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Sample records for fr03au10p medicare program

  1. 77 FR 32407 - Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-01

    ... Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for...; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year...), the final rule with comment period entitled ``Medicare Program; Changes to the Medicare Advantage...

  2. 75 FR 32858 - Medicare Program; Policy and Technical Changes to the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-10

    ...-AP77 Medicare Program; Policy and Technical Changes to the Medicare Advantage and the Medicare...; Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit... entitled ``Medicare Program; Policy and Technical Changes to the Medicare Advantage and the...

  3. 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...

  4. 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

    ... 42 CFR Parts 422 and 423 Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage... Loss Ratio Requirements for the Medicare Advantage and the Medicare Prescription Drug Benefit Programs... proposed rule would implement medical loss ratio (MLR) requirements for the Medicare Advantage Program...

  5. 77 FR 1877 - Medicare Program; Medicare Advantage and Prescription Drug Benefit Programs: Negotiated Pricing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-01-12

    ...; Medicare Advantage and Prescription Drug Benefit Programs: Negotiated Pricing and Remaining Revisions..., governing what was renamed the Medicare Advantage (MA) program (formerly Medicare+Choice). The MMA...

  6. 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...

  7. 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... Insurance; and Program No. 93.774, Medicare-- Supplementary Medical Insurance Program) Dated: March 13, 2013..., Utilization and Quality Control Peer Review, private health insurance, and related matters. They are...

  8. 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.

  9. 75 FR 19677 - Medicare Program; Policy and Technical Changes to the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-04-15

    ... Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs; Final Rule... Parts 417, 422, 423, and 480 [CMS-4085-F] RIN 0938-AP77 Medicare Program; Policy and Technical Changes.... Provisions of the Proposed Rule and Analysis and Responses to Public Comments A. Changes to Strengthen...

  10. 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.

  11. 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 ...

  12. 76 FR 54599 - Medicare Program; Medicare Advantage and Prescription Drug Benefit Programs

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-01

    ... 42 CFR Parts 417, 422, and 423 Medicare Program; Medicare Advantage and Prescription Drug Benefit... Prescription Drug Benefit Programs AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Final... (MA) program (Part C), prescription drug benefit program (Part D) and section 1876 cost...

  13. 75 FR 29555 - Medicare Program; Medicare Coverage Gap Discount Program Model Manufacturer Agreement and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-05-26

    ... Services [CMS-4151-NC] RIN 0938-AQ04 Medicare Program; Medicare Coverage Gap Discount Program Model... contains a draft model agreement for use by the Secretary and manufacturers under the Medicare Coverage Gap Discount Program established by section 3301 of the Patient Protection and Affordable Care Act, as...

  14. 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.

  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

    ... the Medicare Prescription Drug Benefit Programs for Contract Year 2013 and Other Proposed Changes... Prescription Drug Benefit Programs for Contract Year 2013 and Other Proposed Changes; Considering Changes to... (MA) program (Part C) regulations and prescription drug benefit program (Part D) regulations...

  16. 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...

  17. 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...

  18. 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.

  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. 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

  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 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.

  3. 75 FR 81885 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Correcting Amendment

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-29

    ... Programs; Electronic Health Record Incentive Program; Correcting Amendment AGENCY: Centers for Medicare...; Electronic Health Record Incentive Program'' that appeared in the July 28, 2010 Federal Register. DATES... 44314) the final rule entitled ``Medicare and Medicaid Programs; Electronic Health Record...

  4. 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.

  5. 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.

  6. 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.

  7. 78 FR 31283 - Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-23

    ..., and others. Overall, commenters supported our decision to model Medicare MLR policy after the commercial MLR rules. In this final rule, we address comments and concerns regarding the policies included in... applicability to various plan types. Part 422 of the Code of Federal Regulations (CFR) regulates the MA...

  8. 77 FR 27778 - Medicare Program; Meeting of the Medicare Economic Index Technical Advisory Panel-May 21, 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-11

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

  9. Medicare

    MedlinePlus

    ... supplies Quality, planning, & compare tools Latest Updates Get smart about antibiotics Saving money on health costs: get ... Get Medicare forms Publications Information in other languages Phone numbers & websites Helpful Links Site Map Site policies & ...

  10. 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)....

  11. 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

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Solicitation of Two... Health and Human Services (DHHS) (the Secretary) and the Administrator of the Centers for Medicare... of the following: geography; rural or urban practice; race, ethnicity, sex, and disability;...

  12. 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,...

  13. 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...

  14. 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...

  15. 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.

  16. 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.

  17. 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

    .... Sec. 423.100 and 423.104) 9. Medication Therapy Management Comprehensive Medication Reviews and... Medication Therapy Management MTMP Medication Therapy Management Program NAIC National Association Insurance... publication First Tier and applicable 01/01/13 Downstream Entities. II.E.9 Medication Therapy effective...

  18. 75 FR 41503 - Medicare and Medicaid Programs; Approval of the Community Health Accreditation Program for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-16

    ... services, and the conditions for Medicare payment for hospice care. Provider agreement regulations are... Community Health Accreditation Program for Continued Deeming Authority for Hospices AGENCY: Centers for... the Community Health Accreditation Program (CHAP) hospice accreditation program meet or exceed...

