible hospitals and critical access hospitals (CAHs) participating in Medicare and Medicaid programs that adopt and successfully demonstrate meaningful use of certified electronic health record (EHR) technology. This final rule specifies--the initial criteria EPs, eligible hospitals, and CAHs must meet in order to qualify for an incentive payment; calculation of the incentive payment amounts; payment adjustments under Medicare for covered professional services and inpatient hospital services provided by EPs, eligible hospitals and CAHs failing to demonstrate meaningful use of certified EHR technology; and other program participation requirements. Also, the Office of the National Coordinator for Health Information Technology (ONC) will be issuing a closely related final rule that specifies the Secretary's adoption of an initial set of standards, implementation, specifications, and certification criteria for electronic health records. ONC has also issued a separate final rule on the establishment of certification programs for health information technology.

  17. Impact of Continued Biased Disenrollment from the Medicare Advantage Program to Fee-for-Service

    PubMed Central

    Riley, Gerald F

    2012-01-01

    Background Medicare managed care enrollees who disenroll to fee-for-service (FFS) historically have worse health and higher costs than continuing enrollees and beneficiaries remaining in FFS. Objective To examine disenrollment patterns by analyzing Medicare payments following disenrollment from Medicare Advantage (MA) to FFS in 2007. Recent growth in the MA program, introduction of limits on timing of enrollment/disenrollment, and initiation of prescription drug benefits may have substantially changed the dynamics of disenrollment. Study design The study was based on MA enrollees who disenrolled to FFS in 2007 (N=248,779) and a sample of “FFS stayers” residing in the same counties as the disenrollees (N=551,616). Actual Medicare Part A and Part B payments (excluding hospice payments) in the six months following disenrollment were compared with predicted payments based on claims experience of local FFS stayers, adjusted for CMS-Hierarchical Condition Category (CMS-HCC) risk scores. Results Disenrollees incurred $1,021 per month in Medicare payments, compared with $798 in predicted payments (ratio of actual/predicted=1.28, p < 0.001). Differences between actual and predicted payments were smaller for disenrollees of Preferred Provider Organizations and Private Fee-for-Service plans than of Health Maintenance Organizations. Analysis of 10 individual MA plans revealed variation in the degree of selective disenrollment. Conclusions Despite substantial changes in policies and market characteristics of the Medicare managed care program, disenrollment to FFS continues to occur disproportionately among high-cost beneficiaries, raising concerns about care experiences among sicker enrollees and increased costs to Medicare. PMID:24800156

  18. Medicare program; physician fee freeze sanctions--HHS. Notice of proposed rulemaking.

    PubMed

    1985-09-13

    This notice of proposed rulemaking sets forth OIG procedures for the imposition of civil money penalties and Medicare program exclusions on physicians who choose not to be participating physicians and who raise charges to Medicare beneficiaries in violation of the freeze on such fees contained in Section 2306 of Pub. L. 98-369 (the Deficit Reduction Act of 1984). The proposed rule also modifies existing regulations to permit the OIG to impose civil money penalties and assessments on those who choose to be participating physicians under the Medicare program and who violate their participation agreements as set forth in Section 2306. This regulation does not pertain to HCFA's responsibility for the Physician Fee Freeze.

  19. Favorable selection, risk adjustment, and the Medicare Advantage program.

    PubMed

    Morrisey, Michael A; Kilgore, Meredith L; Becker, David J; Smith, Wilson; Delzell, Elizabeth

    2013-06-01

    To examine the effects of changes in payment and risk adjustment on (1) the annual enrollment and switching behavior of Medicare Advantage (MA) beneficiaries, and (2) the relative costliness of MA enrollees and disenrollees. From 1999 through 2008 national Medicare claims data from the 5 percent longitudinal sample of Parts A and B expenditures. Retrospective, fixed effects regression analysis of July enrollment and year-long switching into and out of MA. Similar regression analysis of the costliness of those switching into (out of) MA in the 6 months prior to enrollment (after disenrollment) relative to nonswitchers in the same county over the same period. Payment generosity and more sophisticated risk adjustment were associated with substantial increases in MA enrollment and decreases in disenrollment. Claims experience of those newly switching into MA was not affected by any of the policy reforms, but disenrollment became increasingly concentrated among high-cost beneficiaries. Enrollment is very sensitive to payment levels. The use of more sophisticated risk adjustment did not alter favorable selection into MA, but it did affect the costliness of disenrollees. © Health Research and Educational Trust.

  20. Favorable Selection, Risk Adjustment, and the Medicare Advantage Program

    PubMed Central

    Morrisey, Michael A; Kilgore, Meredith L; Becker, David J; Smith, Wilson; Delzell, Elizabeth

    2013-01-01

    Objectives To examine the effects of changes in payment and risk adjustment on (1) the annual enrollment and switching behavior of Medicare Advantage (MA) beneficiaries, and (2) the relative costliness of MA enrollees and disenrollees. Data From 1999 through 2008 national Medicare claims data from the 5 percent longitudinal sample of Parts A and B expenditures. Study Design Retrospective, fixed effects regression analysis of July enrollment and year-long switching into and out of MA. Similar regression analysis of the costliness of those switching into (out of) MA in the 6 months prior to enrollment (after disenrollment) relative to nonswitchers in the same county over the same period. Findings Payment generosity and more sophisticated risk adjustment were associated with substantial increases in MA enrollment and decreases in disenrollment. Claims experience of those newly switching into MA was not affected by any of the policy reforms, but disenrollment became increasingly concentrated among high-cost beneficiaries. Conclusions Enrollment is very sensitive to payment levels. The use of more sophisticated risk adjustment did not alter favorable selection into MA, but it did affect the costliness of disenrollees. PMID:23088500

  1. 78 FR 79081 - Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-27

    ... Institute of Medicine JCAHO Joint Commission on the Accreditation of Healthcare Organizations JPATS Joint...)(2)(i) through (iv)) U. Summary of the Total Costs V. Benefits of the Proposed Rule W. Alternatives... disasters. The SNS program ensures the availability of necessary medicines, antidotes, medical supplies, and...

  2. 78 FR 40835 - Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-08

    ... July 8, 2013 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services...; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 413 and 414 RIN... address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention...

  3. 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

    ... 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 purpose of the Panel is to review all aspects of the Medicare Economic Index (MEI). This first meeting will...

  4. 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

    ...-dependent, small rural hospital MedPAC Medicare Payment Advisory Commission MedPAR Medicare Provider... Fraction of the Medicare DSH Calculation G. Medicare-Dependent, Small Rural Hospitals (MDHs): Change...

  5. 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

    ... 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 Health... through a Medicare Advantage (MA) organization that contracts with the Centers for Medicare &...

  6. 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

    ... skilled nursing facility (SNF) in the Medicare program, or as a nursing facility (NF) in the Medicaid..., approximately 1.4 million elderly and disabled nursing home residents are receiving care in nearly 16,000... percent of older Americans die in nursing homes. (Johnson, Sandra H., Hastings Center Report, Making Room...

  7. 75 FR 39641 - Medicare and Medicaid Programs; Civil Money Penalties for Nursing Homes

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-12

    ... and Medicaid Programs; Civil Money Penalties for Nursing Homes AGENCY: Centers for Medicare & Medicaid... when nursing homes are not in compliance with Federal participation requirements in accordance with the... certified as meeting Federal participation requirements. Long-term care facilities include skilled nursing...

  8. 42 CFR 424.530 - Denial of enrollment in the Medicare program.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    .... (a) Reasons for denial. CMS may deny a provider's or supplier's enrollment in the Medicare program for the following reasons: (1) Compliance. The provider or supplier at any time is found not to be in..., rape, or assault, and other similar crimes for which the individual was convicted, including...

  9. 76 FR 47301 - Medicare Program; Hospice Wage Index for Fiscal Year 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-04

    ... Least Three Indicators Related to Patient Care B. Outcome Measure: NQF Measure 0209, Percentage of... under the Medicare program to reflect local differences in area wage levels. Our regulations at Sec. 418... economic differences between hospitals in the United States and those in Puerto Rico, including the...

  10. 76 FR 22709 - Medicare and Medicaid Programs; Approval of the American Association for Accreditation of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-22

    ... occupational therapy services. Therefore, it was not necessary for occupational therapy services to be... Organizations That Provide Outpatient Physical Therapy and Speech-Language Pathology Services AGENCY: Centers... therapy and speech-language pathology services seeking to participate in the Medicare or Medicaid programs...

  11. 75 FR 24437 - Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-05-05

    .... Background The Medicare program, title XVIII of the Social Security Act (the Act), is the primary payer of... of both the Employer Identification Number (EIN) and Social Security Number (SSN) of each provider or... organizations and charities. The ``Report to Congress on Steps Taken to Assure Confidentiality of Social...

  12. 75 FR 68799 - Medicare Program; Inpatient Hospital Deductible and Hospital and Extended Care Services...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-09

    ... Services [CMS-8040-N] RIN 0938-AP86 Medicare Program; Inpatient Hospital Deductible and Hospital and... (CMS), HHS. ACTION: Notice. SUMMARY: This notice announces the inpatient hospital deductible and the hospital and extended care services coinsurance amounts for services furnished in calendar year (CY) 2011...

  13. 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... wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed... certain requirements are met. Sections 1861(o) and 1891 of the Social Security Act (the Act), establish...

  14. 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…

  15. 78 FR 31472 - Medicare and Medicaid Programs; Survey, Certification and Enforcement Procedures; Extension of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-24

    ... Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). The proposed revisions would also... an accreditation program in accordance with the Social Security Act. The comment period for the... building. A stamp- in clock is available for persons wishing to retain a proof of filing by stamping in and...

  16. 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 Assistance...

  17. 78 FR 64953 - Medicare Program; Inpatient Hospital Deductible and Hospital and Extended Care Services...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-10-30

    ... rates for FY 2014 for hospitals excluded from the inpatient prospective payment system is as follows... Register on August 19, 2013 entitled, ``Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year...

  18. 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

    ... Health Records Hospital Inpatient Quality Data Reporting AGENCY: Centers for Medicare & Medicaid Services... associated with hospital collection and submission of patient-level data on clinical quality measures (CQMs... quality reporting programs through automatic collection and reporting of data on CQMs using CEHRT....

  19. 76 FR 47835 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-05

    ... for the IRF prospective payment system (PPS) case-mix groups and a description of the methodology and... research and computations used to support an un-weighted regression methodology. ] Response: We provided... 42 CFR Part 412 Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for...

  20. 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

    ...-AR12 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific...

  1. 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

    ...-AR12 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific...

  2. 76 FR 41178 - Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-13

    ...This document corrects technical errors that occurred in Tables 2 and 4J, that were referenced in the proposed rule entitled ``Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2012 Rates'' which appeared in the May 5, 2011 Federal...

  3. Medicare program; uniform electronic cost reporting system for hospitals--HCFA. Final rule with comment period.

    PubMed

    1994-05-25

    This final rule with comment period implements the provisions of section 4007(b) of the Omnibus Budget Reconciliation Act of 1987, as amended by section 411(b)(6) of the Medicare Catastrophic Coverage Act of 1988, which require the Secretary to place into effect a standardized electronic cost reporting system for all hospitals under the Medicare program. Under this final rule with comment period, all hospitals are required to submit their cost reports, for hospital cost reporting periods beginning on or after October 1, 1989, in a uniform electronic format. The Secretary may grant a delay or a waiver of this requirement where implementation could result in financial hardship for a hospital.

  4. 76 FR 5861 - Medicare, Medicaid, and Children's Health Insurance Programs; Additional Screening Requirements...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-02

    ...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.

  5. Factors associated with program utilization of radiation therapy treatment for VHA and medicare dually enrolled patients.

    PubMed

    French, Dustin D; Bradham, Douglas D; Campbell, Robert R; Haggstrom, David A; Myers, Laura J; Chumbler, Neale R; Hagan, Michael P

    2012-08-01

    We examine how distance to a Veterans Health Administration (VHA) facility, patient hometown classification (e.g., small rural town), and service-connected disability are associated with veterans' utilization of radiation therapy services across the VHA and Medicare. In 2008, 45,914 dually-enrolled veteran patients received radiation therapy. Over 3-quarters (35,513) of the patients received radiation therapy from the Medicare program. Younger age, male gender, shorter distance to a VHA facility, and VHA priority or disability status increased the odds of utilizing the VHA. However, veterans residing in urban areas were less likely to utilize the VHA. Urban dwelling patients' utilization of Medicare instead of the VHA suggests a complex decision that incorporates geographic access to VHA services, financial implications of veteran priority status, and the potential availability of multiple sources of radiation therapy in competitive urban markets.

  6. 75 FR 21175 - Medicare and Medicaid Programs; Waiver of Disapproval of Nurse Aide Training Program in Certain...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-04-23

    ... a waiver of a nurse aide training disapproval as it applies to skilled nursing facilities, in the Medicare program, and nursing facilities, in the Medicaid program, that are assessed a civil money penalty... Federal participation requirements. Long-term care facilities include skilled nursing facilities (SNFs...

  7. 77 FR 44721 - Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face to...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-30

    ... July 30, 2012 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services... Prospective and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Electronic Reporting Pilot; Inpatient Rehabilitation Facilities Quality Reporting Program; Quality Improvement...

  8. Sugar daddy. Most Americans know Medicare as the health insurance program for the elderly, but to providers, it's a jobs program, a capital financier and a safety net.

    PubMed

    Hallam, K; Gardner, J

    1999-11-08

    Most Americans know Medicare as the health insurance program that covers the elderly. But to providers it's much more that. The program pays for medical education, finances capital projects and subsidizes care for the indigent. Should Medicare continue making those add-on payments? Is that the program's mission? The debate is intensifying.

  9. 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.

  10. The Medicare Hospital Readmissions Reduction Program: Potential Unintended Consequences for Hospitals Serving Vulnerable Populations

    PubMed Central

    Gu, Qian; Koenig, Lane; Faerberg, Jennifer; Steinberg, Caroline Rossi; Vaz, Christopher; Wheatley, Mary P

    2014-01-01

    Objective To explore the impact of the Hospital Readmissions Reduction Program (HRRP) on hospitals serving vulnerable populations. Data Sources/Study Setting Medicare inpatient claims to calculate condition-specific readmission rates. Medicare cost reports and other sources to determine a hospital's share of duals, profit margin, and characteristics. Study Design Regression analyses and projections were used to estimate risk-adjusted readmission rates and financial penalties under the HRRP. Findings were compared across groups of hospitals, determined based on their share of duals, to assess differential impacts of the HRRP. Principal Findings Both patient dual-eligible status and a hospital's dual-eligible share of Medicare discharges have a positive impact on risk-adjusted hospital readmission rates. Under current Centers for Medicare and Medicaid Service methodology, which does not adjust for socioeconomic status, high-dual hospitals are more likely to have excess readmissions than low-dual hospitals. As a result, HRRP penalties will disproportionately fall on high-dual hospitals, which are more likely to have negative all-payer margins, raising concerns of unintended consequences of the program for vulnerable populations. Conclusions Policies to reduce hospital readmissions must balance the need to ensure continued access to quality care for vulnerable populations. PMID:24417309

  11. The Medicare Hospital Readmissions Reduction Program: potential unintended consequences for hospitals serving vulnerable populations.

    PubMed

    Gu, Qian; Koenig, Lane; Faerberg, Jennifer; Steinberg, Caroline Rossi; Vaz, Christopher; Wheatley, Mary P

    2014-06-01

    To explore the impact of the Hospital Readmissions Reduction Program (HRRP) on hospitals serving vulnerable populations. Medicare inpatient claims to calculate condition-specific readmission rates. Medicare cost reports and other sources to determine a hospital's share of duals, profit margin, and characteristics. Regression analyses and projections were used to estimate risk-adjusted readmission rates and financial penalties under the HRRP. Findings were compared across groups of hospitals, determined based on their share of duals, to assess differential impacts of the HRRP. Both patient dual-eligible status and a hospital's dual-eligible share of Medicare discharges have a positive impact on risk-adjusted hospital readmission rates. Under current Centers for Medicare and Medicaid Service methodology, which does not adjust for socioeconomic status, high-dual hospitals are more likely to have excess readmissions than low-dual hospitals. As a result, HRRP penalties will disproportionately fall on high-dual hospitals, which are more likely to have negative all-payer margins, raising concerns of unintended consequences of the program for vulnerable populations. Policies to reduce hospital readmissions must balance the need to ensure continued access to quality care for vulnerable populations. © Health Research and Educational Trust.

  12. A simulation shows limited savings from meeting quality targets under the Medicare Shared Savings Program.

    PubMed

    Eddy, David M; Shah, Roshan

    2012-11-01

    The Medicare Shared Savings Program, created under the Affordable Care Act, will reward participating accountable care organizations that succeed in lowering health care costs while improving performance. Depending on how the organizations perform on several quality measures, they will "share savings" in Medicare Part A and B payments-that is, they will receive bonus payments for lowering costs. We used a simulation model to analyze the effects of the Shared Savings Program quality measures and performance targets on Medicare costs in a simulated population of patients ages 65-75 with type 2 diabetes. We found that a ten-percentage-point improvement in performance on diabetes quality measures would reduce Medicare costs only by up to about 1 percent. After the costs of performance improvement, such as additional tests or visits, are accounted for, the savings would decrease or become cost increases. To achieve greater savings, accountable care organizations will have to lower costs by other means, such as through improved use of information technology and care coordination.

  13. Will choice-based reform work for Medicare? Evidence from the Federal Employees Health Benefits Program.

    PubMed

    Florence, Curtis S; Atherly, Adam; Thorpe, Kenneth E

    2006-10-01

    . To examine the effect of premiums and benefits on the health plan choices of older enrollees who choose Federal Employees Health Benefits Program (FEHBP) health plans as their primary payer. Administrative enrollment data from the Office of Personnel Management (OPM) and plan premiums and benefits data taken from the Checkbook Guide to health plans. We estimate individual plan choice models where the choice of health plan is a function of out-of-pocket premium, actuarial value, plan attributes, and individual characteristics. Plan attributes include plan structure (fee-for-service/preferred provider organization, point-of-service, or health maintenance organization), drug benefit structure, and whether or not the plan covers other types of spending such as dental services and diabetic supplies. The models are estimated by conditional logit. Our study focuses on three populations that currently choose FEHBP as their primary health care coverage and are similar to the Medicare population: current employees and retirees who are approaching the age of Medicare eligibility (ages 60-64) and current federal employees age 65+. Current employees age 65+ are eligible for Medicare, but their FEHBP plan is their primary payer. Retirees and employees 60-64 are not yet eligible for Medicare but are similar in many respects to recently age-eligible Medicare beneficiaries. We also estimate our model for current employees age 55 and younger as a comparison group. We select a random sample of retirees and employees age 60-64, as well as all current employees age 65+, from the OPM administrative database for the calendar year 2001. The plan choices available to each person are determined by the plans participating in their metropolitan statistical area. We match plan premium and attribute information from the Checkbook Guide to each plan in the enrollee's list of choices. We find that current workers 65+, 60-64, and non-Medicare eligible retirees are sensitive to variation in plan

  14. 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.

  15. Medicare and Rural Health

    MedlinePlus

    ... differences exist in rural and urban Medicare enrollee populations? According to MedPAC’s Report to the Congress (June ... rural people make up 19% of the U.S. population and you will see why the Medicare program ...

  16. Assessing Medicare Beneficiary Eligibility for Medication Therapy Management Programs Using PINNACLE, a National Cardiovascular Data Registry.

    PubMed

    Spinler, Sarah A; Cziraky, Mark J; Tang, Fengming; Dueñas, Gladys G; Thomas, Tyan; Reinhold, Jennifer A; Willey, Vincent J

    2013-09-01

    Medication therapy management (MTM) is a mandated component of the 2003 Medicare Modernization Act for Part D prescription drug plans and Medicare Advantage plans, authorizing the pharmacist or other qualified provider to identify, resolve, and prevent medication-related problems for patients with chronic diseases. MTM programs have been shown to improve medication adherence and reduce medication errors while reducing overall costs in patients with cardiovascular (CV) disease; however, MTM has been greatly underutilized for patients with chronic diseases. To identify the proportion of Medicare beneficiaries who are eligible for, and who could potentially benefit from, participating in MTM among patients enrolled in the National Cardiovascular Data Registry's PINNACLE Registry. Patient MTM eligibility is based on the presence of multiple chronic diseases and meeting a minimum annual insurance medication costs. We used patient data from 462 academic and private cardiology practices in the United States who participated in the PINNACLE Registry between May 1, 2008, and September 30, 2010, to determine Medicare beneficiaries' eligibility to participate in an MTM program for patients meeting the MTM criteria of (1) a number of chronic diseases (in this case, the number of CV conditions) and (2) an estimated minimum annual medication expenses, using a weighted average cost calculated based on the average wholesale price of the most often prescribed medications, by class, as extracted from the HealthCore Integrated Research Database and weighted according to prescribing frequency within a class. Among the Medicare beneficiaries in the PINNACLE Registry, 93,089 (58%) had ≥3 chronic CV conditions, and the median annual estimated medication expenditure per patient enrolled in the PINNACLE Registry was $1329. Of the total of 93,089 Medicare beneficiaries, 21.4% were eligible for MTM, based on the 2010 minimum eligibility criterion of an annual insurer medication expenditure

  17. Medicare premium buy-in programs: results of SSA demonstration projects.

    PubMed

    Nadel, M; Alecxih, L; Parent, R; Sears, J

    2000-01-01

    Three programs known collectively as the Medicare buy-in programs are available to pay Medicare Part B premiums and, in some cases, other medical expenses for certain low-income individuals. The Health Care Financing Administration administers those programs, with most functions performed by the states. The Social Security Administration (SSA) plays an indirect role in the buy-in programs: with certain exceptions, people who qualify for Medicare and hence for buy-in are beneficiaries of Social Security retirement or disability programs. SSA is often cited as an agency that might be able to increase enrollment in the buy-in programs through outreach to its beneficiaries and by acting as an intermediary in the enrollment process. The three buy-in programs have different requirements for eligibility. The Qualified Medicare Beneficiary (QMB) program includes individuals who have Part A Medicare benefits and whose income does not exceed 100 percent of federal poverty guidelines. People in the Specified Low-Income Medicare Beneficiary (SLMB) program are individuals who would otherwise be QMBs but whose income is more than 100 percent but less than 120 percent of poverty guidelines. People in the Qualified Individual (QI) program are those who meet the other criteria but whose income is less than 175 percent of poverty guidelines. Various reports and studies by government agencies and advocacy organizations conclude that the buy-in programs are not reaching many of the people who are eligible. Low enrollment appears to be a particular issue for the SLMB and QI programs. States have tried various outreach efforts, but the effectiveness of those efforts has not been adequately assessed. In 1998, Congress mandated that SSA conduct a demonstration project to determine how to increase participation in the buy-in programs. The project tested six different administrative models in which outreach letters were sent to potential beneficiaries asking them to contact SSA and then be

  18. Medicare and Medicaid programs; conditions for coverage for organ procurement organizations (OPOs). Final rule.

    PubMed

    2006-05-31

    This rule finalizes the February 4, 2005 proposed rule entitled "Medicare and Medicaid Programs; Conditions for Coverage for Organ Procurement Organizations (OPOs)." It establishes new conditions for coverage for organ procurement organizations (OPOs) that include multiple new outcome and process performance measures based on organ donor potential and other related factors in each service area of qualified OPOs. Our goal is to improve OPO performance and increase organ donation. In addition, this final rule re-certifies these 58 OPOs from August 1, 2006 through July 31, 2010 and provides an opportunity for them to sign agreements with the Secretary that will begin on August 1, 2006 and end on January 31, 2011. New agreements are needed so that the Medicare and Medicaid Programs can continue to pay them for their organ procurement activities after July 31, 2006.

  19. 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

    ... December 2, 2013 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services...; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 413 and 414 RIN... 5. Scoring for the PY 2016 ESRD QIP and Future Payment Years 6. Performance Period for the PY 2016...

  20. 76 FR 26489 - Medicare Program; Hospital Inpatient Value-Based Purchasing Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-06

    ... 6, 2011 Part V Department of Health and Human Services Centers for Medicare & Medicaid Services 42...; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 422 and 480 RIN... to hospitals that meet performance standards with respect to a performance period for the fiscal year...

  1. 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

    ...This final rule finalizes several provisions of the Affordable Care Act implemented in the May 5, 2010 interim final rule with comment period. It requires all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment......

  2. 78 FR 64603 - Medicare Program: Conditions of Participation (CoPs) for Community Mental Health Centers

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-10-29

    ...This final rule establishes, for the first time, conditions of participation (CoPs) that community mental health centers (CMHCs) must meet in order to participate in the Medicare program. These CoPs focus on the care provided to the client, establish requirements for staff and provider operations, and encourage clients to participate in their care plan and treatment. The new CoPs enable CMS to survey CMHCs for compliance with health and safety requirements.

  3. 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.

  4. Association Between Extending CareFirst's Medical Home Program to Medicare Patients and Quality of Care, Utilization, and Spending.

    PubMed

    Peterson, G Greg; Geonnotti, Kristin Lowe; Hula, Lauren; Day, Timothy; Blue, Laura; Kranker, Keith; Gilman, Boyd; Stewart, Kate; Hoag, Sheila; Moreno, Lorenzo

    2017-09-01

    CareFirst, the largest commercial insurer in the mid-Atlantic Region of the United States, runs a medical home program focusing on financial incentives for primary care practices and care coordination for high-risk patients. From 2013 to 2015, CareFirst extended the program to Medicare fee-for-service (FFS) beneficiaries in participating practices. If the model extension improved quality while reducing spending, the Centers for Medicare and Medicaid Services could expand the program to Medicare beneficiaries broadly. To test whether extending CareFirst's program to Medicare FFS patients improves care processes and reduces hospitalizations, emergency department visits, and spending. This difference-in-differences analysis compared outcomes for roughly 35 000 Medicare FFS patients attributed to 52 intervention practices (grouped by CareFirst into 14 "medical panels") to outcomes for 69 000 Medicare patients attributed to 42 matched comparison panels during a 1-year baseline period and 2.5-year intervention at Maryland primary care practices. Hospitalizations (all-cause and ambulatory-care sensitive), emergency department visits, Medicare Part A and B spending, and 3 quality-of-care process measures: ambulatory care within 14 days of a hospital stay, cholesterol testing for those with ischemic vascular disease, and a composite measure for those with diabetes. CareFirst hired nurses who worked with patients' usual primary care practitioners to coordinate care for 3656 high-risk Medicare patients. CareFirst paid panels rewards for meeting cost and quality targets for their Medicare patients and advised panels on how to meet these targets based on analyses of claims data. On average, each of the 14 intervention panels had 9.3 primary care practitioners and was attributed 2202 Medicare FFS patients in the baseline period. The panels' attributed Medicare patients were, on average, 73.8 years old, 59.2% female, and 85.1% white. The extension of CareFirst's program to

  5. 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.

  6. Medicare program; standards for e-prescribing under Medicare Part D and identification of backward compatible version of adopted standard for e-prescribing and the Medicare prescription drug program (version 8.1). Final rule.

    PubMed

    2008-04-07

    This final rule adopts uniform standards for medication history, formulary and benefits, and fill status notification (RxFill) for the Medicare Part D electronic prescribing (e-prescribing) drug program as required by section 1860D-4(e)(4)(D) of the Social Security Act (the Act). In addition, we are adopting the National Provider Identifier (NPI) as a standard for identifying health care providers in e-prescribing transactions. It also finalizes the June 23, 2006 interim final rule with comment period that identified the National Council for Prescription Drug Programs (NCPDP) Prescriber/Pharmacist Interface SCRIPT standard, Implementation Guide, Version 8.1 ("NCPDP SCRIPT 8.1") as a backward compatible update of the NCPDP SCRIPT 5.0 ("NCPDP SCRIPT 5.0"), until April 1, 2009. This final rule also retires NCPDP SCRIPT 5.0 and adopts the newer version, NCPDP SCRIPT 8.1, as the adopted standard. Finally, except as otherwise set forth herein, we are implementing our compliance date of 1 year after the publication of these final uniform standards. This is the second set in a continuing process of issuing e-prescribing final standards for the Medicare Part D program,

  7. Comparison of Medicaid Payments Relative to Medicare Using Inpatient Acute Care Claims from the Medicaid Program: Fiscal Year 2010-Fiscal Year 2011.

    PubMed

    Stone, Devin A; Dickensheets, Bridget A; Poisal, John A

    2017-01-10

    To compare Medicaid fee-for-service (FFS) inpatient hospital payments to expected Medicare payments. Medicaid and Medicare claims data, Medicare's MS-DRG grouper and inpatient prospective payment system pricer (IPPS pricer). Medicaid FFS inpatient hospital claims were run through Medicare's MS-DRG grouper and IPPS pricer to compare Medicaid's actual payment against what Medicare would have paid for the same claim. Average inpatient hospital claim payments for Medicaid were 68.8 percent of what Medicare would have paid in fiscal year 2010, and 69.8 percent in fiscal year 2011. Including Medicaid disproportionate share hospital (DSH), graduate medical education (GME), and supplemental payments reduces a substantial proportion of the gap between Medicaid and Medicare payments. Medicaid payments relative to expected Medicare payments tend to be lower and vary by state Medicaid program, length of stay, and whether payments made outside of the Medicaid claims process are included. © Health Research and Educational Trust.

  8. Impact of a Medicare MTM program: evaluating clinical and economic outcomes.

    PubMed

    Hui, Rita L; Yamada, Brian D; Spence, Michele M; Jeong, Erwin W; Chan, James

    2014-02-01

    To assess the impact of a Medicare Medication Therapy Management (MTM) program in a large integrated health plan on patient mortality, hospitalization and emergency department (ED) utilization, and daily prescription costs. Retrospective matched cohort study. Patients who received MTM services between 2006 and 2010 were matched to control patients who were enrolled in Medicare but did not receive MTM services. They were matched in a 1:4 ratio based on age, gender, geographic location, and prospective diagnostic-cost-group (DxCG) risk score. Multivariate regressions were used to analyze the outcomes. Subgroup analyses were conducted for patients enrolled in 2010 because the Centers for Medicare & Medicaid Services lowered the drug-cost threshold for MTM eligibility and changed from opt-in to optout participation. We identified 34,532 members who received MTM services and 138,128 control members. The MTM group was found to have a significantly reduced mortality (hazard ratio 0.86, 95% confidence interval [CI], 0.84-0.88; P <.001), lower odds for hospitalization (odds ratio [OR] = 0.97, 95% CI, 0.94-0.99; P = .018), higher odds for emergency department visits (OR = 1.17, 95% CI, 1.14-1.20; P <.001), and no differences in change in daily medication costs when compared to the matched group. The subgroup analysis of the 2010 cohort found similar results with better outcomes than the overall cohort. Medicare MTM services resulted in lower mortality and odds for hospitalization for enrolled patients compared with matched controls. This study observed an increase in ED visits and no differences in change in daily medication costs in MTM services.

  9. Integrated telehealth and care management program for Medicare beneficiaries with chronic disease linked to savings.

    PubMed

    Baker, Laurence C; Johnson, Scott J; Macaulay, Dendy; Birnbaum, Howard

    2011-09-01

    Treatment of chronically ill people constitutes nearly four-fifths of US health care spending, but it is hampered by a fragmented delivery system and discontinuities of care. We examined the impact of a care coordination approach called the Health Buddy Program, which integrates a telehealth tool with care management for chronically ill Medicare beneficiaries. We evaluated the program's impact on spending for patients of two clinics in the US Northwest who were exposed to the intervention, and we compared their experience with that of matched controls. We found significant savings among patients who used the Health Buddy telehealth program, which was associated with spending reductions of approximately 7.7-13.3 percent ($312-$542) per person per quarter. These results suggest that carefully designed and implemented care management and telehealth programs can help reduce health care spending and that such programs merit continued attention by Medicare. Meanwhile, mortality differences in the treatment and control groups suggest that the intervention may have produced noticeable changes in health outcomes, but we leave it to future research to explore these effects fully.

  10. 77 FR 33547 - Privacy Act of 1974, as Amended; Computer Matching Program (SSA/Centers for Medicare and Medicaid...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-06

    ... ADMINISTRATION Privacy Act of 1974, as Amended; Computer Matching Program (SSA/ Centers for Medicare and Medicaid... of the Privacy Act, as amended, this notice announces a new computer matching program that we will... Privacy Act We have taken action to ensure that all of our computer matching programs comply with...

  11. The Influence of a Community Pharmacy Automatic Prescription Refill Program on Medicare Part D Adherence Metrics.

    PubMed

    Lester, Corey A; Mott, David A; Chui, Michelle A

    2016-07-01

    The Centers for Medicare & Medicaid Services (CMS) include measures of medication adherence within its Medicare Part D star ratings program. These adherence measures have motivated the development of new methods to improve patient adherence. Automatic prescription refill programs in community pharmacies are an intervention that has seen widespread adoption in recent years. These automatic refill programs anticipate and initiate prescription refills on a standardized, recurrent basis. As a result, prescription refills may be filled before a patient typically might initiate a refill. This study measures the effect of an automatic prescription refill program on 3 adherence metrics used by CMS within Medicare Part D star ratings. To compare the value of Medicare Part D adherence metrics for an automatic prescription refill program relative to standard prescription refills. Prescription dispensing data (January 1, 2014-December 31, 2014) from a chain of 29 pharmacies in a midwestern state were used to conduct this analysis. A post-only, quasi-experimental design separated patients into automatic and standard prescription refill cohorts. Refill adherence was calculated using proportion of days covered (PDC) for each of the 3 adherence metrics used by CMS for statins, renin angiotensin aldosterone system antagonists (RASA), and noninsulin diabetes medications. The adherence rate was defined as the proportion of patients with a PDC ± 80%. Inclusion criteria for patients followed the Pharmacy Quality Alliance technical specifications. Chi-square analysis and multiple logistic regression were used to examine differences in PDC > 80% between the 2 study cohorts. There were 1,018, 1,006, and 368 patients for the automatic refill cohort and 3,928, 3,409, and 1,207 patients for the standard refill cohort in the statin, RASA, and diabetes adherence metrics, respectively. The mean age [SD] of patients was between 79.2 [±8.5] and 80.8 [±9.9] years across all cohorts. Patients in

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

    PubMed

    2016-05-04

    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.

  13. Medicare Access and CHIP Reauthorization Act: What do Geriatrics Healthcare Professionals Need to Know About the Quality Payment Program?

    PubMed

    Unroe, Kathleen T; Hollmann, Peter A; Goldstein, Alanna C; Malone, Michael L

    2017-03-17

    Commencing in 2017, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 will change how Medicare pays health professionals. By enacting MACRA, Congress brought an end to the (un)sustainable growth rate formula while also setting forth a vision for how to transform the U.S. healthcare system so that clinicians deliver higher-quality care with smarter spending by the Centers for Medicare and Medicaid Services (CMS). In October 2016, CMS released the first of what stakeholders anticipate will be a number of (annual) rules related to implementation of MACRA. CMS received extensive input from stakeholders including the American Geriatrics Society. Under the Quality Payment Program, CMS streamlined multiple Medicare value-based payment programs into a new Merit-based Incentive Payment System (MIPS). CMS also outlined how it will provide incentives for participation in Advanced Alternative Payment Models (called APMs). Although Medicare payments to geriatrics health professionals will not be based on the new MIPS formula until 2019, those payments will be based upon performance during a 90-day period in 2017. This article defines geriatrics health professionals as clinicians who care for a predominantly older adult population and who are eligible to bill under the Medicare Physician Fee Schedule. Given the current paucity of eligible APMs, this article will focus on MIPS while providing a brief overview of APMs.

  14. Medicare's Hospital Readmissions Reduction Program in Surgery May Disproportionately Affect Minority-serving Hospitals.

    PubMed

    Shih, Terry; Ryan, Andrew M; Gonzalez, Andrew A; Dimick, Justin B

    2015-06-01

    To project readmission penalties for hospitals performing cardiac surgery and examine how these penalties will affect minority-serving hospitals. The Hospital Readmissions Reduction Program will potentially expand penalties for higher-than-predicted readmission rates to cardiac procedures in the near future. The impact of these penalties on minority-serving hospitals is unknown. We examined national Medicare beneficiaries undergoing coronary artery bypass grafting in 2008 to 2010 (N = 255,250 patients, 1186 hospitals). Using hierarchical logistic regression, we calculated hospital observed-to-expected readmission ratios. Hospital penalties were projected according to the Hospital Readmissions Reduction Program formula using only coronary artery bypass grafting readmissions with a 3% maximum penalty of total Medicare revenue. Hospitals were classified into quintiles according to proportion of black patients treated. Minority-serving hospitals were defined as hospitals in the top quintile whereas non-minority-serving hospitals were those in the bottom quintile. Projected readmission penalties were compared across quintiles. Forty-seven percent of hospitals (559 of 1186) were projected to be assessed a penalty. Twenty-eight percent of hospitals (330 of 1186) would be penalized less than 1% of total Medicare revenue whereas 5% of hospitals (55 of 1186) would receive the maximum 3% penalty. Minority-serving hospitals were almost twice as likely to be penalized than non-minority-serving hospitals (61% vs 32%) and were projected almost triple the reductions in reimbursement ($112 million vs $41 million). Minority-serving hospitals would disproportionately bear the burden of readmission penalties if expanded to include cardiac surgery. Given these hospitals' narrow profit margins, readmission penalties may have a profound impact on these hospitals' ability to care for disadvantaged patients.

  15. Impact of Medicare Shared Savings Program Accountable Care Organizations at Screening Mammography: A Retrospective Cohort Study.

    PubMed

    Narayan, Anand K; Harvey, Susan C; Durand, Daniel J

    2017-02-01

    Purpose To evaluate the impact of accountable care organizations (ACOs) on use of screening mammography in the Medicare Shared Savings Program (MSSP), the largest value-based reimbursement program in U.S. Materials and Methods Institutional review board approval was waived, as the study used publicly available unidentifiable data. Medicare data were retrospectively obtained for participating ACOs from 2012 to 2014. Baseline information and the ACO-20 measure (percentage of women aged 40-69 years who underwent screening mammography within 24 months) were obtained. Negative binomial regression models were used to evaluate baseline and longitudinal mammography use, with stratified analyses performed for year of entry into the ACO, number of beneficiaries, and geographic region. Results A total of 333 ACOs with 5 329 831 Medicare beneficiaries (mean size, 16 006 beneficiaries) participated in the MSSP. Screening use varied across ACOs (median, 63.0%; range, 8.8%-90.3%), with differences found across regions (use was highest in the Midwest [66.6%] and lowest in the South [58.2%], P = .038). A total of 208 ACOs reported longitudinal outcomes, with mean change in screening mammography use of +2.6% (range, -33.2% to +42.2%), with 128 (61.6%) ACOs reporting improvements (incidence rate ratio, 1.04; 95% confidence interval: 1.02, 1.07) (P = .002). No longitudinal differences in use were seen across regions (P = .078), year of entry (P = .902), number of beneficiaries (P = .814), or total composite quality score (P = .324), nor was there a difference between ACOs that saved money and those that did not (P = .391). Conclusion ACOs in the MSSP have produced small significant improvements in screening mammography use. (©) RSNA, 2016.

  16. 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

  17. 77 FR 64344 - Medicare and Medicaid Programs; Approval of the Community Health Accreditation Program for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-10-19

    ... incorporated into the plan of care and considered in the bereavement plan of care.'' To meet the requirements..., and the conditions for Medicare payment for hospice care. Generally, to enter into an agreement, a... to address the needs of ``other individuals'' in the bereavement assessment. In addition,...

  18. 78 FR 9215 - Medicare and Medicaid Programs; Part II-Regulatory Provisions To Promote Program Efficiency...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-07

    ...This proposed rule would reform Medicare regulations that CMS has identified as unnecessary, obsolete, or excessively burdensome on health care providers and suppliers, as well as certain regulations under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). This proposed rule would increase the ability of health care professionals to devote resources to improving patient care, by......

  19. 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

  20. 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 program, or a nursing facility (NF) in the Medicaid program. These requirements implement section 6113 of..., as of April 2010, there are 15,713 long-term care (LTC) facilities (commonly referred to as nursing...

  1. 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

    ... category MDH Medicare-dependent, small rural hospital MedPAC Medicare Payment Advisory Commission MedPAR.... Technical Change to Regulations D. Medicare-Dependent, Small Rural Hospitals (MDHs): Change to Criteria 1...-dependent, small rural hospital (MDH) received the higher of the Federal rate or the Federal rate plus...

  2. 42 CFR 424.510 - Requirements for enrolling in the Medicare program.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... receiving payments via EFT, providers and suppliers must agree to receive Medicare payments via EFT, if not already receiving payment through EFT. In order to receive Medicare payments via EFT, providers and... Medicare payment via electronic funds transfer (EFT) at the time of enrollment, revalidation, change...

  3. 42 CFR 424.510 - Requirements for enrolling in the Medicare program.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... receiving payments via EFT, providers and suppliers must agree to receive Medicare payments via EFT, if not already receiving payment through EFT. In order to receive Medicare payments via EFT, providers and... Medicare payment via electronic funds transfer (EFT) at the time of enrollment, revalidation, change...

  4. 42 CFR 424.510 - Requirements for enrolling in the Medicare program.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... via EFT, providers and suppliers must agree to receive Medicare payments via EFT, if not already receiving payment through EFT. In order to receive Medicare payments via EFT, providers and suppliers must... Medicare payment via electronic funds transfer (EFT) at the time of enrollment, revalidation, change...

  5. 42 CFR 424.510 - Requirements for enrolling in the Medicare program.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... receiving payments via EFT, providers and suppliers must agree to receive Medicare payments via EFT, if not already receiving payment through EFT. In order to receive Medicare payments via EFT, providers and... Medicare payment via electronic funds transfer (EFT) at the time of enrollment, revalidation, change...

  6. 76 FR 40987 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-12

    ... July 12, 2011 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services... 12, 2011 / Proposed Rules#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare... only: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS...

  7. 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

  8. Medicare and Medicaid: Effects of Recent Legislation on Program and Beneficiary Costs. Report to the Chairman, Select Committee on Aging, House of Representatives.

    ERIC Educational Resources Information Center

    General Accounting Office, Washington, DC.