  19. 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...

  20. 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).

  1. 76 FR 19655 - Medicare Program; Waiver Designs in Connection With the Medicare Shared Savings Program and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-07

    ... integrated-care models envisioned by the Medicare Shared Savings Program. Section 1899(f) of the Act... models. We may consider waivers (where authorized under the Affordable Care Act), exceptions, or safe harbors, as applicable, for other types of ACOs, integrated-care delivery models, or...

  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. 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...

  4. 78 FR 53769 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-30

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

  5. 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...

  6. 76 FR 46814 - Medicare Program; Evaluation Criteria and Standards for Quality Improvement Program Contracts...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-03

    ...) Model (See Section C.10 of the 10th Statement of Work) Learning and Action Networks are mechanisms by... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Evaluation Criteria and... & Medicaid Services (CMS), HHS. ACTION: Notice with comment period. SUMMARY: This notice with comment...

  7. 76 FR 19527 - Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-07

    ... Guidance Relating to Tax Exempt Organization 3. Antitrust Policy Statement 4. Prohibition Against the... Innovation CMP Civil Monetary Penalties CMS Centers for Medicare and Medicaid Services CNM Certified Nurse... new approach to the delivery of health care aimed at: (1) Better care for individuals; (2)...

  8. 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

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Establishment of a program to collect suggestions... Medicare Fraud and Abuse, and Establishment of a Program to Collect Suggestions for Improving Medicare... collect suggestions for improving Medicare program efficiency and to reward suggesters for...

  9. 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...

  10. 77 FR 14989 - Medicare Program; Revisions to the Durable Medical Equipment, Prosthetics, Orthotics, and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-14

    ... are included in the definition of ``medical and other health services'' in section 1861(s)(8) of the... HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part 424 RIN 0938-AQ57 Medicare Program... Safeguards AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Final rule. SUMMARY:...

  11. 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...

  12. 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...

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

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-27

    ... plan shall reimburse the appropriate Medicare Trust Fund for Medicare's payments for items and services... to such items and services. The responsibility for payment on the part of workers' compensation... right under MSP of an individual or any other entity to payment for items or services under a...

  14. 76 FR 76541 - Medicare Program; Availability of Medicare Data for Performance Measurement

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-07

    ...This final rule implements Section 10332 of the Affordable Care Act regarding the release and use of standardized extracts of Medicare claims data for qualified entities to measure the performance of providers of services (referred to as providers) and suppliers. This rule explains how entities can become qualified by CMS to receive standardized extracts of claims data under Medicare Parts A,......

  15. 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...

  16. 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...

  17. 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).

  18. 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…

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

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-11

    ... Washington, DC--Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G... of the building. A stamp- in clock is available for persons wishing to retain a proof of filing...

  1. 77 FR 38067 - Medicare Program; Public Meeting Regarding Inherent Reasonableness of Medicare Fee Schedule...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-26

    ... what Medicare pays for mail order supplies versus non-mail order supplies may encourage fraud and abuse... or other animals except Seeing Eye dogs and other dogs trained to assist the handicapped,...

  2. 77 FR 71423 - Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-30

    ... 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...

  3. 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...

  4. 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...

  5. 76 FR 67567 - Medicare Program; Inpatient Hospital Deductible and Hospital and Extended Care Services...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-01

    ... Medicare Program; Inpatient Hospital Deductible and Hospital and Extended Care Services Coinsurance Amounts... Services RIN 0938-AQ14 Medicare Program; Inpatient Hospital Deductible and Hospital and Extended Care... extended care services coinsurance amounts for services furnished in calendar year (CY) 2012 under...

  6. 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...

  7. 76 FR 35683 - Medicare Program; Conditions of Participation (CoPs) for Community Mental Health Centers

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-17

    ... 42 CFR Part 485 Medicare Program; Conditions of Participation (CoPs) for Community Mental Health... 485 RIN 0938-AP51 Medicare Program; Conditions of Participation (CoPs) for Community Mental Health... (no password required). I. Background A. Introduction In 2007, 224 certified Community Mental...

  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. 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

    ...; Home Health Prospective Payment System Rate Update for Calendar Year 2011; Changes in Certification... Federal Register entitled ``Medicare Program; Home Health Prospective Payment System Rate Update for... Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011; Changes...

  10. 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.

  11. 78 FR 26038 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-January Through March 2013

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-03

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

  12. 78 FR 45233 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-April Through June 2013

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-26

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

  13. 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.

  14. 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.

  15. 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.

  16. 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...

  17. 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...

  18. 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...

  19. 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...

  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...

  1. 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... Centers for Medicare & Medicaid Services RIN 0938-AP87 Medicare Program; Prospective Payment System and... forth an update to the payment rates used under the prospective payment system for skilled...

  2. 42 CFR 424.535 - Revocation of enrollment and billing privileges in the Medicare program.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 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...

  3. 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...