    The General Accounting Office reviewed the effects of major legislative changes on Medicare and Medicaid program costs and the out-of-pocket costs to the programs' beneficiaries. Of 30 laws that affected Medicare and Medicaid enacted by Congress during the period 1980 through 1986, 5 were estimated to have the greatest effects on the costs of the…

  9. 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.

  10. Medicare program; limitations on the reimbursement of nonphysician medical services--HCFA. Proposed rule.

    PubMed

    1985-08-16

    We are proposing to amend the regulations that govern determining reasonable charges for certain nonphysician medical services under the Medicare Supplementary Medical Insurance Program (Part B). An additional charge factor would be added to those currently taken into consideration by carriers in determining reasonable charges for nonphysician services, supplies and equipment that are reimbursed on a reasonable charge basis. This new factor, the "inflation-indexed charge," would represent the reasonable charge from the preceding fee screen year plus an inflation adjustment factor. For fee screen years beginning on or after October 1, 1986, the inflation adjustment factor to be used in determining the inflation-indexed charge would be the annual change in the level of the consumer price index for urban consumers for the 12-month period ending on March 31. For the fee screen year beginning on October 1, 1985, the inflation adjustment factor would be zero.

  11. Spurring enrollment in Medicare savings programs through a substitute for the asset test focused on investment income.

    PubMed

    Dorn, Stan; Shang, Baoping

    2012-02-01

    Fewer than one-third of eligible Medicare beneficiaries enroll in Medicare savings programs, which pay premiums and, in some cases, eliminate out-of-pocket cost sharing for poor and near-poor enrollees. Many beneficiaries don't participate in savings programs because they must complete a cumbersome application process, including a burdensome asset test. We demonstrate that a streamlined alternative to the asset test-allowing seniors to qualify for Medicare savings programs by providing evidence of limited assets or showing a lack of investment income-would permit 78 percent of currently eligible seniors to bypass the asset test entirely. This simplified approach would increase the number of beneficiaries who qualify for Medicare savings programs from the current 3.6 million seniors to 4.6 million. Such an alternative would keep benefits targeted to people with low assets, eliminate costly administrative expenses and obstacles to enrollment associated with the asset test, and avoid the much larger influx of seniors that would occur if the asset test were eliminated entirely.

  12. 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

    ... inpatient prospective payment system (IPPS) for hospitals that have residents in an approved GME program in...; Revisions to the Reductions and Increases to Hospitals' FTE Resident Caps for Graduate Medical Education... Medicare and Medicaid Extenders Act of 2010 relating to the treatment of teaching hospitals that are...

  13. 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

    ... services in a community” apply. (c) When the Inspector General proposes to exclude a nursing facility from... 42 Public Health 5 2010-10-01 2010-10-01 false Exclusion from participation in Medicare, Medicaid and all Federal health care programs. 1003.105 Section 1003.105 Public Health OFFICE OF...

  14. 78 FR 21314 - Medicare and State Health Care Programs: Fraud and Abuse; Electronic Health Records Safe Harbor...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-04-10

    ... HUMAN SERVICES Office of Inspector General 42 CFR Part 1001 RIN 0936-AA03 Medicare and State Health Care... technologies in the health care industry. In accordance with this authority, OIG published a safe harbor to... induce or reward the referral of business reimbursable under any of the Federal health care programs, as...

  15. 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...

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

    PubMed

    2016-08-05

    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).

  17. 76 FR 21091 - Privacy Act of 1974, as Amended; Computer Matching Program (SSA/Centers for Medicare & Medicaid...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-14

    ... 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 a...

  18. 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

  19. 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.

  20. MACRA, MIPS, and the New Medicare Quality Payment Program: An Update for Radiologists.

    PubMed

    Rosenkrantz, Andrew B; Nicola, Gregory N; Allen, Bibb; Hughes, Danny R; Hirsch, Joshua A

    2017-03-01

    The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 advances the goal of tying Medicare payments to quality and value. In April 2016, CMS published an initial proposed rule for MACRA, renaming it the Quality Payment Program (QPP). Under QPP, clinicians receive payments through either advanced alternative payment models or the Merit-Based Incentive Payment System (MIPS), a consolidation of existing federal performance programs that applies positive or negative adjustments to fee-for-service payments. Most physicians will participate in MIPS. This review highlights implications of the QPP and MIPS for radiologists. Although MIPS incorporates radiology-specific quality measures, radiologists will also be required to participate in other practice improvement activities, including patient engagement. Recognizing physicians' unique practice patterns, MIPS will provide special considerations in performance evaluation for physicians with limited face-to-face patient interaction. Although such considerations will affect radiologists' likelihood of success under QPP, many practitioners will be ineligible for the considerations under currently proposed criteria. Reporting using qualified clinical data registries will benefit radiologists' performance by allowing expanded arrays of MIPS and non-MIPS specialty-specific measures. A group practice reporting option will substantially reduce administrative burden but introduce new challenges by requiring uniform determination of patient-facing status and performance measurement for all of the group's physicians (diagnostic radiologists, interventional radiologists, and nonradiologists) under the same taxpayer identification number. Given that the initial MIPS performance period begins in 2017, radiologists must begin preparing for QPP and taking actions to ensure their future success under this new quality-based payment system.

  1. Primary care focus and utilization in the Medicare shared savings program accountable care organizations.

    PubMed

    Herrel, Lindsey A; Ayanian, John Z; Hawken, Scott R; Miller, David C

    2017-02-15

    Although Accountable Care Organizations (ACOs) are defined by the provision of primary care services, the relationship between the intensity of primary care and population-level utilization and costs of health care services has not been examined during early implementation of Medicare Shared Savings Program (MSSP) ACOs. Our objective was to evaluate the association between primary care focus and healthcare utilization and spending in the first performance period of the Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs). In this retrospective cohort study, we divided the 220 MSSP ACOs into quartiles of primary care focus based on the percentage of all ambulatory evaluation and management services delivered by a PCP (internist, family physician, or geriatrician). Using multivariable regression, we evaluated rates of utilization and spending during the initial performance period, adjusting for the percentage of non-white patients, region, number of months enrolled in the MSSP, number of beneficiary person years, percentage of dual eligible beneficiaries and percentage of beneficiaries over the age of 74. The proportion of ambulatory evaluation and management services delivered by a PCP ranged from <38% (lowest quartile, ACOs with least PCP focus) to >46% (highest quartile, ACOs with greatest PCP focus). ACOs in the highest quartile of PCP focus had higher adjusted rates of utilization of acute care hospital admissions (328 per 1000 person years vs 292 per 1000 person years, p = 0.01) and emergency department visits (756 vs 680 per 1000 person years, p = 0.02) compared with ACOs in the lowest quartile of PCP focus. ACOs in the highest quartile of PCP focus achieved no greater savings per beneficiary relative to their spending benchmarks ($142 above benchmark vs $87 below benchmark, p = 0.13). Primary care focus was not associated with increased savings or lower utilization of healthcare during the initial implementation of MSSP

  2. Medicare and Medicaid programs; changes in provider and supplier enrollment, ordering and referring, and documentation requirements; and changes in provider agreements. Interim final rule with comment period.

    PubMed

    2010-05-05

    This interim final rule with comment period implements several provisions set forth in the Patient Protection and Affordable Care Act (Affordable Care Act). It implements the provision which requires all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs. This interim final rule with comment period also requires physicians and eligible professionals to order and refer covered items and services for Medicare beneficiaries to be enrolled in Medicare. In addition, it adds requirements for providers, physicians, and other suppliers participating in the Medicare program to provide documentation on referrals to programs at high risk of waste and abuse, to include durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), home health services, and other items or services specified by the Secretary.

  3. Medicare and Medicaid program; regulatory provisions to promote program efficiency, transparency, and burden reduction. Final rule.

    PubMed

    2012-05-16

    This final rule identifies reforms in Medicare and Medicaid regulations that CMS has identified as unnecessary, obsolete, or excessively burdensome on health care providers and beneficiaries. This rule increases the ability of health care professionals to devote resources to improving patient care, by eliminating or reducing requirements that impede quality patient care or that divert providing high quality patient care. This is one of several rules that we are finalizing to achieve regulatory reforms under Executive Order 13563 on Improving Regulation and Regulatory Review and the Department's Plan for Retrospective Review of Existing Rules.

  4. 76 FR 78267 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-July Through September 2011

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-16

    ...) Facilities. XIII 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....

  5. 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...

  6. Impact of the Medicare Chronic Disease Management program on the conduct of Australian dietitians' private practices.

    PubMed

    Jansen, Sarah; Ball, Lauren; Lowe, Catherine

    2015-04-01

    This study explored private practice dietitians' perceptions of the impact of the Australian Chronic Disease Management (CDM) program on the conduct of their private practice, and the care provided to patients. Twenty-five accredited practising dietitians working in primary care participated in an individual semistructured telephone interview. Interview questions focussed on dietitians' perceptions of the proportion of patients receiving care through the CDM program, fee structures, adhering to reporting requirements and auditing. Transcript data were thematically analysed using a process of open coding. Half of the dietitians (12/25) reported that most of their patients (>75%) received care through the CDM program. Many dietitians (19/25) reported providing identical care to patients using the CDM program and private patients, but most (17/25) described spending substantially longer on administrative tasks for CDM patients. Dietitians experienced pressure from doctors and patients to keep their fees low or to bulk-bill patients using the CDM program. One-third of interviewed dietitians (8/25) expressed concern about the potential to be audited by Medicare. Recommendations to improve the CDM program included increasing the consultation length and subsequent rebate available for dietetic consultations, and increasing the number of consultations to align with dietetic best-practice guidelines. The CDM program creates challenges for dietitians working in primary care, including how to sustain the quality of patient-centred care and yet maintain equitable business practices. To ensure the CDM program appropriately assists patients to receive optimal care, further review of the CDM program within the scope of dietetics is required.

  7. Comparing mandated health care reforms: the Affordable Care Act, accountable care organizations, and the Medicare ESRD program.

    PubMed

    Watnick, Suzanne; Weiner, Daniel E; Shaffer, Rachel; Inrig, Jula; Moe, Sharon; Mehrotra, Rajnish

    2012-09-01

    In addition to extending health insurance coverage, the Affordable Care Act of 2010 aims to improve quality of care and contain costs. To this end, the act allowed introduction of bundled payments for a range of services, proposed the creation of accountable care organizations (ACOs), and established the Centers for Medicare and Medicaid Innovation to test new care delivery and payment models. The ACO program began April 1, 2012, along with demonstration projects for bundled payments for episodes of care in Medicaid. Yet even before many components of the Affordable Care Act are fully in place, the Medicare ESRD Program has instituted legislatively mandated changes for dialysis services that resemble many of these care delivery reform proposals. The ESRD program now operates under a fully bundled, case-mix adjusted prospective payment system and has implemented Medicare's first-ever mandatory pay-for-performance program: the ESRD Quality Incentive Program. As ACOs are developed, they may benefit from the nephrology community's experience with these relatively novel models of health care payment and delivery reform. Nephrologists are in a position to assure that the ACO development will benefit from the ESRD experience. This article reviews the new ESRD payment system and the Quality Incentive Program, comparing and contrasting them with ACOs. Better understanding of similarities and differences between the ESRD program and the ACO program will allow the nephrology community to have a more influential voice in shaping the future of health care delivery in the United States.

  8. Trends in end-of-life cancer care in the Medicare program.

    PubMed

    Wang, Shi-Yi; Hall, Jane; Pollack, Craig E; Adelson, Kerin; Bradley, Elizabeth H; Long, Jessica B; Gross, Cary P

    2016-03-01

    To examine contemporary trends in end-of-life cancer care and geographic variation of end-of-life care aggressiveness among Medicare beneficiaries. Using the Surveillance, Epidemiology, and End Results-Medicare data, we identified 132,051 beneficiaries who died as a result of cancer in 2006-2011. Aggressiveness of end-of-life care was measured by chemotherapy received within 14 days of death, >1 emergency department (ED) visit within 30 days of death, >1 hospitalization within 30 days of death, ≥1 intensive care unit (ICU) admission within 30 days of death, in-hospital death, or hospice enrollment ≤3 days before death. Using hierarchical generalized linear models, we assessed potentially aggressive end-of-life care adjusting for patient demographics, tumor characteristics, and hospital referral region (HRR)-level market factors. The proportion of beneficiaries receiving at least one potentially aggressive end-of-life intervention increased from 48.6% in 2006 to 50.5% in 2011 (P<.001). From 2006 to 2011, increases were apparent in repeated hospitalization (14.1% vs. 14.8%; P=.01), repeated ED visits (34.3% vs. 36.6%; P<.001), ICU admissions (16.2% vs. 21.3%; P<.001), and late hospice enrollment (11.2% vs. 12.9%; P<.001), whereas in-hospital death declined (23.5% vs. 20.9%; P<.001). End-of-life chemotherapy use (4.4% vs. 4.5%) did not change significantly over time (P=.12). The use of potentially aggressive end-of-life care varied substantially across HRRs, ranging from 40.3% to 58.3%. Few HRRs had a decrease in aggressive end-of-life care during the study period. Despite growing focus on providing appropriate end-of-life care, there has not been an improvement in aggressive end-of-life cancer care in the Medicare program. Copyright © 2016 Elsevier Inc. All rights reserved.

  9. Physician-Owned Surgical Hospitals Outperform Other Hospitals in Medicare Value-Based Purchasing Program.

    PubMed

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

    2016-10-01

    The Hospital Value-Based Purchasing Program measures value of care provided by participating Medicare hospitals and creates financial incentives for quality improvement and fosters increased transparency. Limited information is available comparing hospital performance across health care business models. The 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. Of 3,089 hospitals with total performance scores, categories of representative health care business models included 104 physician-owned surgical hospitals, 111 University HealthSystem Consortium, 14 US News & World Report Honor Roll hospitals, 33 Kaiser Permanente, and 124 Pioneer accountable care organization affiliated hospitals. Estimated mean total performance scores for physician-owned surgical hospitals (64.4; 95% CI, 61.83-66.38) and Kaiser Permanente (60.79; 95% CI, 56.56-65.03) were significantly higher compared with all remaining hospitals, and University HealthSystem Consortium 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 physician-owned surgical hospitals (mean 2.32; p < 0.0001), US News & World Report honorees (mean 2.24; p = 0.0140), and University HealthSystem Consortium members (mean 1.99; p < 0.0001), and Kaiser Permanente hospitals had lower case mix value (mean 1.54; p < 0.0001). Re-estimation of total performance scores did not change the original results after adjustment for differences in hospital case mix index. The Hospital Value-Based Purchasing Program revealed superior hospital performance associated with business model. Closer inspection of high-value hospitals can guide value improvement and policy-making decisions for all Medicare Value

  10. What Medicare Covers

    MedlinePlus

    ... your Medicare coverage — Original Medicare or a Medicare Advantage Plan (Part C). What Part A covers Medicare ... health plans cover Medicare health plans include Medicare Advantage, Medical Savings Account (MSA), Medicare Cost plans, PACE, ...

  11. 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

    ... Electronic clinical quality measures EHR Electronic health record EMTALA Emergency Medical Treatment and... December 10, 2013 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services...; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 405, 410, 411...

  12. 78 FR 47859 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-06

    ... August 6, 2013 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services... / Rules and Regulations#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid... regulations text, and revise and update quality measures and reporting requirements under the IRF quality...

  13. 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 and...

  14. 78 FR 32663 - Medicare Program; Notification of Closure of Teaching Hospitals and Opportunity To Apply for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-31

    ... Teaching Hospitals and Opportunity To Apply for Available Slots AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice announces the closure of two teaching hospitals and the initiation of an application process where hospitals must apply to the Centers for Medicare...

  15. 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 that...

  16. 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... Centers for Medicare & Medicaid Services (CMS), was created to develop and test innovative health...

  17. 42 CFR 424.510 - Requirements for enrolling in the Medicare program.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... contractors where the provider or supplier was already receiving payments via EFT, providers and suppliers must agree to receive Medicare payments via EFT, if not already receiving payment through EFT. In order to receive Medicare payments via EFT, providers and suppliers must submit the CMS-588 form....

  18. 76 FR 55917 - Medicare Program; Notification of Closure of St. Vincent's Medical Center; Extension of the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-09

    ... Medicare & Medicaid Services (CMS), HHS. ACTION: Notice of extension of the Deadline for Submission of... & Medicaid Services (CMS) to receive St. Vincent's Medical Center's full time equivalent (FTE) resident cap... apply to the Centers for Medicare & Medicaid Services (CMS) to receive St. Vincent's Medical...

  19. 76 FR 26363 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-06

    ... 6, 2011 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services 42...; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 413, 424, and... the United States Department of Health and Human Services (the Secretary) and other entities regarding...

  20. Medicare and Medicaid programs; regulatory provisions to promote program efficiency, transparency, and burden reduction; Part II.

    PubMed

    2014-05-12

    This final rule reforms Medicare regulations that CMS has identified as unnecessary, obsolete, or excessively burdensome on health care providers and suppliers, as well as certain regulations under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). This final rule also increases the ability of health care professionals to devote resources to improving patient care, by eliminating or reducing requirements that impede quality patient care or that divert resources away from providing high quality patient care. We are issuing this rule to achieve regulatory reforms under Executive Order 13563 on improving regulation and regulatory review and the Department's plan for retrospective review of existing rules. This is the latest in a series of rules developed by CMS over the last 5 years to reform existing rules to reduce unnecessary costs and increase flexibility for health care providers.

  1. Medicare and Medicaid programs; changes in provider and supplier enrollment, ordering and referring, and documentation requirements; and changes in provider agreements. Final rule.

    PubMed

    2012-04-27

    This final rule finalizes several provisions of the Affordable Care Act implemented in the May 5, 2010 interim final rule with comment period. It requires all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs. In addition, it requires physicians and other professionals who are permitted to order and certify covered items and services for Medicare beneficiaries to be enrolled in Medicare. Finally, it mandates document retention and provision requirements on providers and supplier that order and certify items and services for Medicare beneficiaries.

  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.

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

    PubMed

    2014-11-06

    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.

  4. 75 FR 40039 - Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-13

    ...This proposed rule addresses proposed changes to the physician fee schedule and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. It also addresses, implements or discusses certain provisions of both the Affordable Care Act and the Medicare Improvements for Patients and Providers Act of 2008. In addition, this proposed rule discusses payments under the Ambulance Fee Schedule, Clinical Laboratory Fee Schedule, payments to ESRD facilities, and payments for Part B drugs. Finally, the proposed rule includes a discussion regarding the Chiropractic Services Demonstration program, the Competitive Bidding Program for Durable Medical Equipment and Provider and Supplier Enrollment Issues associated with Air Ambulances. (See the Table of Contents for a listing of the specific issues addressed in this proposed rule.)

  5. Catching flies with vinegar: a critique of the Centers for Medicare and Medicaid self-disclosure program.

    PubMed

    Veilleux, Jean Wright

    2012-01-01

    This Article argues that the current approach of the Department of Health and Human Services and the Centers for Medicare and Medicaid Services (CMS) to enforcement of the Ethics in Patient Referrals Act (the "Stark Law") is unnecessarily punitive and discourages health-care providers from self-disclosing even very minor violations of the Stark Law. This Article suggests a number of specific changes to encourage provider self-disclosure and proposes that CMS create a demonstration project under the authority of the Patient Protection and Affordable Care Act to test the reforms. A demonstration project provides the perfect vehicle to prove that increased self-disclosure protocols for the Stark Law can decrease the government's costs of enforcement, improve program integrity, and encourage providers to deal responsibly with the inevitable minor lapses in compliance that arise in such an enormous government program as Medicare.

  6. 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

    ... Authority of the Utilization Review Accreditation Commission for Medicare Advantage Health Maintenance... ``deeming authority'' of the Utilization Review Accreditation Commission (URAC) for Health Maintenance... Utilization Review Accreditation Commission (URAC) was approved as a CMS approved accreditation organization...

  7. 77 FR 47223 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-07

    ...This notice updates the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs). These changes are applicable to IPF discharges occurring during the fiscal year (FY) beginning October 1, 2012 through September 30,...

  8. 78 FR 43281 - Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule, Clinical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-19

    ... the PPIS data with Medicare-recognized specialty data. We do not use the PPIS data for sleep medicine... sleep medicine for CY 2015 when we will have a full year of data to make the calculations. Previously...

  9. 78 FR 16632 - Medicare Program; Part B Inpatient Billing in Hospitals

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-18

    ... therapy, including materials and services of technicians. Surgical dressings, and splints, casts, and... the patient's physical condition. Outpatient physical therapy, outpatient speech-language pathology services, and outpatient occupational therapy (see the Medicare Benefit Policy Manual, Chapter...

  10. 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...

  11. Medicare program; limitations on reimbursement of nonphysician medical services--HCFA. Final rule.

    PubMed

    1985-10-01

    We are amending the regulations that govern the determination of reasonable charges for certain nonphysician medical services under the Medicare Supplementary Medical Insurance Program (Part B). An additional charge factor is added to those currently taken into consideration by carriers in determining reasonable charges for nonphysician services, supplies and equipment that are reimbursed on a reasonable charge basis. This new factor, the "inflation-indexed charge," represents the lowest of the fee screens from the preceding fee screen year as updated by an inflation adjustment factor. For fee screen years beginning on or after October 1, 1986, the inflation adjustment factor to be used in determining the inflation-indexed charge is the annual change in the level of the consumer price index for urban consumers for the 12-month period ending on March 31 of each year. For services, supplies, and equipment furnished during Federal fiscal year (FY) 1986 only, the inflation adjustment factor is zero, which results in the lowest of the FY 1986 fee screens for nonphysician medical services and items being effectively capped at FY 1985 levels.

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

    PubMed

    2014-08-06

    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.

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

    PubMed

    2003-12-05

    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.

  14. 75 FR 49029 - Medicare Program; End-Stage Renal Disease Prospective Payment System

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-12

    ...This final rule implements a case-mix adjusted bundled prospective payment system (PPS) for Medicare outpatient end-stage renal disease (ESRD) dialysis facilities beginning January 1, 2011 (ESRD PPS), in compliance with the statutory requirement of the Medicare Improvements for Patients and Providers Act (MIPPA), enacted July 15, 2008. This ESRD PPS also replaces the current basic case-mix adjusted composite payment system and the methodologies for the reimbursement of separately billable outpatient ESRD services.

  15. 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.

  16. Medicare program; demonstration project to develop a uniform cost reporting system for hospitals--HCFA. Interim final rule with comment period.

    PubMed

    1989-08-25

    This interim final rule with comment period implements the provisions of section 4007(c) of the Omnibus Budget Reconciliation Act of 1987, as amended by section 411(b)(6)(C) of the Medicare Catastrophic Coverage Act of 1988, which require that the Secretary conduct a demonstration project to develop a uniform cost reporting system for hospitals under the Medicare program. Under this rule, all hospitals in the States of California and Colorado are required to participate in this demonstration project. For the duration of the demonstration, those hospitals are required to submit the cost report currently required under Medicare regulations and additional worksheets specifically developed for the demonstration in a uniform, electronic format.

  17. 76 FR 2453 - Medicare Program; Hospital Inpatient Value-Based Purchasing Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-01-13

    ... quickly as possible. We believe that speed of implementation is a critical factor in the success and... Hospital IQR program. The survey contains 18 core questions about critical aspects of patients' hospital...

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

    PubMed

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

    2016-06-01

    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. 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. Retrospective matched case control analysis examined medical, pharmaceutical, and capitation expenses after an offset by premium revenue. 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. 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 < 0.001) during the last three months of life. Members with advanced

  19. Medicare program; limitation on recoupment of provider and supplier overpayments. Final rule.

    PubMed

    2009-09-16

    This final rule implements a provision of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) which prohibits recouping Medicare overpayments from a provider or supplier that seeks a reconsideration from a Qualified Independent Contractor (QIC). This provision changes how interest is to be paid to a provider or supplier whose overpayment is reversed at subsequent administrative or judicial levels of appeal. This final rule defines the overpayments to which the limitation applies, how the limitation works in concert with the appeals process, and the change in our obligation to pay interest to a provider or supplier whose appeal is successful at levels above the QIC.

  20. Evaluation of an integrated adherence program aimed to increase Medicare Part D star rating measures.

    PubMed

    Leslie, R Scott; Tirado, Breanne; Patel, Bimal V; Rein, Philip J

    2014-12-01

    The Centers for Medicare Medicaid Services (CMS) Plan Quality and Performance Program, or Star Ratings Program, allows Medicare beneficiaries to compare quality of care among available Medicare Advantage prescription drug (MA-PD) plans and stand-alone prescription drug plans (PDPs). Health plans have increased intervention efforts and applied existing care management infrastructure as an approach to improving member medication adherence and subsequent Part D star rating performance. Independent Care Health Plan (iCare), an MA-PD plan; MedImpact Healthcare Systems, Inc. (MedImpact), a pharmacy benefits manager; and US MED, a mail order pharmacy, partnered to engage and enroll iCare's dual-eligible special needs population in an intervention designed to improve patient medication adherence and health plan performance for 3 Part D patient safety outcome measures: Medication Adherence for Oral Diabetes Medications (ODM), Medication Adherence for Hypertension (HTN), and Medication Adherence for Cholesterol (CHOL). To (a) assess the effectiveness of a coordinated member-directed medication adherence intervention and (b) determine the overall impact of the intervention on adherence rates and CMS Part D star rating adherence measures.  Administrative pharmacy claims and health plan eligibility data from MedImpact's databases were used to identify members using 3 target medication classes. Adherence was estimated by the proportion of days covered (PDC) for all members. Those members considered at high risk for nonadherence were prioritized for care management services. Risk factors were based on members' use of more than 1 target medication class, newly started therapy, and suboptimal adherence (PDC  less than  80%) in the most recent 6-month period. Data files listing member adherence rates and contact information were formatted and loaded monthly into iCare's care management system, which triggered an alert for care coordinators to counsel members on the importance

  1. Outcomes of a Digital Health Program With Human Coaching for Diabetes Risk Reduction in a Medicare Population.

    PubMed

    Castro Sweet, Cynthia M; Chiguluri, Vinay; Gumpina, Rajiv; Abbott, Paul; Madero, Erica N; Payne, Mike; Happe, Laura; Matanich, Roger; Renda, Andrew; Prewitt, Todd

    2017-01-01

    To examine the outcomes of a Medicare population who participated in a program combining digital health with human coaching for diabetes risk reduction. People at risk for diabetes enrolled in a program combining digital health with human coaching. Participation and health outcomes were examined at 16 weeks and 6 and 12 months. A total of 501 participants enrolled; 92% completed at least nine of 16 core lessons. Participants averaged 19 of 31 possible opportunities for weekly program engagement. At 12 months, participants lost 7.5% ( SD = 7.8%) of initial body weight; among participants with clinical data, glucose control improved (glycosylated hemoglobin [HbA1c] change = -0.14%, p = .001) and total cholesterol decreased (-7.08 mg/dL, p = .008). Self-reported well-being, depression, and self-care improved ( p < .0001). This Medicare population demonstrated sustained program engagement and improved weight, health, and well-being. The findings support digital programs with human coaching for reducing chronic disease risk among older adults.

  2. 76 FR 67991 - Medicare Program; Final Waivers in Connection With the Shared Savings Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-02

    ... organizations (ACOs) under section 1899 of the Social Security Act (the Act) (the Shared Savings Program... the Physician Self-Referral Law is the responsibility of CMS; the OIG is responsible for enforcement of the CMP provisions under the Physician Self-Referral Law. OIG shares responsibility for the...

  3. 76 FR 31547 - Medicare Program; Proposed Changes to the Electronic Prescribing (eRx) Incentive Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-01

    ... practice (for example, a nurse practitioner who may not write prescriptions under his or her own NPI, a... Program. Many stakeholders voiced concerns about differences between the requirements under the eRx... not a physician (includes doctors of medicine, doctors of osteopathy, and podiatrists),...

  4. 75 FR 58203 - Medicare, Medicaid, and Children's Health Insurance Programs; Additional Screening Requirements...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-09-23

    ... enrollment and Medicaid payment suspension issues. Joseph Strazzire (410) 786-2775 for Medicare payment... Practitioner Data Bank (NPDB), accreditation status of institutional providers and suppliers with national... Provider Identifier (NPI), the National Practitioner Data Bank (NPDB) licensure, an OIG exclusion,...

  5. 75 FR 42885 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-22

    ... System and Consolidated Billing for Skilled Nursing Facilities for FY 2011; Notice #0;#0;Federal Register... Consolidated Billing for Skilled Nursing Facilities for FY 2011 AGENCY: Centers for Medicare & Medicaid... forth an update to the payment rates used under the prospective payment system for skilled nursing...

  6. 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

    ...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. Some of the proposed changes implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and......

  7. 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

    ...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. Some of the changes implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation......

  8. 76 FR 51475 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-18

    ...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 statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010......

  9. 76 FR 25787 - Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-05

    ...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 and to implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act......

  10. 78 FR 59701 - Medicare Program; Approval of Accrediting Organization for Suppliers of Advanced Diagnostic...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-27

    ... Medicare & Medicaid Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice announces our approval of Rad... from RadSite TM to be considered as a designated accreditation organization for advanced diagnostic... following information specified in 42 CFR 414.68(c): A list of the categories of advanced diagnostic...

  11. 77 FR 34047 - Medicare Program; Proposal Evaluation Criteria and Standards for End Stage Renal Disease (ESRD...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-08

    ... and Standards for End Stage Renal Disease (ESRD) Network Organizations AGENCY: Centers for Medicare... procedures we will use to evaluate an End-Stage Renal Disease (ESRD) Network Organization's capabilities to perform, and actual performance of, the duties and functions under the ESRD Network Statement of Work (SOW...

  12. 76 FR 44010 - Medicare Program; Hospice Wage Index for Fiscal Year 2012; Correction

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-22

    ... Index for Fiscal Year 2012; Correction AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS... appeared in the notice of CMS ruling published in the Federal Register on May 9, 2011 entitled ``Hospice Wage Index for Fiscal Year 2012''. DATES: Effective Date: This document is effective on May 9, 2011...

  13. 77 FR 44242 - Medicare Program; Hospice Wage Index for Fiscal Year 2013

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-27

    ... ``CBSA-based'' refers to wage index values and designations based on the OMB revised MSA designations in... index. In the August 8, 1997 Federal Register (62 FR 42860), we published a final rule implementing a...). The reduction in overall Medicare payments if a new wage index were adopted was noted in the November...

  14. 75 FR 76293 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-08

    ... Requirements for Home Health Agencies and Hospices; Correction AGENCY: Centers for Medicare & Medicaid Services... Calendar Year 2011; Changes in Certification Requirements for Home Health Agencies and Hospices'' final... Certification Requirements for Home Health Agencies and Hospices'' final rule. Accordingly, the corrections are...

  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 agreement...

  16. 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. The...

  17. 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 agreement...

  18. 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 the...

  19. 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

    ... Appointments to the Advisory Panel on Hospital Outpatient Payment AGENCY: Centers for Medicare & Medicaid... announces six new membership appointments to the Advisory Panel on Hospital Outpatient Payment (HOP, the... prepare the annual updates for the hospital outpatient prospective payment system. FOR FURTHER INFORMATION...

  20. 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

    ...). A QMB is an individual entitled to Medicare Part A with income at or below 100 percent of the... income is above 100 percent of the FPL and does not exceed 120 percent of the FPL. Effective January 1, 2010, the resource limits for a QMB, SLMB, and QI are $6,600 for a single person and $9,910 for...

  1. 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

    ...This notice announces a meeting of the Advisory Panel on Outreach and Education (APOE) (the Panel) in accordance with the Federal Advisory Committee Act. The Panel advises and makes recommendations to the Secretary of Health and Human Services and the Administrator of the Centers for Medicare & Medicaid Services on opportunities to enhance the effectiveness of consumer education strategies......

  2. 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

    ...This notice announces a meeting of the Advisory Panel on Outreach and Education (APOE) (the Panel) in accordance with the Federal Advisory Committee Act. The Panel advises and makes recommendations to the Secretary of Health and Human Services and the Administrator of the Centers for Medicare & Medicaid Services on opportunities to enhance the effectiveness of consumer education strategies......

  3. 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

    ...This notice announces a meeting of the Advisory Panel on Outreach and Education (APOE) (the Panel) in accordance with the Federal Advisory Committee Act. The Panel advises and makes recommendations to the Secretary of Health and Human Services and the Administrator of the Centers for Medicare & Medicaid Services on opportunities to enhance the effectiveness of consumer education strategies......

  4. 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

    ...This notice announces a meeting of the Advisory Panel on Outreach and Education (APOE) (the Panel) in accordance with the Federal Advisory Committee Act. The Panel advises and makes recommendations to the Secretary of Health and Human Services and the Administrator of the Centers for Medicare & Medicaid Services on opportunities to enhance the effectiveness of consumer education strategies......

  5. 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

    ...This notice announces a meeting of the Advisory Panel on Outreach and Education (APOE) (the Panel) in accordance with the Federal Advisory Committee Act. The Panel advises and makes recommendations to the Secretary of Health and Human Services and the Administrator of the Centers for Medicare & Medicaid Services on opportunities to enhance the effectiveness of consumer education strategies......

  6. 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

    ...This notice announces a meeting of the Advisory Panel on Outreach and Education (APOE) (the Panel) in accordance with the Federal Advisory Committee Act. The Panel advises and makes recommendations to the Secretary of Health and Human Services and the Administrator of the Centers for Medicare & Medicaid Services on opportunities to enhance the effectiveness of consumer education strategies......

  7. 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

    ...This notice announces that the charter of the Advisory Panel on Medicare Education (APME), as renamed the Advisory Panel on Outreach and Education (APOE), has been renewed and the scope of the charter has been expanded. It also requests nominations for individuals to serve on the...

  8. 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

    ...This notice announces a meeting of the Advisory Panel on Outreach and Education (APOE) (the Panel) in accordance with the Federal Advisory Committee Act. The Panel advises and makes recommendations to the Secretary of Health and Human Services and the Administrator of the Centers for Medicare & Medicaid Services on opportunities to enhance the effectiveness of consumer education strategies......

  9. 42 CFR 424.535 - Revocation of enrollment in the Medicare program.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... regulations and the Department of Health and Human Services nonprocurement common rule at 45 CFR part 76. (3... regulations.) (5) On-site review. CMS determines, upon on-site review, that the provider or supplier is no... requirements under statute or regulation to supervise treatment of, or to provide Medicare covered items or...

  10. 76 FR 48485 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-08

    ... Nursing Facilities for FY 2012; Final Rule #0;#0;Federal Register / Vol. 76 , No. 152 / Monday, August 8... Consolidated Billing for Skilled Nursing Facilities for FY 2012 AGENCY: Centers for Medicare & Medicaid... prospective payment system for skilled nursing facilities (SNFs) for fiscal year 2012. In addition,...

  11. 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: Notice...

  12. 42 CFR 424.535 - Revocation of enrollment and billing privileges in the Medicare program.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... enrolled provider or supplier's Medicare billing privileges and any corresponding provider agreement or supplier agreement for the following reasons: (1) Noncompliance. The provider or supplier is determined not... application applicable for its provider or supplier type, and has not submitted a plan of corrective action as...

  13. 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

    ... Appointments to the Advisory Panel on Ambulatory Payment Classification Groups AGENCY: Centers for Medicare... notice announces two new membership appointments to the Advisory Panel on Ambulatory Payment Classification (APC) Groups (the Panel). The two appointments are for 4-year periods through January 31, 2016...

  14. 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 at...

  15. 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....

  16. 75 FR 23105 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System Payment-Update for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-04-30

    ...This notice updates the payment rates for the Medicare prospective payment system (PPS) for inpatient psychiatric hospital services provided by inpatient psychiatric facilities (IPFs). These changes are applicable to IPF discharges occurring during the rate year beginning July 1, 2010 through June 30, 2011. We are also responding to comments on the IPF PPS teaching adjustment and the market......

  17. 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... acknowledges the receipt of an application from the Joint Commission for recognition as a national accrediting... application. The purpose of this proposed notice is to inform the public of the Joint Commission's request...

  18. 75 FR 3743 - Medicare Program; Meeting of the Practicing Physicians Advisory Council, March 8, 2010

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-01-22

    ... Physicians Advisory Council, March 8, 2010 AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS... meeting is open to the public. DATES: Meeting Date: Monday, March 8, 2010, from 8:30 a.m. to 5 p.m., eastern standard time (e.s.t.). Deadline for Registration without Oral Presentation: Thursday, March 4...

  19. 76 FR 25459 - Medicare & Medicaid Programs; Influenza Vaccination Standard for Certain Participating Providers...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-04

    ...This proposed rule would require certain Medicare and Medicaid providers and suppliers to offer all patients an annual influenza vaccination, unless medically contraindicated or unless the patient or patient's representative or surrogate declined vaccination. This proposed rule is intended to increase the number of patients receiving annual vaccination against seasonal influenza and to......

  20. 77 FR 67067 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2013...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-08

    ... November 8, 2012 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services..., November 8, 2012 / Rules and Regulations#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for..., such as the number of therapy visits, as predictors in the model, as such variables are provider...

  1. 78 FR 20564 - Medicare and Medicaid Programs; Survey, Certification and Enforcement Procedures

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-04-05

    ...This proposed rule would revise the survey, certification, and enforcement procedures related to CMS oversight of national accreditation organizations (AOs). These revisions would implement certain provisions under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). The proposed revisions would also clarify and strengthen our oversight of AOs that apply for, and are......

  2. 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...

  3. 78 FR 29139 - Medicare Program; Bundled Payments for Care Improvement Model 1 Open Period

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-17

    ... committed to achieving better health, better care, and lower costs through continuous improvement for... costs through continuous improvement. Create a cycle that leads to continually decreasing the cost of an... Improvement Model 1 Open Period AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice...

  4. 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

    ... 489.102); (5) ensure the patient's right to have a family member or representative of his or her... patient whom to contact at the hospital to file a grievance; and (7) ensure that the hospital's grievance...). (Additional information regarding the Medicare beneficiary patient's right to file a grievance or a complaint...

  5. 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...

  6. 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

    ..... (410) 786-7205 Volume Reduction Surgery Facilities. XIV Medicare-Approved Kate Tillman, RN, (410) 786-9252 Bariatric Surgery MAS. Facilities. XV Fluorodeoxyglucose Stuart Caplan, RN, (410) 786-8564...

  7. 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

    ... JoAnna 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...

  8. 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

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

  9. 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.

  10. Medicare program; performance criteria and statistical standards for evaluating intermediary performance during fiscal year 1984--HCFA. Proposed notice.

    PubMed

    1984-04-12

    This notice would update the performance criteria and statistical standards to be used for evaluating the performance of fiscal intermediaries in the administration of the Medicare program for fiscal year 1984. The performance criteria and statistical standards have been developed from available statistical data contained in routine intermediary reports; past performance results for the intermediaries; and from substantive input from the intermediary community, HCFA central office and HCFA regional offices. The results of these evaluations would be considered whenever we enter into, renew, or terminate an intermediary agreement; assign or reassign providers of services to an intermediary; or designate regional or national intermediaries.

  11. Medicare, Medicaid, Children's Health Insurance Programs; transparency reports and reporting of physician ownership or investment interests. Final rule.

    PubMed

    2013-02-08

    This final rule will 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 purchasing organizations (GPOs) are required to report annually certain physician ownership or investment interests. The Secretary is required to publish applicable manufacturers' and applicable GPOs' submitted payment and ownership information on a public Web site.

  12. Low-Cost Generic Program Use by Medicare Beneficiaries: Implications for Medication Exposure Misclassification in Administrative Claims Data.

    PubMed

    Pauly, Nathan J; Talbert, Jeffery C; Brown, Joshua

    2016-06-01

    Administrative claims data are used for a wide variety of research and quality assurance purposes; however, they are prone to medication exposure misclassification if medications are purchased without using an insurance benefit. Low-cost generic drug programs (LCGPs) offered at major chain pharmacies are a relatively new and sparsely investigated source of exposure misclassification. LCGP medications are often purchased out of pocket; thus, a pharmacy claim may never be submitted, and the exposure may go unobserved in claims data. As heavy users of medications, Medicare beneficiaries have much to gain from the affordable medications offered through LCGPs. This use may put them at increased risk of exposure misclassification in claims data. Many high-risk medications (HRMs) and medications tracked for adherence and utilization quality metrics are available through LCGPs, and exposure misclassification of these medications may impact the quality assurance efforts reliant on administrative claims data. Presently, there is little information regarding the use of these programs among a geriatric population. To (a) quantify the prevalence of LCGP users in a nationally representative population of Medicare beneficiaries; (b) compare clinical and demographic characteristics of LCGP users and nonusers; (c) assess determinants of LCGP use and medications acquired through these programs; and (d) analyze patterns of LCGP use during the years 2007-2012. This study relied on data from the Medical Expenditure Panel Survey (MEPS) from 2007 to 2012. The first 3 objectives were completed with a cohort of individuals in the most recent MEPS panel, while the fourth objective was completed with a separate cohort composed of individuals who participated in MEPS from 2007 to 2012. Inclusion in either study cohort required that individuals were Medicare beneficiaries aged 65 years or greater, used at least 1 prescription drug during their 2-year panel period, and participated in all 5

  13. Medicare program; civil money penalties, assessments, and revised sanction authorities. Final rule with comment period.

    PubMed

    2001-09-28

    This final rule with comment period is a technical rule that updates our civil money penalty (CMP) regulations to add CMP authorities already enacted as part of the Balanced Budget Act of 1997 (BBA) and delegated to us. The rule delineates our authority to assess penalties for: failure to bill outpatient therapy services or comprehensive outpatient rehabilitation services (CORS) on an assignment-related basis, failure to bill ambulance services on an assignment-related basis, failure to provide an itemized statement for Medicare items and services to a Medicare beneficiary upon his/her request, and failure of physicians or nonphysician practitioners to provide diagnostic codes for items or services they furnish or failure to provide this information to the entity furnishing the item or service ordered by the practitioner. The rule also contains technical changes to further conform our current CMP rules to changes in the statute enacted by the BBA.