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

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-18

    .... Screening pap smears. Influenza, pneumococcal pneumonia, and hepatitis B vaccines. Colorectal screening... Program; Part B Inpatient Billing in Hospitals AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Proposed rule. SUMMARY: The proposed rule would revise Medicare Part B billing policies when...

  6. 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...

  7. 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...

  8. 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...

  9. 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

    ...This notice announces the annual adjustment in the amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective for requests for ALJ hearings and judicial review filed on or after January 1, 2014. The calendar year 2014 AIC threshold amounts are......

  10. 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... selected genetic tests for cancer diagnosis (for cancers of unknown primary site and for cervical...

  11. 75 FR 52629 - Medicare Program; Establishing Additional Medicare Durable Medical Equipment, Prosthetics...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-27

    ... to furnish outpatient physical therapy or speech pathology services, or a community mental health... From the Federal Register Online via the Government Publishing Office ] DEPARTMENT OF HEALTH AND... health agency (HHA), or a hospice that has in effect an agreement to participate in Medicare, or a...

  12. 77 FR 50110 - Medicare Program; Request for Nominations for Members for the Medicare Evidence Development...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-20

    ... reviews and evaluates medical literature, technology assessments, and hears public testimony on the evidence available to address the impact of medical items and services on health outcomes of Medicare... Federal Official. The MEDCAC reviews and evaluates medical literature, technology assessments, and...

  13. 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.

  14. 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)......

  15. 77 FR 67449 - Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-09

    ...This final rule updates and makes revisions to the end-stage renal disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2013. This rule also sets forth requirements for the ESRD quality incentive program (QIP), including for payment year (PY) 2015 and beyond. In addition, this rule implements changes to bad debt reimbursement for all Medicare providers, suppliers, and other......

  16. 75 FR 1843 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-01-13

    ...This proposed rule would implement the provisions of the American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111-5) that provide incentive payments to eligible professionals (EPs) and eligible hospitals participating in Medicare and Medicaid programs that adopt and meaningfully use certified electronic health record (EHR) technology. The proposed rule would specify the--initial......

  17. 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.

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

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-27

    ... Services (HHS). Under section 1861(s) of the Social Security Act (the Act), the Medicare program will only... enforcement procedures for laboratories found to be out of compliance with its requirements. The ability...

  2. 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.

  3. 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

  4. 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)...

  5. 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...

  6. 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

  7. 75 FR 32480 - Funding Opportunity: Affordable Care Act Medicare Beneficiary Outreach and Assistance Program...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-08

    ... Outreach and Assistance Program Funding for Title VI Native American Programs Purpose of Notice... Medicare Beneficiary Outreach and Assistance Program Funding for Title VI Native American Programs... Older Americans Act Title VI Native American program awardee. The purpose of these grants will be...

  8. 77 FR 31620 - Medicare Program; Public Meeting in Calendar Year 2012 for New Clinical Laboratory Tests Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-29

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Public Meeting in Calendar... for Medicare payment under the clinical laboratory fee schedule (CLFS) for calendar year (CY)...

  9. 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...

  10. 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...

  11. 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.

  12. 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

    ... and approval of a national accrediting organization's requirements consider, among other factors, the... will be conducted in accordance with, but not necessarily limited to, the following factors: The... Program No. 93.778, Medical Assistance Program; No. 93.773 Medicare--Hospital Insurance Program; and...

  13. 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......

  14. 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...

  15. 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.

  16. 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.

  17. 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

  18. 77 FR 34326 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-11

    ... 0938-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... Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term...

  19. 77 FR 17070 - Medicare and Medicaid Programs; Application From Det Norske Veritas Healthcare (DNVHC) for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-23

    ... national accrediting organization's requirements consider, among other factors, the applying accrediting... accordance with, but not necessarily limited to, the following factors: The equivalency of DNVHC's standards.... 93.778, Medical Assistance Program; No. 93.773 Medicare--Hospital Insurance Program; and No....

  20. 77 FR 37681 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-22

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

  1. 78 FR 32664 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-31

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

  2. 76 FR 11782 - Medicare, Medicaid, and Children's Health Insurance Programs; Renewal, Expansion, and Renaming of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-03

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

  3. 77 FR 70785 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-27

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

  4. 76 FR 61365 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-04

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

  5. 78 FR 12327 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-22

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

  6. 78 FR 32661 - Medicare, Medicaid, and Children's Health Insurance Programs; Renewal of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-31

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

  7. 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...

  8. 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.

  9. 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.

  10. 78 FR 79201 - Medicare and State Health Care Programs: Fraud and Abuse; Electronic Health Records Safe Harbor...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-27

    ... 1001 Medicare and State Health Care Programs: Fraud and Abuse; Electronic Health Records Safe Harbor... Inspector General 42 CFR Part 1001 RIN 0991-AB33 Medicare and State Health Care Programs: Fraud and Abuse... and technologies in the health care industry. In accordance with this authority, OIG published a...

  11. 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

  12. 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 &...

  13. 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...

  14. 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

    ... 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... therapy and speech language pathology covered services from a provider of services, a clinic,...

  15. 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

    ... 42 CFR Parts 409, 424, 484, et al. Medicare Program; Home Health Prospective Payment System Rate...; Home Health Prospective Payment System Rate Update for Calendar Year 2013, Hospice Quality Reporting... Prospective Payment System (HH PPS) rates, including the national standardized 60-day episode rates,...

  16. 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...

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

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-10-22

    ... 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...

  18. 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…

  19. 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....

  20. 76 FR 47301 - Medicare Program; Hospice Wage Index for Fiscal Year 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-04

    ... Medicare and Medicaid Programs h. Accounting Statement i. Conclusion B. Regulatory Flexibility Act Analysis....306(c) require each hospice's labor market to be established using the most current hospital wage data... the most current available hospital wage data, as well as any changes by the OMB to the definitions...

  1. 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...

  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. 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...

  4. 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...

  5. 78 FR 31558 - Medicare Program; Second Semi-Annual Meeting of the Advisory Panel on Hospital Outpatient Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-24

    ... conversion factor, charge compression, revisions to the cost report, pass-through payments, correct coding...--Hospital Insurance Program; and No. 93.774, Medicare-- Supplementary Medical Insurance Program) Dated:...

  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

    ... (CMS), HHS. ACTION: Notice. SUMMARY: This quarterly notice lists CMS manual instructions, substantive... through June 2012, relating to the Medicare and Medicaid programs and other programs administered by CMS... each of the addenda published in this notice. Addenda Contact Phone No. I CMS Manual...

  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

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

  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. 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.

  10. 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.

  11. 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...), HHS. ACTION: Final notice. SUMMARY: This notice announces our decision to renew the Medicare Advantage... receive covered services through a Medicare Advantage (MA) organization that contracts with CMS....

  12. 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......

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

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-16

    ... May 16, 2012 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services..., 2012 / Rules and Regulations#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare... Medicaid regulations that CMS has identified as unnecessary, obsolete, or excessively burdensome on...

  14. 77 FR 13697 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 2

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-07

    ...This proposed rule would specify the Stage 2 criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to qualify for Medicare and/or Medicaid electronic health record (EHR) incentive payments. In addition, it would specify payment adjustments under Medicare for covered professional services and hospital services provided by EPs,......

  15. 77 FR 53967 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 2

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-09-04

    ...This final rule specifies the Stage 2 criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to qualify for Medicare and/or Medicaid electronic health record (EHR) incentive payments. In addition, it specifies payment adjustments under Medicare for covered professional services and hospital services provided by EPs, eligible......

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

    PubMed

    2016-09-16

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

  17. Medicare 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.

  18. 76 FR 59136 - Medicare and Medicaid Programs; Application by Community Health Accreditation Program for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-23

    ... Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G, Hubert H. Humphrey... building. A stamp- in clock is available for persons wishing to retain a proof of filing by stamping in...

  19. 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.

  20. 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

    ... ADMINISTRATION Privacy Act of 1974, as Amended; Computer Matching Program (SSA/ Centers for Medicare & Medicaid... renewal of an existing computer matching program that will expire on October 16, 2013. SUMMARY: In... computer matching program that we conduct with CMS. DATES: We will file a report of the subject...

  1. 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...

  2. 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.

  3. 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.

  4. 77 FR 19288 - Medicare Program; Renewal of Deeming Authority of the Utilization Review Accreditation Commission...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-30

    ... of the Utilization Review Accreditation Commission for Medicare Advantage Health Maintenance... Advantage ``deeming authority'' of the Utilization Review Accreditation Commission (URAC) for Health... covered services through a Medicare Advantage (MA) organization that contracts with CMS. The...

  5. 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

  6. 77 FR 70447 - Medicare Program; Semi-Annual Meeting of the Advisory Panel on Hospital Outpatient Payment (HOP...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-26

    ... factor, charge compression, revisions to the cost report, pass-through payments, correct coding, new... to, the conversion factor, charge compression, revisions to the cost report, pass-through payments...--Hospital Insurance Program; and No. 93.774, Medicare-- Supplementary Medical Insurance Program)...

  7. 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

  8. 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

    ..., and the conditions for Medicare payment for hospice care. Generally, to enter into an agreement, a... provide hospice care and services.'' To meet the requirements at Sec. 418.100(c), CHAP revised its standards to specify that a hospice must be primarily engaged in providing care and services consistent...

  9. 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

    ... February 7, 2013 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services.... 78 , No. 26 / Thursday, February 7, 2013 / Proposed Rules#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN... identified as unnecessary, obsolete, or excessively burdensome on health care providers and suppliers,...

  10. 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

    .... Thirty-Day Hospital Readmissions b. Efficiency c. Population/Community Health 6. Proposed Scoring for the... July 11, 2012 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services... Register / Vol. 77, No. 133 / Wednesday, July 11, 2012 / Proposed Rules#0;#0; ] DEPARTMENT OF HEALTH...

  11. 75 FR 73086 - Medicare and Medicaid Programs; Renewal of Deeming Authority of the National Committee for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-29

    ... Deeming Authority of the National Committee for Quality Assurance for Medicare Advantage Health... application to renew the Medicare Advantage Deeming Authority of the National Committee for Quality Assurance... beneficiaries may receive covered services through a Medicare Advantage (MA) organization that contracts...