  14. 75 FR 46169 - Medicare Program; Proposed Changes to the Hospital Outpatient Prospective Payment System and CY...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-03

    ...This proposed rule would revise the Medicare hospital outpatient prospective payment system (OPPS) to implement applicable statutory requirements and changes arising from our continuing experience with this system and to implement certain provisions of the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (Affordable Care Act). In this proposed rule, we describe the proposed changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These proposed changes would be applicable to services furnished on or after January 1, 2011. In addition, this proposed rule would update the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system and to implement certain provisions of the Affordable Care Act. In this proposed rule, we set forth the proposed applicable relative payment weights and amounts for services furnished in ASCs, specific HCPCS codes to which these proposed changes would apply, and other pertinent ratesetting information for the CY 2011 ASC payment system. These proposed changes would be applicable to services furnished on or after January 1, 2011. This proposed rule also includes proposals to implement provisions of the Affordable Care Act relating to payments to hospitals for direct graduate medical education (GME) and indirect medical education (IME) costs; and new limitations on certain physician referrals to hospitals in which they have an ownership or investment interest.

  15. 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. Project HOPE—The People-to-People Health Foundation, Inc.

  16. Association of Hospital Participation in a Quality Reporting Program with Surgical Outcomes and Expenditures for Medicare Beneficiaries

    PubMed Central

    Osborne, Nicholas H.; Nicholas, Lauren H.; Ryan, Andrew M.; Thumma, Jyothi R.; Dimick, Justin B.

    2015-01-01

    Importance The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) provides feedback to hospitals on risk-adjusted outcomes. It is not known if NSQIP participation improves outcomes and reduces costs relative to non-participating hospitals. Objective To evaluate the association of enrollment and participation in the ACS-NSQIP with outcomes and Medicare payments compared to control hospitals that did not participate in this program. Design Quasi-experimental study using national Medicare data (2003 to 2012) for patients undergoing general and vascular surgery. A difference-in-difference analytic approach was used to evaluate whether participation in ACS-NSQIP was associated with improved outcomes and reduced Medicare payments compared to non-participating hospitals that were otherwise similar. Control hospitals were selected using propensity score matching (2 control hospitals for each ACS-NSQIP hospital). Setting and Participants 263 hospitals participating in ACS NSQIP and 526 non-participating hospitals and a total of 1,226,479 patients undergoing general and vascular surgical procedures Main Outcome Measures 30-day mortality, serious complications (e.g. pneumonia, myocardial infarction, or acute renal failure and a length of stay > 75th percentile), reoperation and readmission within 30 days. Hospital costs were assessed using price-standardized Medicare payments during hospitalization and 30 days post-discharge. Results After accounting for patient factors and preexisting time trends toward improved outcomes, there were no statistically significant improvements in outcomes at 1-, 2- or 3-years after (vs before) enrollment in ACS-NSQIP. For example, in analyses comparing outcomes at 3-years after (vs. before) enrollment, there were no statistically significant differences in risk-adjusted 30-day mortality (4.3% vs. 4.5%, Relative risk [RR] 0.96, 95% CI, 0.89–1.03), serious complications (11.1% vs. 11.0%, RR 0.96, 95% CI, 0

  17. 76 FR 42771 - Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-19

    ...This proposed rule addresses changes to the physician fee schedule and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. It also addresses, implements or discusses certain provisions 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) and the Medicare Improvements for Patients and Providers Act of 2008. In addition, this proposed rule discusses payments for Part B drugs; Physician Quality Reporting System; the Electronic Prescribing (eRx) Incentive Program; the Physician Resource-Use Feedback Program and the value modifier; productivity adjustment for ambulatory surgical center payment system and the ambulance, clinical laboratory, and durable medical equipment prosthetics orthotics and supplies (DMEPOS) fee schedules; and other Part B related issues. (See the Table of Contents for a listing of the specific issues addressed in this proposed rule.)

  18. Components of Medicare reimbursement.

    PubMed

    Malatestinic, William; Braun, LeeAnn; Jorgenson, James A; Eskew, Jim

    2003-11-01

    The history of the Medicare reimbursement system, how it works, and issues related to fraud and abuse are discussed. The statutory charge of Medicare is to ensure adequate reimbursement through a Prospective Payment System (PPS) to cover the costs for providing a given service to Medicare beneficiaries. The PPS was introduced as a way to change hospital behavior through financial incentives that encourage cost-efficient management of resources. The system utilizes a rate of payment in which a hospital is paid a fixed amount that is expected to cover the costs of care while treating a typical patient in a particular diagnosis-related group (DRG). The PPS uses DRGs as payment categories and Major Diagnostic Categories (MDCs) for classifying the DRGs into similar groupings. One of the first steps in DRG assignment is identification of the principal diagnosis represented by an International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code. The secondary diagnoses (referred to as complications or comorbidities), presence or absence of surgery, age of the patient, and discharge status are the other pieces of information making up assignment of a specific DRG to a patient. A basic knowledge of the Medicare program will help in the understanding of how hospitals will be reimbursed for patient care, as well as how changes in Medicare payment may affect reimbursement. Medicare is one of the largest health insurance providers in the United States. A basic understanding of the Medicare system will provide valuable insights into Medicare reimbursement and the influence it has on a hospital's bottom line.

  19. 78 FR 40271 - Medicare and Medicaid Programs; Home Health Prospective Payment System Rate Update for CY 2014...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-03

    ... July 3, 2013 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services... Rules#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR... Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1450-P, P.O. Box 8016...

  20. Impact of a National Bariatric Surgery Center of Excellence Program on Medicare Expenditures.

    PubMed

    Scally, Christopher P; Shih, Terry; Thumma, Jyothi R; Dimick, Justin B

    2016-04-01

    In 2006, the Centers for Medicare and Medicaid Services (CMS) issued a national coverage decision restricting bariatric surgery to designated centers of excellence (COE). Although prior studies show mixed results on complications and reoperations, no prior studies evaluated whether this policy reduced spending for bariatric surgery. We sought to determine whether the coverage restriction to COE-designated hospitals was associated with lower payments from CMS. We utilized national Medicare claims data to examine 30-day episode payments for patients who underwent bariatric surgery from 2003 to 2010 (n = 72,117 patients). We performed an interrupted time series analysis, adjusting for patient factors, preexisting temporal trends, and changes in procedure type, to determine whether the 2006 coverage decision was associated with lower Medicare payments above and beyond any existing secular trends. For these analyses, we included payments for the index hospitalization, readmissions, physician services, and post-discharge ancillary care. After accounting for patient factors, preexisting temporal trends, and changes in procedure type, there were no statistically significant improvements in episode payments after (US$14,720) vs before (US$14,283) the coverage decision (+US$437, 95% CI, -US$10 to +US$883). In a direct assessment of payments for COE-designated hospitals (US$14,481) vs. non-COE-designated hospitals (US$14,756), no significant differences in episode payments were found (-US$275, 95% CI, -US$696 to +US$145). We found no significant reductions in 30-day episode payments after vs before restricting coverage to COE-designated hospitals. Center of excellence status is not a proxy for savings to the healthcare system.

  1. 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

  2. 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

    ... facilities. Section 1871(c) of the Social Security Act requires that we publish a list of Medicare issuances..., 1902, and related provisions of the Social Security Act (the Act). We also issue various manuals... Social Security Laws are current as of January 1, 2005. (Updated titles of the Social Security Laws are...

  3. 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

    ... notice is a list of the American College of Cardiology's National Cardiovascular Data registry sites... concerning Medicare's recognition of the American College of Cardiology-National Cardiovascular Data Registry... list of the American College of Cardiology's National Cardiovascular Data registry sites. We...

  4. 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

    ..., active CMS coverage-related guidance documents, and special one-time notices regarding national coverage... clinical trials for fluorodeoxyglucose positron emissions tomogrogphy for dementia, and a list of Medicare... substantive and interpretive regulations (proposed and final) published during this 3-month time frame. FOR...

  5. 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

  6. Predicting the Incremental Hospital Cost of Adverse Events Among Medicare Beneficiaries in the Comprehensive Joint Replacement Program During Fiscal Year 2014.

    PubMed

    Culler, Steven D; Jevsevar, David S; McGuire, Kevin J; Shea, Kevin G; Little, Kenneth M; Schlosser, Michael J

    2017-06-01

    The Medicare program's Comprehensive Care for Joint Replacement (CJR) payment model places hospitals at financial risk for the treatment cost of Medicare beneficiaries (MBs) undergoing lower extremity joint replacement (LEJR). This study uses Medicare Provider Analysis and Review File and identified 674,777 MBs with LEJR procedure during fiscal year 2014. Adverse events (death, acute myocardial infarction, pneumonia, sepsis or shock, surgical site bleeding, pulmonary embolism, mechanical complications, and periprosthetic joint infection) were studied. Multivariable regressions were modeled to estimate the incremental hospital cost of treating each adverse event. The risk-adjusted estimated hospital cost of treating adverse events varied from a high of $29,061 (MBs experiencing hip fracture and joint infection) to a low of $6308 (MBs without hip fracture that experienced pulmonary embolism). Avoidance of adverse events in the LEJR hospitalization will play an important role in managing episode hospital costs in the Comprehensive Care for Joint Replacement program. Copyright © 2017 Elsevier Inc. All rights reserved.

  7. Does It Pay to Penalize Hospitals for Excess Readmissions? Intended and Unintended Consequences of Medicare's Hospital Readmissions Reductions Program.

    PubMed

    Mellor, Jennifer; Daly, Michael; Smith, Molly

    2016-07-15

    To incentivize hospitals to provide better quality care at a lower cost, the Affordable Care Act of 2010 included the Hospital Readmissions Reduction Program (HRRP), which reduces payments to hospitals with excess 30-day readmissions for Medicare patients treated for certain conditions. We use triple difference estimation to identify the HRRP's effects in Virginia hospitals; this method estimates the difference in changes in readmission over time between patients targeted by the policy and a comparison group of patients and then compares those difference-in-differences estimates in patients treated at hospitals with readmission rates above the national average (i.e., those at risk for penalties) and patients treated at hospitals with readmission rates below or equal to the national average (those not at risk). We find that the HRRP significantly reduced readmission for Medicare patients treated for acute myocardial infarction (AMI). We find no evidence that hospitals delay readmissions, treat patients with greater intensity, or alter discharge status in response to the HRRP, nor do we find changes in the age, race/ethnicity, health status, and socioeconomic status of patients admitted for AMI. Future research on the specific mechanisms behind reduced AMI readmissions should focus on actions by healthcare providers once the patient has left the hospital. Copyright © 2016 John Wiley & Sons, Ltd.

  8. 42 CFR 422.108 - Medicare secondary payer (MSP) procedures.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 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 §...

  9. 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

  10. 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.

  11. Association of Get With The Guidelines-Stroke Program Participation and Clinical Outcomes for Medicare Beneficiaries With Ischemic Stroke.

    PubMed

    Song, Sarah; Fonarow, Gregg C; Olson, DaiWai M; Liang, Li; Schulte, Phillip J; Hernandez, Adrian F; Peterson, Eric D; Reeves, Mathew J; Smith, Eric E; Schwamm, Lee H; Saver, Jeffrey L

    2016-05-01

    Get With The Guidelines (GWTG)-Stroke is a national, hospital-based quality improvement program developed by the American Heart Association. Although studies have suggested improved processes of care in GWTG-Stroke-participating hospitals, it is not known whether this improved care translates into improved clinical outcomes compared with nonparticipating hospitals. From all acute care US hospitals caring for Medicare beneficiaries with acute stroke between April 2003 and December 2008, we matched hospitals that joined the GWTG-Stroke program with similar hospitals that did not. Using a difference-in-differences design, we analyzed whether hospital participation in GWTG-Stroke was associated with a greater improvement in clinical outcomes compared with the underlying secular change. The matching algorithm identified 366 GWTG-Stroke-adopting hospitals that cared for 88 584 acute ischemic stroke admissions and 366 non-GWTG-Stroke hospitals that cared for 85 401 acute ischemic stroke admissions. Compared with the Pre period (18-6 months before program implementation), in the Early period (0-6 months after program implementation), GWTG-Stroke hospitals had accelerated increases in discharge to home and reduced mortality at 30 days and 1 year. In the Sustained period (6-18 months after program implementation), the accelerated reduction in mortality at 1 year was sustained, with a trend toward sustained accelerated increase in discharge home. Hospital adoption of the GWTG-Stroke program was associated with improved functional outcomes at discharge and reduced postdischarge mortality. © 2016 American Heart Association, Inc.

  12. 75 FR 71799 - Medicare Program: Hospital Outpatient Prospective Payment System and CY 2011 Payment Rates...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-24

    ...The final rule with comment period in this document revises the Medicare hospital outpatient prospective payment system (OPPS) to implement applicable statutory requirements and changes arising from our continuing experience with this system and to implement certain provisions of the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (Affordable Care Act). In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These changes are applicable to services furnished on or after January 1, 2011. In addition, this final rule with comment period updates the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system and to implement certain provisions of the Affordable Care Act. In this final rule with comment period, we set forth the applicable relative payment weights and amounts for services furnished in ASCs, specific HCPCS codes to which these changes apply, and other pertinent ratesetting information for the CY 2011 ASC payment system. These changes are applicable to services furnished on or after January 1, 2011. In this document, we also are including two final rules that implement provisions of the Affordable Care Act relating to payments to hospitals for direct graduate medical education (GME) and indirect medical education (IME) costs; and new limitations on certain physician referrals to hospitals in which they have an ownership or investment interest. In the interim final rule with comment period that is included in this document, we are changing the effective date for otherwise eligible hospitals and critical access hospitals that have been reclassified from urban to rural under section 1886(d)(8)(E) of the Social Security

  13. 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

  14. Medicare program; revised procedures for paying claims from providers of services--HCFA. Final notice.

    PubMed

    1992-10-21

    This final notice announces the implementation of a uniform payment policy and procedures for paying providers of services under Medicare Parts A and B. The revised payment policy allows providers to elect to receive claims payments through either (1) electronic funds transfer; or (2) hard copy checks sent directly by first class mail. The procedures allow intermediaries and carriers to pay providers through direct deposits into providers' bank accounts if the providers (1) are already electronic media claims billers; (2) accept an electronic remittance notice in lieu of a paper remittance notice; and (3) request electronic funds transfer in writing. The procedures are issued in response to requests from both contractors and HCFA regional offices to implement a policy for payment methods that treats all payees uniformly.

  15. 77 FR 68891 - Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face-to...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-16

    ...This major final rule with comment period addresses changes to the physician fee schedule, payments for Part B drugs, and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. It also implements provisions of the Affordable Care Act by establishing a face-to-face encounter as a condition of payment for certain durable medical equipment (DME) items. In addition, it implements statutory changes regarding the termination of non-random prepayment review. This final rule with comment period also includes a discussion in the Supplementary Information regarding various programs . (See the Table of Contents for a listing of the specific issues addressed in this final rule with comment period.)

  16. Medicare program; schedule of limits on home health agency costs per visit for cost reporting periods beginning on or after July 1, 1993--HCFA. Notice with comment period.

    PubMed

    1993-07-08

    This notice sets forth a revised schedule of limits on home health agency costs that may be paid under the Medicare program. As required by section 1861(v)(1)(L)(iii) of the Social Security Act (the Act), these limits are based on the current hospital wage index.

  17. Medicare program; statistical standards for evaluating intermediary performance during fiscal year 1982--Health Care Financing Administration. General notice with comment period.

    PubMed

    1982-10-05

    This is HCFAs annual notice containing statistical standards to be used for evaluating the performance of fiscal intermediaries in the administration of the Medicare program for fiscal year 1982. The standards were developed from available statistical data contained in routine intermediary reports and consists of measures of timeliness and of cost of an intermediary's Medicare operations. The results of the evaluations are considered whenever we make, renew or terminate an intermediary agreement; assign or reassing providers of services to an intermediary; or designate regional or national intermediaries.

  18. What Is Medicare?

    MedlinePlus

    ... supplies, and preventive services. Medicare Part C (Medicare Advantage Plans) A type of Medicare health plan offered ... your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, ...

  19. Society for Health Psychology (APA Division 38) and Society of Behavioral Medicine joint position statement on the Medicare Diabetes Prevention Program.

    PubMed

    Fitzpatrick, Stephanie L; Wilson, Dawn K; Pagoto, Sherry L

    2017-06-01

    Beginning in January 2018, the Centers for Medicare and Medicaid Services (CMS) plans to cover the Diabetes Prevention Program (DPP), also referred to as Medicare DPP. The American Psychological Association Society for Health Psychology (SfHP) and the Society for Behavioral Medicine (SBM) reviewed the proposed plan. SfHP and SBM are in support of the CMS decision to cover DPP for Medicare beneficiaries but have a significant concern that aspects of the proposal will limit the public health impact. Concerns include the emphasis on weight outcomes to determine continued coverage and the lack of details regarding requirements for coaches. SfHP and SBM are in strong support of modifications to the proposal that would remove the minimum weight loss stipulation to determine coverage and to specify type and qualifications of "coaches."

  20. Medicare program; prospective payment system for hospital outpatient services--HCFA. Proposed rule.

    PubMed

    1998-09-08

    As required by sections 4521, 4522, and 4523 of the Balanced Budget Act of 1997, this proposed rule would eliminate the formula-driven overpayment for certain outpatient hospital services, extend reductions in payment for costs of hospital outpatient services, and establish in regulations a prospective payment system for hospital outpatient services (and for Medicare Part B services furnished to inpatients who have no Part A coverage). The prospective payment system would simplify our current payment system and apply to all hospitals, including those that are excluded from the inpatient prospective payment system. The Balanced Budget Act provides for implementation of the prospective payment system effective January 1, 1999, but delays application of the system to cancer hospitals until January 1, 2000. The hospital outpatient prospective payment system would also apply to partial hospitalization services furnished by community mental health centers. Although the statutory effective date for the outpatient prospective payment system is January 1, 1999, implementation of the new system will have to be delayed because of year 2000 systems concerns. The demands on intermediary bill processing systems and HCFA internal systems to become compliant for the year 2000 preclude making the major systems changes that are required to implement the prospective payment system. The outpatient prospective payment system will be implemented for all hospitals and community mental health centers as soon as possible after January 1, 2000, and a notice of the anticipated implementation date will be published in the Federal Register at least 90 days in advance. This document also proposes new requirements for provider departments and provider-based entities. These proposed changes, as revised based on our consideration of public comments, will be effective 30 days after publication of a final rule. This proposed rule would also implement section 9343(c) of the Omnibus Budget

  1. 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.

  2. 76 FR 68525 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-04

    ...This final rule sets forth updates to the home health prospective payment system (HH PPS) rates, including: the national standardized 60-day episode rates; the national per-visit rates; and the low utilization payment amount (LUPA) under the Medicare PPS for home health agencies effective January 1, 2012. This rule applies a 1.4 percent update factor to the episode rates, which reflects a 1 percent reduction applied to the 2.4 percent market basket update factor, as mandated by the Affordable Care Act. This rule also updates the wage index used under the HH PPS, and further reduces home health payments to account for continued nominal growth in case-mix which is unrelated to changes in patient health status. This rule removes two hypertension codes from the HH PPS case-mix system, thereby requiring recalibration of the case-mix weights. In addition, the rule implements two structural changes designed to decrease incentives to upcode and provide unneeded therapy services. Finally, this rule incorporates additional flexibility regarding face-to-face encounters with providers related to home health care.

  3. Large Variations In Medicare Payments For Surgery Highlight Savings Potential From Bundled Payment Programs

    PubMed Central

    Miller, David C.; Gust, Cathryn; Dimick, Justin B.; Birkmeyer, Nancy; Skinner, Jonathan; Birkmeyer, John D.

    2014-01-01

    Payers are considering bundled payments for inpatient surgery, combining provider reimbursements into a single payment for the entire episode. We found that current Medicare episode payments for certain inpatient procedures varied by 49–130 percent across hospitals sorted into five payment groups. Intentional differences in payments attributable to such factors as geography or illness severity explained much of this variation. But after adjustment for these differences, per episode payments to the highest-cost hospitals were higher than those to the lowest-cost facilities by up to $2,549 for colectomy and $7,759 for back surgery. Postdischarge care accounted for a large proportion of the variation in payments, as did discretionary physician services, which may be driven in turn by variations in surgeons’ practice styles. Our study suggests that bundled payments could yield sizable savings for payers, although the effect on individual institutions will vary because hospitals that were relatively expensive for one procedure were often relatively inexpensive for others. More broadly, our data suggest that many hospitals have considerable room to improve their cost efficiency for inpatient surgery and should look for patterns of excess utilization, particularly among surgical specialties, other inpatient specialist consultations, and various types of postdischarge care. PMID:22068403

  4. 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

  5. 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

    ... 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 be very technical in nature and will focus on the actuarial and...

  6. 76 FR 65195 - Office of the Assistant Secretary for Planning and Evaluation; Medicare Program; Meeting of the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-20

    ... 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... to be very technical in nature and will focus on the actuarial and economic assumptions and...

  7. 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... spending in the short run. The Panel's discussion is expected to be very technical in nature and will...

  8. 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

    ... of the Technical Advisory Panel on Medicare Trustee Reports AGENCY: Assistant Secretary for Planning... Technical Advisory Panel on Medicare Trustee Reports (Panel). Notice of this meeting is given under the... discussion is expected to be very technical in nature and will focus on the actuarial and...

  9. 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... to be very technical in nature and will focus on the actuarial and economic assumptions and...

  10. 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 be very technical in nature and will focus on the actuarial and...