  12. 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...

  13. 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...

  14. 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...

  15. 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...

  16. 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

  17. 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.

  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. 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...

  20. 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.

  1. 78 FR 48995 - Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face-to...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-12

    ...This document corrects technical errors that appeared in the final rule with comment period published in the Federal Register on November 16, 2012, entitled ``Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face-to-Face Encounters, Elimination of the Requirement for Termination of Non-Random Prepayment Complex Medical Review and Other Revisions to Part B......

  2. 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,...

  3. 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...

  4. 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.

  5. 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.

  6. 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, ...

  7. 76 FR 17870 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-October Through December 2010

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-31

    ...) Facilities. Addendum XIV: Lung Volume Reduction Surgery. Addendum XV: Medicare-approved Bariatric Surgery... Cardiovascular Data Registry Sites, Carotid Stent Facilities, approved Bariatric Surgery Facilities, National... XV: Medicare-Approved Bariatric Surgery Facilities October Through December 2010 On February 21,...

  8. 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...

  9. 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....

  10. 76 FR 48563 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-January Through March 2011...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-08

    ... Volume Reduction Surgery Facilities. XIV Medicare-Approved Bariatric Kate Tillman, RN, (410) 786-9252..., Addendum XIV: Medicare-Approved Bariatric Surgery Facilities, Addendum XV: FDG-PET for Dementia and... information, contact JoAnna Baldwin, MS (410-786-7205). Addendum XIV Medicare-Approved Bariatric...

  11. 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......

  12. 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...

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

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-31

    .... Vincent's Medical Center AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice... application process for hospitals to apply to the Centers for Medicare & Medicaid Services (CMS) to receive St... process for qualifying hospitals to apply to CMS to receive direct graduate medical education (GME)...

  14. 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

    ... Advance Payment Model for certain accountable care organizations participating in the Medicare Shared..., coordinated care and generate cost savings. The Advance Payment Model will test whether and how pre-paying a... Application Deadline for the Advance Payment Model AGENCY: Centers for Medicare & Medicaid Services (CMS),...

  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

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

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

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-24

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

  17. 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...

  18. 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....

  19. 75 FR 23851 - Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-05-04

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

  20. 78 FR 43533 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-19

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

  1. 76 FR 74121 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-30

    ...This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) for CY 2012 to implement applicable statutory requirements and changes arising from our continuing experience with this system. 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......

  2. 76 FR 42169 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-18

    ...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. 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 OPPS.......

  3. 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.

  4. 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.

  5. Understanding medicare

    MedlinePlus

    ... laws What Medicare decides is covered What local companies decide to cover It's important to always check ... drugs. MA plans are offered by private insurance companies provided who work along with Medicare. You pay ...

  6. 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.

  7. Medicare Rights and Protections

    MedlinePlus

    ... about: Your rights & protections in: ■ ■ Original Medicare ■ ■ Medicare Advantage Plan or other Medicare health plans ■ ■ Medicare Prescription ... 11 Section 3: Your Rights in a Medicare Advantage Plan or Other Medicare Health Plan 13 Section ...

  8. 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

    ... Joint Commission for Deeming Authority for Psychiatric Hospitals AGENCY: Centers for Medicare & Medicaid... announcing the Joint Commission's request for approval as a deeming organization for psychiatric hospitals... of the Joint Commission's application in accordance with the criteria specified by our...

  9. 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 & Medicaid Services, Department of Health and Human Services, Room 445-G, Hubert H. Humphrey... building. A stamp- in clock is available for persons wishing to retain a proof of filing by stamping in...

  10. 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

    ... Washington, DC--Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G... of the building. A stamp- in clock is available for persons wishing to retain a proof of filing...

  11. 78 FR 46733 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-01

    ...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, 2013 through September 30,...

  12. 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,...

  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. 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.

  15. 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

    ... fluorodeoxyglucose positron emissions tomography for dementia, and a list of Medicare-approved bariatric surgery... (410) 786-7205. Questions concerning Medicare-approved bariatric surgery facilities listed in Addendum... must meet our standards in order to receive coverage for bariatric surgery procedures. Addendum...

  16. 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

    ... fluorodeoxyglucose positron emissions tomogrogphy for dementia, and a list of Medicare-approved bariatric surgery... (410) 786-7205. Questions concerning Medicare-approved bariatric surgery facilities listed in Addendum... order to receive coverage for bariatric surgery procedures. Addendum XVI includes a listing of...

  17. 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

    ...-approved bariatric surgery facilities. Section 1871(c) of the Social Security Act requires that we publish... order to receive coverage for bariatric surgery procedures. Addendum XVI includes a listing of Medicare... list of Medicare-approved lung volume reduction surgery facilities, a list of...

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

    PubMed

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

    2011-06-01

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

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

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-04

    ... and ethnic groups and served as an impetus for addressing health inequalities for racial and ethnic... May 4, 2011 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services... / Wednesday, May 4, 2011 / Proposed Rules#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for...

  1. 76 FR 26731 - Medicare Program; Hospice Wage Index for Fiscal Year 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-09

    ... Index for Fiscal Year 2012 AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice of CMS ruling. SUMMARY: This notice announces a CMS Ruling that was signed on April 14, 2011 regarding CMS's determination to grant relief to any hospice provider that has a properly pending appeal...

  2. 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. ACTION: Correction of notice of CMS ruling. SUMMARY: This document corrects technical errors that appeared in the notice of CMS ruling published in the Federal Register on May 9, 2011 entitled...

  3. 75 FR 73088 - Medicare Program; Application by the American Association for Accreditation of Ambulatory Surgery...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-29

    ... Providers of Outpatient Physical Therapy and Speech-Language Pathology Services. AGENCY: Centers for... outpatient physical therapy and speech-language pathology services that wish to participate in the Medicare..., describes the nature of the request, and provides at least a 30-day public comment period. DATES: To...

  4. 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...

  5. 75 FR 68799 - Medicare Program; Inpatient Hospital Deductible and Hospital and Extended Care Services...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-09

    ... the 21st through 100th day of extended care services in a skilled nursing facility in a benefit period... deductible); and the daily coinsurance for the 21st through 100th day of extended care services in a skilled... Extended Care Services Coinsurance Amounts for CY 2011 AGENCY: Centers for Medicare & Medicaid...

  6. 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......

  7. 75 FR 78247 - Medicare Program; Town Hall Meeting on Physician Quality Reporting System

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-15

    ... Quality Reporting System AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice of meeting. SUMMARY: This notice announces a Town Hall Meeting to discuss the Physician Quality Reporting System (previously known as the Physician Quality Reporting Initiative (PQRI)). The purpose of the...

  8. 75 FR 45769 - Medicare Program; Changes to the Hospital Outpatient Prospective Payment System and Ambulatory...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-03

    ... Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System for CY 2010, and Extension of Part B Payment for Services Furnished by Hospitals or Clinics Operated by the Indian Health... Medicare hospital outpatient payment system (OPPS) for CY 2010. This Notice also contains the payment...

  9. 76 FR 18472 - Medicare Program; Revisions to the Durable Medical Equipment, Prosthetics, Orthotics, and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-04

    ... are furnished by two types of entities, providers, and suppliers. At Sec. 400.202, the term ``provider.... The term ``DMEPOS'' encompasses the types of items included in the definition of medical ] equipment..., ] which may result in monetary increases in health care costs and further drains on the Medicare...

  10. 75 FR 70371 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-17

    ...This final rule sets forth an update to the Home Health Prospective Payment System (HH PPS) rates, including: the national standardized 60-day episode rates, the national per-visit rates, the nonroutine medical supply (NRS) conversion factors, and the low utilization payment amount (LUPA) add-on payment amounts, under the Medicare prospective payment system for HHAs effective January 1, 2011.......

  11. 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

    ...This proposed rule would update 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), and outlier payments under the Medicare prospective payment system for home health agencies effective January 1,...

  12. 75 FR 43235 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-23

    ...This proposed rule would set forth an update to the Home Health Prospective Payment System (HH PPS) rates, including: The national standardized 60-day episode rates, the national per-visit rates, the non-routine medical supply (NRS) conversion factors, and the low utilization payment amount (LUPA) add-on payment amounts, under the Medicare prospective payment system for HHAs effective January......

  13. 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...

  14. 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...

  15. 75 FR 30917 - Medicare Program; Supplemental Proposed Changes to the Hospital Inpatient Prospective Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-02

    ...This proposed rule is a supplement to the fiscal year (FY) 2011 hospital inpatient prospective payment systems (IPPS) and long- term care prospective payment system (LTCH PPS) proposed rule published in the May 4, 2010 Federal Register. This supplemental proposed rule would implement certain statutory provisions relating to Medicare payments to hospitals for inpatient services that are......

  16. 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...

  17. 76 FR 48485 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-08

    ...-148, the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152, enacted on March 30... August 8, 2011 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services..., 2011 / Rules and Regulations#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for...

  18. 75 FR 58203 - Medicare, Medicaid, and Children's Health Insurance Programs; Additional Screening Requirements...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-09-23

    ..., non-government owned or affiliated ambulance service suppliers, community mental health centers (CMHCs...-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152... Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Parts 405, 424, 438, et...

  19. 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...

  20. 76 FR 26431 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Rate...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-06

    ...This final rule updates the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs) for discharges occurring during the rate year (RY) beginning July 1, 2011 through September 30, 2012. The final rule also changes the IPF prospective payment system (PPS) payment rate update period to a RY that coincides with a fiscal year (FY). In......

  1. 76 FR 4997 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Rate...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-01-27

    ...This proposed rule would update the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs) for discharges occurring during the rate year beginning July 1, 2011 through September 30, 2012. The proposed rule would also change the IPF prospective payment system (PPS) payment rate update period to a rate year (RY) that coincides with......

  2. 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......

  3. 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....

  4. 76 FR 15105 - Medicare and Medicaid Programs; Civil Money Penalties for Nursing Homes

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-18

    ...This final rule will revise and expand current Medicare and Medicaid regulations regarding the imposition and collection of civil money penalties by CMS when nursing homes are not in compliance with Federal participation requirements in accordance with section 6111 of the Affordable Care Act of...