  11. 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

    ... of the Technical Advisory Panel on Medicare Trustee Reports AGENCY: Assistant Secretary for Planning... Technical Advisory Panel on Medicare Trustee Reports (Panel). Notice of this meeting is given under the... discussion is expected to be very technical in nature and will focus on the actuarial and...

  12. 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

    ... 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... accurately estimate health spending in the short run. The Panel's discussion is expected to be very...

  13. 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

    ... 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... accurately estimate health spending in the short run. The Panel's discussion is expected to be very...

  14. 78 FR 72255 - Medicare and Medicaid Programs; Home Health Prospective Payment System Rate Update for CY 2014...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-02

    ... December 2, 2013 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services... Regulations#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR.... CVD Cardiovascular disease. CY Calendar year. DG Diagnostic group. DHHS Department of Health and Human...

  15. 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.

  16. 42 CFR 408.21 - Reduction in Medicare Part B premium as an additional benefit under Medicare+Choice plans.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Reduction in Medicare Part B premium as an additional benefit under Medicare+Choice plans. 408.21 Section 408.21 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PREMIUMS FOR SUPPLEMENTARY...

  17. 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

  18. 42 CFR 460.168 - Reinstatement in other Medicare and Medicaid programs.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Participant Enrollment and Disenrollment § 460.168...

  19. 42 CFR 460.168 - Reinstatement in other Medicare and Medicaid programs.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Participant Enrollment and Disenrollment § 460.168...

  20. 42 CFR 460.168 - Reinstatement in other Medicare and Medicaid programs.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Participant Enrollment and Disenrollment § 460.168...

  1. Medicare program; fraud and abuse; civil monetary penalties and exclusions for assistants at cataract surgery--HHS. Final rule with comment period.

    PubMed

    1987-04-10

    This final rule implements section 9307 of Pub. L. 99-272, the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended by section 1895(b)(16) of Pub. L. 99-514, the Tax Reform Act of 1986, by providing the imposition of civil monetary penalties (CMPs) and exclusions against physicians billing the Medicare program or program beneficiaries for services of an assistant at surgery for cataract operations where prior approval has not been granted. The purpose of these regulations is to strengthen existing OIG penalty and exclusion authorities, and to prevent specific abusive and fraudulent practices against the Medicare program with regard to the use of assistants at surgery where not medically necessary.

  2. 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.

  3. Medicare and Medicaid programs: schedules of guidelines for physical therapy and respiratory therapy services--Health Care Financing Administration. Final notice with a request for comments.

    PubMed

    1981-02-25

    This notice amends the current schedules of salary equivalency guidelines for Medicare program reimbursement for the reasonable costs of physical therapy and respiratory therapy services furnished under an arrangement with a hospital or other provider. The schedules will be used by the program's fiscal intermediaries to determine the maximum allowable cost of such services. These schedules update the schedule published on October 6, 1978 (43 FR 46377), for physical therapy services, and those published on June 3, 1980 (45 FR 37527), for respiratory therapy services. In addition, these guidelines apply to reimbursement under the Medicaid program where they have been incorporated in the State plans or where States follow the Medicare principles of reimbursement.

  4. 78 FR 54842 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-06

    ... -1 Genitourinary system 159 5 Integumentary system 130 8 Respiratory system 46 7 Cardiovascular... Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Hospital Value-Based Purchasing... Payment Systems and Quality Reporting Programs; Hospital Value-Based Purchasing Program; Organ...

  5. Cumulative expenditures under the DI, SSI, Medicare, and Medicaid programs for a cohort of disabled working-age adults.

    PubMed

    Riley, Gerald F; Rupp, Kalman

    2015-04-01

    To estimate cumulative DI, SSI, Medicare, and Medicaid expenditures from initial disability benefit award to death or age 65. Administrative records for a cohort of new CY2000 DI and SSI awardees aged 18-64. 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. We matched records for a 10 percent nationally representative sample. 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. 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. Published 2014. This article is a U.S. Government work and is in the public domain in the USA.

  6. 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

  7. Medicare program; schedule of limits on hospital inpatient operating costs for cost reporting periods beginning on or after October 1, 1982--HCFA. Interim final notice with comment period.

    PubMed

    1982-09-30

    This notice sets forth a schedule of limits on the hospital inpatient operating costs that may be reimbursed under Medicare for cost reporting periods beginning on or after October 1, 1982. These limits are needed to implement changes in the Medicare law that were made by section 101(a) of Pub. L. 97-248, the Tax Equity and Fiscal Responsibility Act of 1982. The new limits differ from the current per diem limits on inpatient general routine operating costs in several major respects. First, they are not restricted to costs of inpatient general routine care, but cover total inpatient operating costs, including the costs of general routine service, special care, and ancillary services. The new limits will be applied on a cost per discharge rather than cost per diem basis. Finally, they are adjusted to reflect differences in the mix of Medicare cases treated by each hospital. The limits are similar to the current limits in that they do not apply to outpatient service cost, capital-related costs, malpractice insurance costs, or costs a hospital allocates to the interns and residents (in approved programs) or nursing school cost centers on its Medicare cost report. They also do not apply to children's hospitals, long-term care hospitals, or rural hospitals with fewer than 50 beds. The notice explains our methodology for deriving and applying the new limits.

  8. 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.

  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

    ... 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 program... statutory timetable to ensure that our review of applications for CMS-approval of an accreditation...

  10. Medicare program; Home Health Prospective Payment System rate update for calendar year 2013, hospice quality reporting requirements, and survey and enforcement requirements for home health agencies. Final rule.

    PubMed

    2012-11-08

    This final rule updates the Home Health Prospective Payment System (HH PPS) rates, including the national standardized 60-day episode rates, the national per-visit rates, the low-utilization payment amount (LUPA), the non-routine medical supplies (NRS) conversion factor, and outlier payments under the Medicare prospective payment system for home health agencies effective January 1, 2013. This rule also establishes requirements for the Home Health and Hospice quality reporting programs. This final rule will also establish requirements for unannounced, standard and extended surveys of home health agencies (HHAs) and sets forth alternative sanctions that could be imposed instead of, or in addition to, termination of the HHA's participation in the Medicare program, which could remain in effect up to a maximum of 6 months, until an HHA achieves compliance with the HHA Conditions of Participation (CoPs) or until the HHA's provider agreement is terminated.

  11. Medicare Beneficiary Knowledge: Measurement Implications from a Qualitative Study

    PubMed Central

    Teal, Cayla R.; Paterniti, Debora A.; Murphy, Christi L.; John, Dolly A.; Morgan, Robert O.

    2006-01-01

    Medicare beneficiary knowledge about fee-for-service (FFS) Medicare versus managed care alternatives (MCA) has been studied extensively. However, these efforts might be compromised by lack of familiarity with common Medicare terminology. We used qualitative methods to examine beneficiaries' familiarity with Medicare Programs (FFS and MCA) and terminology. Twenty-one indepth, semi-structured beneficiary interview transcripts were analyzed through iterative review. Across sex, race/ethnicity, and benefits programs, participants found interview questions with Medicare terminology difficult to answer, potentially causing missing, incorrect, and inaccurate responses to interview questions. Assessment of beneficiary knowledge may be fundamentally impacted by absence of basic familiarity with Medicare Programs terminology. PMID:17290655

  12. Impact of a telephonic outreach program on medication adherence in Medicare Advantage Prescription Drug (MAPD) plan beneficiaries.

    PubMed

    Park, Haesuk; Adeyemi, Ayoade; Wang, Wei; Roane, Teresa E

    To determine the impact of a telephone call reminder program provided by a campus-based medication therapy management call center on medication adherence in Medicare Advantage Part D (MAPD) beneficiaries with hypertension. The reminder call services were offered to eligible MAPD beneficiaries, and they included a live interactive conversation with patients to assess the use of their medications. This study used a quasi-experimental design for comparing the change in medication adherence between the intervention and matched control groups. Adherence, defined by proportion of days covered (PDC), was measured using incurred medication claims 6 months before and after the adherence program was implemented. A difference-in-differences approach with propensity score matching was used. After propensity score matching, paired samples included 563 patients in each of the intervention and control groups. The mean PDC (standard deviation) increased significantly during postintervention period by 17.3% (33.6; P <0.001) and 13.8% (32.3; P <0.001) for the intervention and the control groups, respectively; the greater difference-in-differences increase of 3.5% (36.3) in the intervention group over the control group was statistically significant (P = 0.022). A generalized estimating equation model adjusting for covariates further confirmed that the reminder call group had a significant increase in pre-post PDC (P = 0.021), as compared with the control group. Antihypertensive medication adherence increased in both reminder call and control groups, but the increase was significantly higher in the intervention group. A telephonic outreach program was effective in improving antihypertensive medication adherence in MAPD beneficiaries. Copyright © 2017 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

  13. Medicare program; schedule of limits on home health agency costs per visit--HCFA. Notice with comment period.

    PubMed

    1995-02-14

    This notice with comment period sets forth a revised schedule of limits on home health agency costs that may be paid under the Medicare program for cost reporting periods beginning on or after July 1, 1993. These limits replace the per-visit limits that were set forth in our July 8, 1993 notice with comment period (58 FR 36748). This notice also provides, in accordance with the provisions of the Omnibus Budget Reconciliation Act of 1993 (OBRA '93), that there will be no changes in the home health agency (HHA) cost limits for cost reporting periods beginning on or after July 1, 1994, and before July 1, 1996. In addition, this notice responds to public comments on the July 8, 1993 notice with comment period, which originally set forth the HHA cost limits for cost reporting periods beginning on or after July 1, 1993, and on the January 6, 1994 notice with comment period (59 FR 760), which announced the elimination of the hospital based add-on effective for cost reporting periods beginning on or after October 1, 1993.

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

    PubMed

    2015-08-06

    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.

  15. Medicare program; schedule of limits on home health agency costs per visit for cost reporting periods beginning on or after July 1, 1991--HCFA. Notice with comment period.

    PubMed

    1991-12-09

    This notice sets forth a revised schedule of limits on home health agency costs that may be paid under the Medicare program. This revised schedule of limits applies to cost reporting periods beginning on or after July 1, 1991. As required by section 4207(d) of the Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508), this revised schedule of limits incorporates a blended hospital wage index.

  16. Medicare program; schedule of limits on home health agency costs per visit for cost reporting periods beginning on or after July 1, 1997--HCFA. Notice with comment period.

    PubMed

    1997-07-01

    This notice sets fort a revised schedule of limits on home health agency costs that may be paid under the Medicare program for cost reporting periods beginning on or after July 1, 1997. These limits replace the per visit limits that were set forth in our July 1, 1996 notice with comment period (61 FR 34344). This notice also responds to comments on the July 1, 1996 notice.

  17. Medicare program; schedule of limits on home health agency costs per visit for cost reporting periods beginning on or after July 1, 1992--HCFA. Notice with comment period.

    PubMed

    1992-07-01

    This notice sets forth a revised schedule of limits on home health agency costs that may be paid under the Medicare program. This revised schedule of limits applies to cost reporting periods beginning on or after July 1, 1992. As required by section 4207(d)(3)(B) of the Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508), this revised schedule of limits incorporates a blended hospital wage index.

  18. 78 FR 61202 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-10-03

    ... Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2014... for Skilled Nursing Facilities for FY 2014.'' DATES: These corrections are effective October 1, 2013...

  19. Trials and tribulations: a small pilot telehealth home care program for medicare patients.

    PubMed

    Walsh, Maureen; Coleman, John R

    2005-01-01

    This article describes a home care agency's experience initiating the technology of a telehealth program for a selected view of its home care patients. The goal of the telehealth program was to improve patient outcomes by augmenting patients' regularly scheduled in-home skilled nursing visits with video-conferencing encounters. Patient selection, costs, projected savings, patient satisfaction, and the technical, clinical, and patient problems with the telehealth system are discussed.

  20. Concordance between Self-Reports and Medicare Claims among Participants in a National Study of Chronic Disease Self-Management Program.

    PubMed

    Jiang, Luohua; Zhang, Ben; Smith, Matthew Lee; Lorden, Andrea L; Radcliff, Tiffany A; Lorig, Kate; Howell, Benjamin L; Whitelaw, Nancy; Ory, Marcia G

    2015-01-01

    To evaluate the concordance between self-reported data and variables obtained from Medicare administrative data in terms of chronic conditions and health care utilization. Retrospective observational study. We analyzed data from a sample of Medicare beneficiaries who were part of the National Study of Chronic Disease Self-Management Program (CDSMP) and were eligible for the Centers for Medicare and Medicaid Services (CMS) pilot evaluation of CDSMP (n = 119). Self-reported and Medicare claims-based chronic conditions and health care utilization were examined. Percent of consistent numbers, kappa statistic (κ), and Pearson's correlation coefficient were used to evaluate concordance. The two data sources had substantial agreement for diabetes and chronic obstructive pulmonary disease (COPD) (κ = 0.75 and κ = 0.60, respectively), moderate agreement for cancer and heart disease (κ = 0.50 and κ = 0.47, respectively), and fair agreement for depression (κ = 0.26). With respect to health care utilization, the two data sources had almost perfect or substantial concordance for number of hospitalizations (κ = 0.69-0.79), moderate concordance for ED care utilization (κ = 0.45-0.61), and generally low agreement for number of physician visits (κ ≤ 0.31). Either self-reports or claim-based administrative data for diabetes, COPD, and hospitalizations can be used to analyze Medicare beneficiaries in the US. Yet, caution must be taken when only one data source is available for other types of chronic conditions and health care utilization.

  1. 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).

  2. Design of a medication management program for Medicare beneficiaries: Qualitative findings from patients and physicians

    PubMed Central

    Lauffenburger, Julie C.; Vu, Maihan B.; Burkhart, Jena Ivey; Weinberger, Morris; Roth, Mary T.

    2012-01-01

    Background The quality of pharmacologic care provided to older adults is less than optimal. Medication therapy management (MTM) programs delivered to older adults in the ambulatory care setting may improve the quality of medication use for these individuals. Objectives We conducted focus groups with older adults and primary care physicians to explore: (1) older adults' experiences working with a clinical pharmacist in managing medications, (2) physician perspectives on the role of clinical pharmacists in facilitating medication management, and (3) key attributes of an effective MTM program and potential barriers from both patient and provider perspectives. Methods Five focus groups (4 with older adults, 1 with primary care physicians) were conducted by a trained moderator using a semi-structured interview guide. Each participant completed a demographic questionnaire. Sessions were recorded, transcribed verbatim, and analyzed using qualitative analysis software for theme identification. Results Twenty-eight older adults and 8 physicians participated. Older adults valued the professional, trusting nature of their interactions with the pharmacist. They found the clinical pharmacist to be a useful resource, thorough, personable, and a valuable team member. Physicians believe the clinical pharmacist fills a unique role as a specialized practitioner, contributing meaningfully to patient care. Physicians emphasized the importance of effective communication, pharmacist's access to the medical record, and a mutually-trusting relationship as key attributes of a program. Potential barriers to an effective program include poor communication and lack of familiarity with the patient's history. The lack of a sustainable reimbursement model was cited as a barrier to widespread implementation of MTM. Conclusions This study provides information to assist pharmacists in designing MTM programs in the ambulatory setting. Key attributes of an effective program include one that is

  3. Design of a medication therapy management program for Medicare beneficiaries: qualitative findings from patients and physicians.

    PubMed

    Lauffenburger, Julie C; Vu, Maihan B; Burkhart, Jena Ivey; Weinberger, Morris; Roth, Mary T

    2012-04-01

    The quality of pharmacologic care provided to older adults is less than optimal. Medication therapy management (MTM) programs delivered to older adults in the ambulatory care setting may improve the quality of medication use for these individuals. We conducted focus groups with older adults and primary care physicians to explore (1) older adults' experiences working with a clinical pharmacist in managing medications, (2) physician perspectives on the role of clinical pharmacists in facilitating medication management, and (3) key attributes of an effective MTM program and potential barriers from patient and provider perspectives. Five focus groups (4 with older adults, 1 with physicians) were conducted by a trained moderator using a semistructured interview guide. Each participant completed a demographic questionnaire. Sessions were recorded, transcribed verbatim, and analyzed using qualitative analysis software for theme identification. Twenty-eight older adults and 8 physicians participated. Older adults valued the professional, trusting nature of their interactions with the pharmacist. They found the clinical pharmacist to be a useful resource, thorough, personable, and a valuable team member. Physicians believe that the clinical pharmacist fills a unique role as a specialized practitioner, contributing meaningfully to patient care. Physicians emphasized the importance of effective communication, pharmacist access to the medical record, and a mutually trusting relationship as key attributes of a program. Potential barriers to an effective program include poor communication and lack of familiarity with the patient's history. The lack of a sustainable reimbursement model was cited as a barrier to widespread implementation of MTM. This study provides information to assist pharmacists in designing MTM programs in the ambulatory setting. Key attributes of an effective program include being comprehensive and addressing all medication-related needs over time. The

  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

    ... effectiveness of those anti-fraud plans. In accordance with section 1893(h) of the ACA, the RACs for the Part C.... 111-152), (collectively known as The Affordable Care Act (ACA)) that requires the expansion of the... plan, if one was offered where the beneficiary lived. The primary goal of the M+C program was...

  5. 78 FR 78751 - Medicare Program; Physicians' Referrals to Health Care Entities With Which They Have Financial...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-27

    ... also specifically sought comment on whether we should, as an alternative, select a later expiration... incentives under the EHR Incentive Programs. Other commenters supported our alternative proposal to extend... previously, we are finalizing our alternative proposal to extend the exception through December 31, 2021...

  6. 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

    ... program provides CAHs with a viable alternative to other healthcare AOs. IV. Provisions of the Final...)(iv), DNVHC revised its standards to include the reference to the National Fire Protection Association...) through Sec. 485.623(d)(7)(iv), DNVHC revised its standards to ensure alcohol- based dispensers are...

  7. 78 FR 4151 - Medicare Program; Request for Information on Hospital and Vendor Readiness for Electronic Health...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-01-18

    ... Hospital and Vendor Readiness for Electronic Health Records Hospital Inpatient Quality Data Reporting... questions regarding their readiness to conduct electronic reporting of certain patient-level data under the Hospital Inpatient Quality Reporting (IQR) Program using the Quality Reporting Document Architecture...

  8. 76 FR 26805 - Medicare Program; Hospice Wage Index for Fiscal Year 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-09

    .... 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 Information... Employee 3. Timeframe for Face-to-Face Encounters 4. Hospice Aide and Homemaker Services E....

  9. 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

    ... Insurance Programs; Meeting of the Advisory Panel on Outreach and Education (APOE), March 27, 2013 AGENCY... Date: Wednesday, March 27, 2013, 8:30 a.m. to 4:00 p.m. Eastern Daylight Time (EDT). Deadline for Meeting Registration, Presentations and Comments: Wednesday, March 13, 2013, 5:00 p.m., EDT. Deadline for...

  10. 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... they had been included in the CY 2012 OPPS/ASC final rule with comment period (76 FR 74122)...

  11. 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.

  12. Medicare physician payments and spending.

    PubMed

    Dummit, Laura A

    2006-10-09

    The Medicare program's physician payment method is intended to control spending while ensuring beneficiary access to physician services, but there are signs that it may not be working. The physician's role in the health care delivery system as the primary source of information and treatment options, together with growing demand for services and the imperfect state of knowledge about appropriate service use, challenge Medicare's ability to achieve these two goals. This issue brief describes the history of physician spending and the contribution of escalating service use and intensity of services to the rise in Medicare outlays, setting the stage for further discussion about the use of the Medicare payment system to control spending and ensure access.

  13. Dominated choices and Medicare Advantage enrollment

    PubMed Central

    Afendulis, Christopher C.; Sinaiko, Anna D.; Frank, Richard G.

    2015-01-01

    Research in behavioral economics suggests that certain circumstances, such as large numbers of complex options or revisiting prior choices, can lead to decision errors. This paper explores the enrollment decisions of Medicare beneficiaries in the Medicare Advantage (MA) program. During the time period we study (2007–2010), private fee-for-service (PFFS) plans offered enhanced benefits beyond those of traditional Medicare (TM) without any restrictions on physician networks, making TM a dominated choice relative to PFFS. Yet more than three quarters of Medicare beneficiaries remained in TM during our study period. We analyze the role of status quo bias in explaining this pattern of enrollment. Our results suggest that status quo bias plays an important role; the rate of MA enrollment was significantly higher among new Medicare beneficiaries than among incumbents. These results illustrate the importance of the choice environment that is in place when enrollees first enter the Medicare program. PMID:26339108

  14. Analysis of Healthcare Cost and Utilization in the First Two Years of the Medicare Shared Savings Program Using Big Data from the CMS Enclave.

    PubMed

    Kury, Fabricio S P; Baik, Seo H; McDonald, Clement J

    2016-01-01

    The Medicare Shared Savings Program (MSSP) is the larger of the first two Accountable Care Organization (ACO) programs by the Centers for Medicare and Medicaid Services (CMS). In this study we assessed healthcare cost and utilization of 1.71 million Medicare beneficiaries assigned to the 333 MSSP ACOs in the calendar years of 2013 and 2014, in comparison to years 2010 and 2011, using the official CMS data. We employed doubly robust estimation (propensity score weighting followed by generalized linear regression) to adjust the analyses to beneficiary personal traits, history of chronic conditions, previous healthcare utilization, ACO administrative region, and ZIP code socioeconomic factors. In comparison to the care delivered to the control cohort of 17.7 million non-ACO beneficiaries, we found that the care patterns for ACO beneficiaries shifted away from some costly types of care, but at the expense of increased utilization of other types, increased imaging and testing expenditures, and increased medication use, with overall net greater increase in cost instead of smaller increase.

  15. Medicare Special Needs Plan (SNP)

    MedlinePlus

    ... change plans Types of Medicare health plans Medicare Advantage Plans + Share widget - Select to show Subcategories Getting ... Types of Medicare health plans , current subcategory Medicare Advantage Plans , current page Medicare Medical Savings Account (MSA) ...

  16. The push to increase the use of EHR technology by hospitals and physicians in the United States through the HITECH Act and the Medicare incentive program.

    PubMed

    Pipersburgh, Jessica

    2011-01-01

    This article reviews key health care spending and electronic health records (EHR) statistics in the United States (Section II); highlights positive and negative aspects of EHR technology (Sections III and IV); briefly reviews the passage of the Health Information Technology for Economic and Clinical Health Act (HITECH) (Section V); discusses the rule passed by the Office of the National Coordinator for Health Information Technology (ONCHIT) and to implement the goals of HITECH (Section VI); discusses the rule passed by the Centers for Medicare & Medicaid Services (CMS) to implement the goals of HITECH and focuses on significant requirements of the Medicare incentive program rule as it applies to hospitals and physicians (Section VII); and finally, concludes by highlighting certain issues that have been raised regarding the goals of HITECH (Section VIII).

  17. Medicare program; schedules of limits and prospectively determined payment rates for skilled nursing facility inpatient routine service costs--HCFA. Final notice with comment period.

    PubMed

    1997-10-01

    This final notice with comment period sets forth an updated schedule of limits on skilled nursing facility (SNF) routine service costs for which payment may be made under the Medicare program and sets forth an updated schedule of payment rates for low Medicare volume SNFs that elect to receive prospectively determined payment rates for routine service costs. Section 1888(a) of the Social Security Act (the Act) requires that the Secretary update the per diem cost limits for SNF routine service costs for cost reporting periods beginning on or after October 1, 1995, and every 2 years thereafter. In addition, section 1888(d)(4) of the Act requires the Secretary to establish and publish prospectively determined payment rates at least 90 days prior to the beginning of the Federal fiscal year (FY) to which such rates are to be applied.

  18. 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.

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

    PubMed

    2016-08-05

    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).

  20. Effect of an intervention to increase statin use in medicare members who qualified for a medication therapy management program.

    PubMed

    Stockl, Karen M; Tjioe, Daniel; Gong, Sherry; Stroup, Jenni; Harada, Ann S M; Lew, Heidi C

    2008-01-01

    The cardiovascular (CV) benefits of lipid-lowering therapy in older adults with hypercholesterolemia and underlying risk factors for coronary artery disease (CAD) have been well documented. Significant reductions in the risk of myocardial infarction (MI) and coronary death have been demonstrated with statin therapy, benefits that are of particular relevance in patients with diabetes. Managed care interventions with prescribers have increased the use of selected drugs such as statins. To (1) measure the increase in new users of statins associated with the implementation of a statin initiation intervention aimed at prescribers for Medicare Part D Medication Therapy Management Program (MTMP) members with diabetes or CAD and (2) estimate the potential cost savings associated with the projected reduction in CV events based on published controlled trials. Medicare Advantage Prescription Drug (MA-PD) and prescription drug plan (PDP) members of a pharmacy benefits manager (PBM) were identified for the intervention who (1) met the criteria for MTMP (expected to incur at least dollars 4,000 in annual pharmacy expenditures for Part D-covered medications, filled at least 10 distinct Part D-covered medications, and had at least 3 of 5 chronic diseases of interest); (2) were identified as having diabetes or CAD (patients with a history of MI were considered to have CAD); and (3) had no pharmacy claims for a statin between January and June 2006. In August 2006, the primary prescribers for antidiabetic or CV medications of 1,144 identified members were sent educational materials and a report listing their patients with diabetes or CAD who were not receiving statin therapy. A comparison group of MA-PD members (N = 700) with diabetes or CAD was identified who did not receive the intervention but who met all of the MTMP criteria except the presence of at least 3 of 5 chronic diseases of interest. Logistic regression was conducted to evaluate the intervention effectiveness after

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

    MedlinePlus

    ... Medicare Prescription Drug Coverage Works with a Medicare Advantage Plan or Medicare Cost Plan Medicare offers prescription ... elect the drug coverage. 2. Join a Medicare Advantage Plan— like a Health Maintenance Organization (HMO), Preferred ...

  2. 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.

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

    PubMed

    2015-08-06

    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).

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

    PubMed

    2013-08-06

    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.

  5. Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2018. Final rule.

    PubMed

    2017-08-03

    This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2018 as required by the statute. As required by section 1886(j)(5) of the Social Security Act (the Act), this rule includes the classification and weighting factors for the IRF prospective payment system's (IRF PPS) case-mix groups and a description of the methodologies and data used in computing the prospective payment rates for FY 2018. This final rule also revises the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnosis codes that are used to determine presumptive compliance under the "60 percent rule," removes the 25 percent payment penalty for inpatient rehabilitation facility patient assessment instrument (IRF-PAI) late transmissions, removes the voluntary swallowing status item (Item 27) from the IRF-PAI, summarizes comments regarding the criteria used to classify facilities for payment under the IRF PPS, provides for a subregulatory process for certain annual updates to the presumptive methodology diagnosis code lists, adopts the use of height/weight items on the IRF-PAI to determine patient body mass index (BMI) greater than 50 for cases of single-joint replacement under the presumptive methodology, and revises and updates measures and reporting requirements under the IRF quality reporting program (QRP).

  6. Medicare program; hospital outpatient prospective payment system and CY 2007 payment rates; CY 2007 update to the ambulatory surgical center covered procedures list; Medicare administrative contractors; and reporting hospital quality data for FY 2008 inpatient prospective payment system annual payment update program--HCAHPS survey, SCIP, and mortality. Final rule with comment period and final rule.

    PubMed

    2006-11-24

    This final rule with comment period revises the Medicare hospital outpatient prospective payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system, and to implement certain related provisions of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 and the Deficit Reduction Act (DRA) of 2005. In this final rule with comment period, we describe changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These changes are applicable to services furnished on or after January 1, 2007. In addition, this final rule with comment period implements future CY 2009 required reporting on quality measures for hospital outpatient services paid under the prospective payment system. This final rule with comment period revises the current list of procedures that are covered when furnished in a Medicare-approved ambulatory surgical center (ASC), which are applicable to services furnished on or after January 1, 2007. This final rule with comment period revises the emergency medical screening requirements for critical access hospitals (CAHs). This final rule with comment period supports implementation of a restructuring of the contracting entities responsibilities and functions that support the adjudication of Medicare fee-for-service (FFS) claims. This restructuring is directed by section 1874A of the Act, as added by section 911 of the MMA. The prior separate Medicare intermediary and Medicare carrier contracting authorities under Title XVIII of the Act have been replaced with the Medicare Administrative Contractor (MAC) authority. This final rule continues to implement the requirements of the DRA that require that we expand the "starter set" of 10 quality measures that we used in FY 2005 and FY 2006 for the hospital inpatient prospective payment system (IPPS) Reporting Hospital Quality Data

  7. Medicare program; revisions to payment policies under the physician fee schedule for calendar year 2001. Health Care Financing Administration (HCFA), HHS. Final rule with comment period.

    PubMed

    2000-11-01

    This final rule with comment period makes several changes affecting Medicare Part B payment. The changes include: refinement of resource-based practice expense relative value units (RVUs); the geographic practice cost indices; resource-based malpractice RVUs; critical care RVUs; care plan oversight and physician certification and recertification for home health services; observation care codes; ocular photodynamic therapy and other ophthalmological treatments; electrical bioimpedance; antigen supply; and the implantation of ventricular assist devices. This rule also addresses the comments received on the May 3, 2000 interim final rule on the supplemental survey criteria and makes modifications to the criteria for data submitted in 2001. Based on public comments we are withdrawing our proposals related to the global period for insertion, removal, and replacement of pacemakers and cardioverter defibrillators and low intensity ultrasound. This final rule also discusses or clarifies the payment policy for incomplete medical direction, pulse oximetry services, outpatient therapy supervision, outpatient therapy caps, HCPCS "G" Codes, and the second 5-year refinement of work RVUs for services furnished beginning January 1, 2002. In addition, we are finalizing the calendar year (CY) 2000 interim physician work RVUs and are issuing interim RVUs for new and revised codes for CY 2001. 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 announces the CY 2001 Medicare physician fee schedule conversion factor under the Medicare Supplementary Medical Insurance (Part B) program as required by section 1848(d) of the Social Security Act. The 2001 Medicare physician fee schedule conversion factor is $38.2581.

  8. 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.

  9. 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

  10. 78 FR 48233 - Medicare Program; FY 2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-07

    ... Major Provisions C. Summary of Costs, Benefits, and Transfers II. Background A. Hospice Care B. History... Quality Reporting 4. Alternatives Considered C. Accounting Statement D. Conclusion 1. Regulatory... rate (Sec. 418.302(e)(4)). B. History of the Medicare Hospice Benefit Before the creation of the...

  11. 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 Web...

  12. 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

    ... Procedure Act (APA) (5 U.S.C. 553(b)). However, we can waive this notice and comment procedure if the... the notice. Section 553(d) of the APA ordinarily requires a 30-day delay in effective date of final... Pub. 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 210.41).''...

  13. 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…

  14. 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

    ...This notice announces a public meeting to receive comments and recommendations (including accompanying data on which recommendations are based) from the public on the appropriate basis for establishing payment amounts for new or substantially revised Healthcare Common Procedure Coding System (HCPCS) codes being considered for Medicare payment under the clinical laboratory fee schedule (CLFS) for calendar year (CY) 2014.

  15. 78 FR 73547 - Medicare Program; Semi-Annual Meeting of the Advisory Panel on Hospital Outpatient Payment (HOP...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-06

    ... Advisory Panel on Hospital Outpatient Payment (HOP Panel) March 10-11, 2014 AGENCY: Centers for Medicare...: Monday, March 10, 2014, 1 p.m. to 5 p.m. EST Tuesday, March 11, 2014, 9 a.m. to 5 p.m. EST Meeting... for the March 2014 meeting will provide for discussion and comment on the following topics as...

  16. 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…

  17. 76 FR 40497 - Medicare Program; Changes to the End-Stage Renal Disease Prospective Payment System for CY 2012...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-08

    ... July 8, 2011 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services... / Friday, July 8, 2011 / Proposed Rules#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for... & Medicaid Services, Department of Health and Human Services, Attention: CMS-1577-P, P.O. Box 8010, Baltimore...

  18. 76 FR 71571 - Medicare Program; Town Hall Meeting on FY 2013 Applications for New Medical Services and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-18

    ... in the main Auditorium in the central building of the Centers for Medicare and Medicaid Services... the device. ++ Decreased pain, bleeding, or other quantifiable symptoms. ++ Reduced recovery time...). All visitors must be escorted in areas other than the lower and first floor levels in the...

  19. 78 FR 71555 - Medicare Program; Town Hall Meeting on FY 2015 Applications for New Medical Services and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-11-29

    ... the central building of the Centers for Medicare and Medicaid Services located at 7500 Security... beneficial resolution of the disease process treatment because of the use of the device. ++ Decreased pain... escorted in areas other than the lower and first floor levels in the Central Building. Seating capacity...

  20. 42 CFR 420.410 - Establishment of a program to collect suggestions for improving Medicare program efficiency and...

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... under a contract, employees of Federally-sponsored research and demonstration projects, Federal officers... under this section. Suggestion means an original idea submitted in writing. Suggestion program means the...

  1. 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

    ... under a contract, employees of Federally-sponsored research and demonstration projects, Federal officers... under this section. Suggestion means an original idea submitted in writing. Suggestion program means the...

  2. 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

    ... under a contract, employees of Federally-sponsored research and demonstration projects, Federal officers... under this section. Suggestion means an original idea submitted in writing. Suggestion program means the...

  3. 42 CFR 420.410 - Establishment of a program to collect suggestions for improving Medicare program efficiency and...

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... under a contract, employees of Federally-sponsored research and demonstration projects, Federal officers... under this section. Suggestion means an original idea submitted in writing. Suggestion program means the...

  4. Medicare program; schedule of limits on home health agency costs per visit for cost reporting periods beginning on or after July 1, 1989--HCFA. Final notice.

    PubMed

    1991-03-28

    This final notice sets forth a revised schedule of limits on home health agency costs that may be paid under the Medicare program. This revised schedule of limits applies to cost reporting periods beginning on or after July 1, 1989 and before July 1, 1991. As required by section 6222 of the Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239), the revised schedule of limits incorporates the hospital wage index in effect for cost reporting periods beginning prior to July 1, 1989.

  5. Medicare program; criteria and standards for evaluating intermediary and carrier performance during fiscal year 1988--HCFA. General notice with comment period.

    PubMed

    1987-10-07

    This notice describes the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program for the fiscal year beginning October 1, 1987. The results of these evaluations are considered whenever we enter into, renew, or terminate an intermediary or carrier contract or take other contract actions; assign or reassign providers of services to an intermediary; or designate regional or national intermediaries. In addition, this notice describes the methodology used for identifying contractors for competitive replacement under section 2326 of the Deficit Reduction Act of 1984.

  6. Medicare program; inpatient psychiatric facilities prospective payment system--update for fiscal year beginning October 1, 2014 (FY 2015). Final rule.

    PubMed

    2014-08-06

    This final rule will update the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs). These changes will be applicable to IPF discharges occurring during the fiscal year (FY) beginning October 1, 2014 through September 30, 2015. This final rule will also address implementation of ICD-10-CM and ICD-10-PCS codes; finalize a new methodology for updating the cost of living adjustment (COLA), and finalize new quality measures and reporting requirements under the IPF quality reporting program.

  7. 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

    ... health care services to American Indian/ Alaska Native (AI/AN) people through a network of hospitals... health care to AI/AN beneficiaries. FOR FURTHER INFORMATION CONTACT: Rodger Goodacre, Centers for... Insurance Program Reauthorization Act of 2009 (CHIPRA), and the Affordable Care Act in 2010 (ACA). AI/AN...

  8. Higher Incentive Payments in Medicare Advantage's Pay-for-Performance Program Did Not Improve Quality But Did Increase Plan Offerings.

    PubMed

    Layton, Timothy J; Ryan, Andrew M

    2015-12-01

    To evaluate the effects of the size of financial bonuses on quality of care and the number of plan offerings in the Medicare Advantage Quality Bonus Payment Demonstration. Publicly available data from CMS from 2009 to 2014 on Medicare Advantage plan quality ratings, the counties in the service area of each plan, and the benchmarks used to construct plan payments. The Medicare Advantage Quality Bonus Payment Demonstration began in 2012. Under the Demonstration, all Medicare Advantage plans were eligible to receive bonus payments based on plan-level quality scores (star ratings). In some counties, plans were eligible to receive bonus payments that were twice as large as in other counties. We used this variation in incentives to evaluate the effects of bonus size on star ratings and the number of plan offerings in the Demonstration using a differences-in-differences identification strategy. We used matching to create a comparison group of counties that did not receive double bonuses but had similar levels of the preintervention outcomes. Results from the difference-in-differences analysis suggest that the receipt of double bonuses was not associated with an increase in star ratings. In the matched sample, the receipt of double bonuses was associated with a statistically insignificant increase of +0.034 (approximately 1 percent) in the average star rating (p > .10, 95 percent CI: -0.015, 0.083). In contrast, the receipt of double bonuses was associated with an increase in the number of plans offered. In the matched sample, the receipt of double bonuses was associated with an overall increase of +0.814 plans (approximately 5.8 percent) (p < .05, 95 percent CI: 0.078, 1.549). We estimate that the double bonuses increased payments by $3.43 billion over the first 3 years of the Demonstration. At great expense to Medicare, double bonuses in the Medicare Advantage Quality Bonus Payment Demonstration were not associated with improved quality but were associated with more plan

  9. 42 CFR 412.110 - Total Medicare payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Total Medicare payment. 412.110 Section 412.110 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Payments to Hospitals Under...

  10. 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…

  11. 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…

  12. 42 CFR 403.205 - Medicare supplemental policy.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... Medicare. (b) The term policy includes both policy form and policy as specified in paragraphs (b)(1) and (b... 42 Public Health 2 2012-10-01 2012-10-01 false Medicare supplemental policy. 403.205 Section 403... GENERAL PROVISIONS SPECIAL PROGRAMS AND PROJECTS Medicare Supplemental Policies General Provisions §...

  13. 42 CFR 403.205 - Medicare supplemental policy.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... Medicare. (b) The term policy includes both policy form and policy as specified in paragraphs (b)(1) and (b... 42 Public Health 2 2014-10-01 2014-10-01 false Medicare supplemental policy. 403.205 Section 403... GENERAL PROVISIONS SPECIAL PROGRAMS AND PROJECTS Medicare Supplemental Policies General Provisions §...

  14. 42 CFR 403.205 - Medicare supplemental policy.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... Medicare. (b) The term policy includes both policy form and policy as specified in paragraphs (b)(1) and (b... 42 Public Health 2 2013-10-01 2013-10-01 false Medicare supplemental policy. 403.205 Section 403... GENERAL PROVISIONS SPECIAL PROGRAMS AND PROJECTS Medicare Supplemental Policies General Provisions §...

  15. 42 CFR 403.205 - Medicare supplemental policy.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... Medicare. (b) The term policy includes both policy form and policy as specified in paragraphs (b)(1) and (b... 42 Public Health 2 2011-10-01 2011-10-01 false Medicare supplemental policy. 403.205 Section 403... GENERAL PROVISIONS SPECIAL PROGRAMS AND PROJECTS Medicare Supplemental Policies General Provisions §...

  16. Medicare program; elimination of inpatient routine nursing salary cost differential--HCFA. Final rule with comment period.

    PubMed

    1982-10-01

    Because patients age 65 and over had been presumed to require more nursing services than the general patient population, the Medicare reimbursement principles have, since 1969, recognized an inpatient routine nursing salary cost differential for hospitals and skilled nursing facilities (SNFs). Legislation enacted in 1981 limits this differential rate for hospitals to no more than 5 percent. Recent studies have cast serious doubt on the assumption that aged patients require more nursing services than do hospital patients generally. In view of these studies and in the interest of avoiding payments to providers of services that exceed the providers' reasonable costs, Pub. L. 97-248, the Tax Equity and Fiscal Responsibility Act of 1982, was enacted on September 3, 1982. Section 103 of this legislation eliminates the inpatient routine nursing salary cost differential as an element of reimbursable cost under Medicare for hospitals or SNFs.

  17. Medicare program; inpatient routine nursing salary cost differential--Health Care Financing Administration. Interim final rule with comment period.

    PubMed

    1981-10-01

    Because patients age 65 and over are presumed to require more nursing services than the general patient population, the Medicare reimbursement principles currently recognize an inpatient routine nursing salary cost differential for hospitals and skilled nursing facilities (SNFs). This differential is presently set at the rate of 8 1/2 percent. On August 13, 1981, Pub. L. 97-35, the Omnibus Budget Reconciliation Act of 1981, amended section 1861(v)(1) of the Social Security Act, by incorporating the nursing salary cost differential for hospitals specifically into the statute and by limiting the rate for hospitals to no more than 5 percent, beginning October 1, 1981. We are amending the Medicare regulations to incorporate the legislative amendment for hospitals.

  18. Medicare program; final waivers in connection with the Shared Savings Program. Interim final rule with comment period.

    PubMed

    2011-11-02

    This interim final rule with comment period establishes waivers of the application of the Physician Self-Referral Law, the Federal anti-kickback statute, and certain civil monetary penalties (CMP) law provisions to specified arrangements involving accountable care organizations (ACOs) under section 1899 of the Social Security Act (the Act) (the Shared Savings Program), including ACOs participating in the Advance Payment Initiative. 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.

  19. TRICARE; sub-acute care program; uniform skilled nursing facility benefit; home health care benefit; adopting Medicare payment methods for skilled nursing facilities and home health care providers. Final rule.

    PubMed

    2005-10-24

    This rule partially implements the TRICARE "sub-acute and long-term care program reform" enacted by Congress in the National Defense Authorization Act for Fiscal Year 2002, specifically: Establishment of "an effective, efficient, and integrated sub-acute care benefits program," with skilled nursing facility (SNF) and home health care benefits modeled after those of the Medicare program; adoption of Medicare payment methods for skilled nursing facility, home health care, and certain other institutional health care providers; adoption of Medicare rules on balance billing of beneficiaries, prohibiting it by institutional providers and limiting it by non-institutional providers; and change in the statutory exclusion of coverage for custodial and domiciliary care.

  20. Medicare Beneficiary Knowledge of and Experience with Prescription Drug Cards

    PubMed Central

    Rudolph, Noemi V.; Williams, Sunyna S.