  5. 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

    ... submit an enrollment application. A physician or eligible professional who is employed by the Public... eligible professionals to order and refer covered items and services for Medicare beneficiaries to be... Information Requirements'' section in this document. For information on viewing public comments, see...

  6. 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

    ...This major final rule with comment period addresses changes to the physician fee schedule, clinical laboratory 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. This final rule with comment period also includes a discussion in the Supplementary Information regarding......

  7. 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

    ...This major 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, as well as changes in the...

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

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-16

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

  10. 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......

  11. 78 FR 21610 - Expansion Funds for the Support of the Senior Medicare Patrol (SMP) Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-04-11

    ... to the incumbent Senior Medicare Patrol (SMP) grantees under limited competition. SUMMARY: The...; Expertise in capturing data in the SMP management, tracking, and reporting system (SMART FACTS); Established... of Elder Rights, One Massachusetts Avenue NW., Washington, DC 20001; telephone (202) 357-3520;...

  12. 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...

  13. 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...

  14. 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)...

  15. 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),...

  16. 76 FR 54953 - Medicare Program; Changes to the Electronic Prescribing (eRx) Incentive Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-06

    ..., authorized the Secretary to establish a program to encourage the adoption and use of eRx technology... prescribing objective and measure to be considered a meaningful user of Certified EHR Technology (``eligible... That Encourage the Use of Health Information Technology,'' available at...

  17. 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.

  18. 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.

  19. 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.

  20. 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.

  1. 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......

  2. 76 FR 5755 - Medicare and Medicaid Programs; Patient Notification of Right To Access State Survey Agencies and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-02

    ...This proposed rule would set forth new requirements for Medicare certified providers and suppliers. This proposed rule would require that the Medicare certified providers and suppliers make available to their Medicare beneficiaries information about their right to file a written complaint with the Quality Improvement Organization (QIO) in the State where healthcare services are being or were......

  3. 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

    ... certain teaching hospitals, both members of Medicare GME affiliated groups and those that were not... them are members of Medicare GME affiliated groups. Many of these teaching hospitals have hundreds of... Medicare and Medicaid Extenders Act of 2010 relating to the treatment of teaching hospitals that...

  4. 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 §...

  5. 42 CFR 420.410 - Establishment of a program to collect suggestions for improving Medicare program efficiency and...

    Code of Federal Regulations, 2010 CFR

    2010-10-01

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

  6. 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

    ...-approved bariatric surgery facilities. Section 1871(c) of the Social Security Act requires that we publish... must meet our standards in order to receive coverage for bariatric surgery procedures. Addendum XVI... list of Medicare-approved lung volume reduction surgery facilities, a list of...

  7. 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

  8. 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.

  9. 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

  10. 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

  11. 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.

  12. 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, ...

  13. Medicare Hospice Benefits

    MedlinePlus

    ... include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare ... Medicare coverage. Original Medicare —Original Medicare is a fee-for-service health plan that has two parts: ...

  14. 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.

  15. 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

    2017-01-31

    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."

  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 MEDICAL INSURANCE Amount of Monthly Premiums...

  17. 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

  18. 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

  19. 75 FR 68798 - Medicare Program; Part A Premiums for CY 2011 for the Uninsured Aged and for Certain Disabled...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-09

    ... and for Certain Disabled Individuals Who Have Exhausted Other Entitlement AGENCY: Centers for Medicare... as the ``uninsured aged'') and by certain disabled individuals who have exhausted other entitlement... or the Railroad Retirement Act and certain others do not have to pay premiums for Medicare Part...

  20. 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...

  1. 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...

  2. 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...

  3. 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...

  4. 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...

  5. 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...

  6. 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...

  7. 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...

  8. 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...

  9. 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......

  10. 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

  11. 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.

  12. 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.

  13. 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.

  14. 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

  15. 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

  16. 77 FR 2983 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-01-20

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

  17. 77 FR 17073 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-23

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

  18. 76 FR 41260 - Supplemental Funding for the Senior Medicare Patrol (SMP) Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-13

    ... need for enhanced and improved collection of SMP outcomes, including new data elements within the SMART... volunteer program have also been generated by the program expansion and capacity building...

  19. 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...

  20. 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.

  1. 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,...

  2. 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.

  3. 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...

  4. 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.

  5. 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.

  6. 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) ...

  7. 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.

  8. 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

    ... the National Council for the Prescription Drug Programs (NCPDP) Prescriber/ Pharmacist Interface... adopted NCPDP Prescriber/Pharmacist Interface SCRIPT standard, Version 8, Release 1 and its equivalent NCPDP Prescriber/Pharmacist Interface SCRIPT Implementation Guide, Version 8, Release 1...

  9. 78 FR 53149 - Medicare and Medicaid Programs: Continued Approval of American Osteopathic Association/Healthcare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-28

    ... accreditation program under part 488, subpart A, must provide CMS with reasonable assurance that the accrediting... SOM, AOA/ HFAP will continue to conduct monthly internal audits to ensure accepted PoC's contain...