    2007-01-01

    Medicare beneficiaries used prescription drug discount cards, both Medicare and non-Medicare cards, to assist them in paying for the cost of prescription drugs. This article describes the beneficiary's awareness and understanding, sources of information, and experience with drug discount cards a year prior and during the implementation of the Medicare-Approved Prescription Drug Discount Card program. Also, it explores beneficiary characteristics that contribute to card ownership and knowledge about drug discount cards. Understanding these experiences and factors can inform future outreach and education campaigns for the Medicare Drug Coverage program. PMID:18624082

  1. State Policies Influence Medicare Telemedicine Utilization.

    PubMed

    Neufeld, Jonathan D; Doarn, Charles R; Aly, Reem

    2016-01-01

    Medicare policy regarding telemedicine reimbursement has changed little since 2000. Many individual states, however, have added telemedicine reimbursement for either Medicaid and/or commercial payers over the same period. Because telemedicine programs must serve patients from all or most payers, it is likely that these state-level policy changes have significant impacts on telemedicine program viability and utilization of services from all payers, not just those services and payers affected directly by state policy. This report explores the impact of two significant state-level policy changes-one expanding Medicaid telemedicine coverage and the other introducing telemedicine parity for commercial payers-on Medicare utilization in the affected states. Medicare claims data from 2011-2013 were examined for states in the Great Lakes region. All valid claims for live interactive telemedicine professional fees were extracted and linked to their states of origin. Allowed encounters and expenditures were calculated in total and on a per 1,000 members per year basis to standardize against changes in the Medicare population by state and year. Medicare telemedicine encounters and professional fee expenditures grew sharply following changes in state Medicaid and commercial payer policy in the examined states. Medicare utilization in Illinois grew by 173% in 2012 (over 2011) following Medicaid coverage expansion, and Medicare utilization in Michigan grew by 118% in 2013 (over 2012) following adoption of telemedicine parity for commercial payers. By contrast, annual Medicare telemedicine utilization growth in surrounding states (in which there were no significant policy changes during these years) varied somewhat but showed no discernible pattern. Although Medicare telemedicine policy has changed little since its inception, changes in state policies with regard to telemedicine reimbursement appear to have significant impacts on the practical viability of telemedicine programs

  2. Medicare dependent hospitals: Who depends on whom?

    PubMed Central

    Goody, Brigid

    1992-01-01

    Small rural hospitals with a large proportion of Medicare patients currently receive special treatment as Medicare dependent hospitals (MDHs) under the prospective payment system (PPS). Other high Medicare hospitals (HMHs)—both urban and rural— have sought to have the additional per case payments extended to them. Current utilization patterns, the availability of alternative facilities, and the socioeconomic and demographic characteristics of the service areas were examined to determine whether either the current MDH or alternative HMH targeting criteria identify hospitals whose closure might impair access to care for Medicare beneficiaries residing in their service areas. Neither MDHs nor HMHs are substantially different from other hospitals in terms of providing access. While some individual MDHs or HMHs might be considered essential access facilities, alternate criteria should be developed to identify these facilities regardless of the proportion of their patients attributable to the Medicare program. PMID:10127457

  3. Monitoring outcomes for the Medicare Advantage program: methods and application of the VR-12 for evaluation of plans.

    PubMed

    Kazis, Lewis E; Selim, Alfredo J; Rogers, William; Qian, Shirley X; Brazier, John

    2012-01-01

    The Veterans RAND 12-Item Health Survey (VR-12) is one of the major patient-reported outcomes for ranking the Medicare Advantage (MA) plans in the Health Outcomes Survey (HOS). Approaches for scoring physical and mental health are given using contemporary norms and regression estimators. A new metric approach for the VR-12 called the "VR-6D" is presented with case-mix adjustments for monitoring plans that combine utilities and mortality. Results show that the models for ranking health outcomes of the plans are robust and credible. Future directions include the use of utilities for evaluating and ranking of MA plans.

  4. 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

    2015-11-05

    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.

  5. Medicare and Graduate Medical Education.

    DTIC Science & Technology

    1995-09-01

    cost were adapted by the Congressional Budget Office (CBO) from Monica Noether , "The Growing Supply of Physicians: Has the Market Become More...spurred by the introduc- tion and expansion of the Medicaid and Medicare programs (and precursors of those programs), which 16. See Monica Noether ...competitive (see Monica Noether , "The Growing Supply of Physicians: Has the Market Be- come More Competitive?"./«?«/-««/ of Labor Economics vol. 4

  6. 42 CFR 417.454 - Charges to Medicare enrollees.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... radiation therapy integral to the treatment regimen. (2) Renal dialysis services as defined at section 1881... (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND...

  7. 42 CFR 417.454 - Charges to Medicare enrollees.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... radiation therapy integral to the treatment regimen. (2) Renal dialysis services as defined at section 1881... (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND...

  8. 42 CFR 417.454 - Charges to Medicare enrollees.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... radiation therapy integral to the treatment regimen. (2) Renal dialysis services as defined at section 1881... (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND...

  9. What your practice should know about Medicare RAC audits.

    PubMed

    Matchinski, Jayme R

    2010-01-01

    The Recovery Audit Contractor (RAC) Program has become permanent by statute, and RACs have expanded their focus and efforts to identify improper Medicare payments in all 50 states. Physicians and practice groups that bill Medicare Parts A and B may be subject to a RAC Audit. There are two types of RAC reviews and audits, and there are five levels of appeals available to providers when Medicare claims are denied or a RAC audit identifies a previous Medicare overpayment. Physicians and practice groups should take steps to ensure compliance with Medicare regulations and to be prepared prior to receiving a letter from a RAC.

  10. Association of Practice-Level Social and Medical Risk With Performance in the Medicare Physician Value-Based Payment Modifier Program.

    PubMed

    Chen, Lena M; Epstein, Arnold M; Orav, E John; Filice, Clara E; Samson, Lok Wong; Joynt Maddox, Karen E

    2017-08-01

    Medicare recently launched the Physician Value-Based Payment Modifier (PVBM) Program, a mandatory pay-for-performance program for physician practices. Little is known about performance by practices that serve socially or medically high-risk patients. To compare performance in the PVBM Program by practice characteristics. Cross-sectional observational study using PVBM Program data for payments made in 2015 based on performance of large US physician practices caring for fee-for-service Medicare beneficiaries in 2013. High social risk (defined as practices in the top quartile of proportion of patients dually eligible for Medicare and Medicaid) and high medical risk (defined as practices in the top quartile of mean Hierarchical Condition Category risk score among fee-for-service beneficiaries). Quality and cost z scores based on a composite of individual measures. Higher z scores reflect better performance on quality; lower scores, better performance on costs. Among 899 physician practices with 5 189 880 beneficiaries, 547 practices were categorized as low risk (neither high social nor high medical risk) (mean, 7909 beneficiaries; mean, 320 clinicians), 128 were high medical risk only (mean, 3675 beneficiaries; mean, 370 clinicians), 102 were high social risk only (mean, 1635 beneficiaries; mean, 284 clinicians), and 122 were high medical and social risk (mean, 1858 beneficiaries; mean, 269 clinicians). Practices categorized as low risk performed the best on the composite quality score (z score, 0.18 [95% CI, 0.09 to 0.28]) compared with each of the practices categorized as high risk (high medical risk only: z score, -0.55 [95% CI, -0.77 to -0.32]; high social risk only: z score, -0.86 [95% CI, -1.17 to -0.54]; and high medical and social risk: -0.78 [95% CI, -1.04 to -0.51]) (P < .001 across groups). Practices categorized as high social risk only performed the best on the composite cost score (z score, -0.52 [95% CI, -0.71 to -0.33]), low risk had the next

  11. 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

  12. 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.

  13. 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

    ...This proposed notice sets forth proposed revisions to work relative value units (RVUs) and corresponding changes to the practice expense and malpractice RVUs affecting payment for physicians' services. The statute requires that we review RVUs no less often than every 5 years. This is our Fourth Five-Year Review of Work RVUs since we implemented the physician fee schedule (PFS) on January 1, 1992. These revisions to work RVUs are proposed to be effective for services furnished beginning January 1, 2012. These revisions reflect changes in medical practice and coding that affect the relative amount of physician work required to perform each service as required by the statute. The Fourth Five-Year Review of Work includes services that were submitted through public comment and by the Medicare contractor medical directors (CMDs), as well as a number of potentially misvalued codes identified by CMS (that is, Harvard valued codes and codes with Site-of-Service anomalies).

  14. Medicare program; standards and criteria for evaluating intermediary and carrier performance during fiscal year 1985--HCFA. General notice with comment period.

    PubMed

    1984-09-28

    This notice describes the standards and criteria to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program for fiscal year 1985. The results of these evaluations are considered whenever we enter into, renew, or terminate an intermediary or carrier agreement or take other contract actions; assign or reassign providers of services to an intermediary; or designate regional or national intermediaries. This notice is published in accordance with sections 1816(f) and 1842(b)(2) of the Social Security Act, as amended by section 2326 of the Deficit Reduction Act of 1984 (Pub. L. 98-369), which requires us to publish for public comment in the Federal Register those criteria and standards against which we evaluate intermediaries and carriers.

  15. Medicare and Medicaid programs; hospital conditions of participation: requirements for history and physical examinations; authentication of verbal orders; securing medications; and postanesthesia evaluations. Final rule.

    PubMed

    2006-11-27

    In this rule, we finalize changes to four of the current requirements (or conditions of participation (CoPs)) that hospitals must meet to participate in the Medicare and Medicaid programs. Specifically, this final rule revises and updates our CoP requirements for: Completion of the history and physical examination in the medical staff and the medical record services CoPs; authentication of verbal orders in the nursing service and the medical record services CoPs; securing medications in the pharmaceutical services CoP; and completion of the postanesthesia evaluation in the anesthesia services CoP. We also respond to timely public comments submitted on the proposed rule published in the March 25, 2005 Federal Register (70 FR 15266). The changes specified in this final rule are consistent with current medical practice and will reduce the regulatory burden on hospitals.

  16. Medicare program; schedule of limits on home health agency costs per visit for cost reporting periods beginning on or after July 1, 1988. HCFA--Notice with comment period.

    PubMed

    1988-10-18

    This final notice with comment period sets forth an updated schedule of limits on home health agency (HHA) costs that may be reimbursed under the Medicare program. This updated schedule of limits applies to cost reporting periods beginning on or after July 1, 1988.

  17. Medicare program; schedules of per-visit and per-beneficiary limitations on home health agency costs for cost reporting periods beginning on or after October 1, 1998; correction--HCFA. Correction of notice with comment period.

    PubMed

    1998-10-28

    In the August 11, 1998 issue of the Federal Register (63 FR 42912), we published a notice with comment period setting forth revised schedules of limitations on home health agency costs that may be paid under the Medicare program for cost reporting periods beginning on or after October 1, 1998. This document corrects technical and typographical errors made in that document.

  18. Medicare, Medicaid, and Children's Health Insurance Programs: Announcement of the Extension of Temporary Moratoria on Enrollment of Part B Non-Emergency Ground Ambulance Suppliers and Home Health Agencies in Designated Geographic Locations. Extension of temporary moratoria.

    PubMed

    2017-07-28

    This document announces the extension of statewide temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance providers and suppliers and Medicare home health agencies, subunits, and branch locations in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey, as applicable, to prevent and combat fraud, waste, and abuse. This extension also applies to the enrollment of new non-emergency ground ambulance suppliers and home health agencies, subunits, and branch locations in Medicaid and the Children's Health Insurance Program in those states.

  19. Health insurance coverage among disabled Medicare enrollees

    PubMed Central

    Rubin, Jeffrey I.; Wilcox-Gök, Virginia

    1991-01-01

    In this article, we use the Survey of Income and Program Participation to identify patterns of non-Medicare insurance coverage among disabled Medicare enrollees. Compared with the aged, the disabled are less likely to have private insurance coverage and more likely to have Medicaid. Probit analysis of the determinants of private insurance for disabled Medicare enrollees shows that income, education, marital status, sex, and having an employed family member are positively related to the likelihood of having private health insurance, whereas age and the probability of Medicaid enrollment are negatively related to this likelihood. PMID:10170806

  20. 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

    2011-02-02

    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.

  1. 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

  2. Medicare fraud and abuse.

    PubMed

    Scala-Foley, Marisa; Bryant, Natasha

    2004-01-01

    Medicare fraud and abuse affects the quality of services and the cost of health care. The Department of Health and Human Services is partnering with federal and local agencies to educate consumers to recognize and report suspected cases. In this brief we discuss the Senior Medicare Patrol Project and the roles of the federal agency organizations in preventing fraudulent activities in the Medicare system. We also profile the Ohio Seniors Fight Fraud Project.

  3. Financial Performance of Rural Medicare ACOs.

    PubMed

    Nattinger, Matthew C; Mueller, Keith; Ullrich, Fred; Zhu, Xi

    2016-08-24

    The Centers for Medicare & Medicaid Services (CMS) has facilitated the development of Medicare accountable care organizations (ACOs), mostly through the Medicare Shared Savings Program (MSSP). To inform the operation of the Center for Medicare & Medicaid Innovation's (CMMI) ACO programs, we assess the financial performance of rural ACOs based on different levels of rural presence. We used the 2014 performance data for Medicare ACOs to examine the financial performance of rural ACOs with different levels of rural presence: exclusively rural, mostly rural, and mixed rural/metropolitan. Of the ACOs reporting performance data, we identified 97 ACOs with a measurable rural presence. We found that successful rural ACO financial performance is associated with the ACO's organizational type (eg, physician-based) and that 8 of the 11 rural ACOs participating in the Advanced Payment Program (APP) garnered savings for Medicare. Unlike previous work, we did not find an association between ACO size or experience and rural ACO financial performance. Our findings suggest that rural ACO financial success is likely associated with factors unique to rural environments. Given the emphasis CMS has placed on rural ACO development, further research to identify these factors is warranted. © 2016 National Rural Health Association.

  4. 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.

  5. 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.

  6. A simple change to the Medicare Part D low-income subsidy program could save $5 billion.

    PubMed

    Zhang, Yuting; Zhou, Chao; Baik, Seo Hyon

    2014-06-01

    Medicare Part D provides a subsidy to beneficiaries with incomes below 150 percent of the federal poverty level. Enrollees with the low-income subsidy accounted for 75 percent of the $60 billion in total federal Part D spending in 2013. The government randomly assigns any new beneficiary who automatically qualifies for the subsidy, or who successfully applies for it without indicating a preferred plan, to a stand-alone Part D plan whose premium is equal to or below the average premium for the basic Part D benefit in the region. We used an intelligent reassignment algorithm and 2008-09 Part D drug use and spending data to match enrollees to available plans according to their medication needs. We found that such a reassignment approach could have saved the federal government over $5 billion in 2009, for mean government savings of $710 (median: $368) per enrollee with a low-income subsidy. Implementing that simple change to reassign beneficiaries would have also lowered the proportion of prescriptions that required utilization review from 29 percent to 20 percent, and the proportion of prescriptions with quantity limits from 27 percent to 19 percent. Project HOPE—The People-to-People Health Foundation, Inc.

  7. Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children's Health Insurance Program Reauthorization Act and the Merit-based Incentive Payment System.

    PubMed

    Barbieri, John S; Miller, Jeffrey J; Nguyen, Harrison P; Forman, Howard P; Bolognia, Jean L; VanBeek, Marta J

    2017-03-30

    As the implementation of the Medicare Access and Children's Health Insurance Program Reauthorization Act begins, many dermatologists who provide Medicare Part B services will be subject to the reporting requirements of the Merit-based Incentive Payment System (MIPS). Clinicians subject to MIPS will receive a composite score based on performance across 4 categories: quality, advancing care information, improvement activities, and cost. Depending on their overall MIPS score, clinicians will be eligible for a positive or negative payment adjustment. Quality will replace the Physician Quality Reporting System and clinicians will report on 6 measures from a list of over 250 options. Advancing care information will replace meaningful use and will assess clinicians on activities related to integration of electronic health record technology into their practice. Improvement activities will require clinicians to attest to completion of activities focused on improvements in care coordination, beneficiary engagement, and patient safety. Finally, cost will be determined automatically from Medicare claims data. In this article, we will provide a detailed review of the Medicare Access and Children's Health Insurance Program Reauthorization Act with a focus on MIPS and briefly discuss the potential implications for dermatologists.

  8. 42 CFR 422.108 - Medicare secondary payer (MSP) procedures.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Benefits and Beneficiary Protections § 422... enrollees with the benefits of the primary payers, including reporting, on an ongoing basis, information... instructions. (c) Collecting from other entities. The MA organization may bill, or authorize a provider to...

  9. Consumer knowledge of Medicare and supplemental health insurance benefits.

    PubMed Central

    McCall, N; Rice, T; Sangl, J

    1986-01-01

    In this article, data from a recent study funded by the Health Care Financing Administration are used to examine the level of knowledge about health care insurance coverage among Medicare beneficiaries. Two related categories of this knowledge are analyzed: knowledge of the Medicare program itself and knowledge of supplemental health insurance policies owned by program beneficiaries. The results indicate that Medicare beneficiaries typically do not have high levels of knowledge either about Medicare or about their supplemental health insurance. Also analyzed are the factors that affect knowledge levels. PMID:3512483

  10. Centers for Medicare & Medicaid Services

    MedlinePlus

    ... Medicare Medicaid/CHIP Medicare-Medicaid Coordination Private Insurance Innovation Center Regulations & Guidance Research, Statistics, Data & Systems Outreach & Education CMS.gov Covering more Americans Making ...

  11. Medicare Rights and Protections

    MedlinePlus

    ... the phone number for your state’s Office for Civil Rights by visiting Medicare. gov/ contacts. ■■ Have your personal ... the phone number for your state’s Office for Civil Rights by visiting Medicare. gov/ contacts. 7 ■■ Get emergency ...

  12. 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

  13. Evaluating outcomes of care and targeting quality improvement using Medicare health outcomes survey data.

    PubMed

    Bowen, Sonya E

    2012-01-01

    The Medicare Health Outcomes Survey (HOS) provides a rich source of outcomes data on the Medicare Advantage (MA) program for the US Department of Health and Human Services, managed care organizations participating in Medicare, quality improvement organizations, and health services researchers working to improve quality of care for Medicare enrollees. Since 1998, the Centers for Medicare and Medicaid Services has collected longitudinal functional status information to assess the performance of Medicare managed care organizations. This introduction reviews the goals of the HOS program, how the HOS supports health care reform, and outlines recent HOS studies exploring data applications for monitoring outcomes and implementing quality improvement activities.

  14. Medicare coverage for oncology services.

    PubMed

    Bagley, G P; McVearry, K

    1998-05-15

    Medicare's mission is to assure health care security for our beneficiaries. Title XVIII of the Social Security Act (the Act) provides the Health Care Financing Administration (HCFA) with the authority to fulfill this mission. Although Medicare is considered a defined benefit program, the Act vested Medicare with the discretionary authority to make specific policy decisions when necessary. HCFA's discretionary authority, which is found at section 1862(a)(1)(A) of the Act, enables HCFA to provide coverage for services that are reasonable and necessary for the treatment and diagnosis of illness or injury or to improve the functioning of a malformed body member. To determine whether a service is reasonable and necessary, HCFA relies on authoritative evidence. This evidence includes, but is not limited to, approvals from appropriate federal agencies, such as the Food and Drug Administration, and systematic evaluations of scientific literature via technology assessments. HCFA also may decide that a service warrants a unique type of coverage policy, which is referred to as coverage with conditions. This form of coverage is a middle ground between strict noncoverage and general coverage for a medical service that appears promising, but still is evolving. All these policy specifications effect Medicare coverage of oncology services. This means that reasonable and necessary diagnostic and therapeutic cancer-related services that are not otherwise prohibited by Medicare's statute, regulations, and manual instructions are covered and paid for by the program. Prior to the Balanced Budget Act of 1997 (BBA '97), Medicare provided coverage for some beneficiaries to undergo mammography and Papanicolaou smear screening. As a result of BBA '97, Congress has mandated expanding coverage for these services as well as adding coverage for pelvic examinations, prostate cancer screening, colorectal screening, and antiemetic drugs used as part of an anticancer chemotherapy regimen. Other

  15. 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 2018 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Program Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Provider-Based Status of Indian Health Service and Tribal Facilities and Organizations; Costs Reporting and Provider Requirements; Agreement Termination Notices. Final rule.

    PubMed

    2017-08-14

    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 2018. Some of these changes implement certain statutory provisions contained in the Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Medicare Access and CHIP Reauthorization Act of 2015, the 21st Century Cures Act, and other legislation. We also are making changes relating to the provider-based status of Indian Health Service (IHS) and Tribal facilities and organizations and to the low-volume hospital payment adjustment for hospitals operated by the IHS or a Tribe. In addition, we are providing the market basket update that will 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 2018. 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 2018. In addition, we are 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). We also are establishing new requirements or revising existing requirements for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. We are updating policies relating to the Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program. We also are making changes relating to transparency of accrediting organization survey

  16. 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

  17. Trends in Medicare Part D Medication Therapy Management Eligibility Criteria.

    PubMed

    Wang, Junling; Shih, Ya-Chen Tina; Qin, Yolanda; Young, Theo; Thomas, Zachary; Spivey, Christina A; Solomon, David K; Chisholm-Burns, Marie

    2015-01-01

    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. To describe trends in MTM eligibility thresholds used by Medicare Part D plans and to identify patterns that may hinder enrollment in MTM programs. 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. 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. 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.

  18. 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.

  19. 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…

  20. 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…