  10. 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.

  11. 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).

  12. 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 ...

  13. 76 FR 24213 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-29

    ...This proposed rule would implement section 3004 of the Affordable Care Act, which establishes a new quality reporting program that provides for a 2 percent reduction in the annual increase factor beginning in 2014 for failure to report quality data to the Secretary of Health and Human Services. This proposed rule would also update the prospective payment rates for inpatient rehabilitation......

  14. 76 FR 47835 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-05

    ...This final rule will implement section 3004 of the Affordable Care Act, which establishes a new quality reporting program that provides for a 2 percent reduction in the annual increase factor beginning in 2014 for failure to report quality data to the Secretary of Health and Human Services. This final rule will also update the prospective payment rates for inpatient rehabilitation facilities......

  15. 78 FR 17677 - Medicare and Medicaid Programs: Application From the American Osteopathic Association/Healthcare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-22

    ... the American Osteopathic Association/Healthcare Facilities Accreditation Program for Continued CMS... commenting, please refer to file code CMS-3281-PN. Because of staff and resource limitations, we cannot... Services, Department of Health and Human Services, Attention: CMS-3281-PN, P.O. Box 8016, Baltimore,...

  16. 77 FR 51537 - Medicare and Medicaid Programs; Continued Approval of Det Norske Veritas Healthcare's (DNVHC's...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-24

    ... Approval of Det Norske Veritas Healthcare's (DNVHC's) Hospital Accreditation Program AGENCY: Centers for... decision to approve the Det Norske Veritas Healthcare (DNVHC) for continued recognition as a national... years or sooner as determined by us. Det Norske Veritas Healthcare's current term of approval for...

  17. 78 FR 21308 - Medicare Program; Physicians' Referrals to Health Care Entities With Which They Have Financial...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-04-10

    ... have a significant effect on program expenditures, and there are no additional substantive costs to... forth in Sec. 411.357(w)(2), ``software is deemed to be interoperable if a certifying body recognized by.... 411.357(w)(2) to reflect that ONC is responsible for ``recognizing'' certifying bodies, as...

  18. 75 FR 52760 - Medicare Program; Listening Session Regarding the Implementation of Section 10332 of the Patient...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-27

    ... these entities; data elements required, and the sources and types of other data that these organizations... potential stakeholders on key components of the design of the program. We are soliciting input on the types of organizations that may be interested in receiving data as qualified entities under this...

  19. 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...

  20. 78 FR 20564 - Medicare and Medicaid Programs; Survey, Certification and Enforcement Procedures

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-04-05

    ... that apply for, and are granted, recognition and approval of an accreditation program in accordance... appropriate notice (including reasons for the determination) to the AO and affected providers or suppliers... the involvement of personnel in the survey or accreditation decision process who have a financial...

  1. 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...

  2. 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)...

  3. 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.

  4. 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).

  5. 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.

  6. 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.

  7. 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.

  8. 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).

  9. 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

  10. 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).

  11. 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.

  12. 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

    ... Medicaid Programs; Waiver of Disapproval of Nurse Aide Training Program in Certain Cases AGENCY: Centers... a waiver of a nurse aide training disapproval as it applies to skilled nursing facilities, in the... INFORMATION: I. Background Waiver of Disapproval of Nurse Aide Training Program in Certain Cases...

  13. 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

  14. 78 FR 16795 - Medicare and Medicaid Programs; Requirements for Long-Term Care (LTC) Facilities; Notice of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-19

    ... addressing health care inequalities for racial and ethnic minorities that rely on Medicare and Medicaid for... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND... overall health of residents. Therefore, having an organized process that facilities must follow in...

  15. 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

    ...This final rule will update the Home Health Prospective Payment System (HH PPS) rates, including the national, standardized 60- day episode payment rates, the national per-visit rates, the low- utilization payment adjustment (LUPA) add-on, and the non-routine medical supply (NRS) conversion factor under the Medicare prospective payment system for home health agencies (HHAs), effective January......

  16. 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

    ...This proposed rule would update the Home Health Prospective Payment System (HH PPS) rates, including the national, standardized 60- day episode payment rates, the national per-visit rates, the low- utilization payment adjustment (LUPA) add-on, the nonroutine medical supplies (NRS) conversion factor, and outlier payments under the Medicare prospective payment system for home health agencies......

  17. 78 FR 5458 - Medicare Program; Request for Information To Aid in the Design and Development of a Survey...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-01-25

    ... new health care delivery models.'' The survey, now under development, hereinafter referred to as the... Hospice Care AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Request for information... experiences with hospice care. DATES: The information solicited in this notice must be received at the...

  18. 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...

  19. 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...

  20. 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

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 410, 414, 415, and 495 RIN 0938... general questions about memory should be included in the HRA.'' is corrected to read ``One commenter... the HRA. However, the commenter believed that general questions about memory should be included in...

  1. 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......

  2. 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…

  3. 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...

  4. 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...

  5. 42 CFR 403.205 - Medicare supplemental policy.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Medicare supplemental policy. 403.205 Section 403.205 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS SPECIAL PROGRAMS AND PROJECTS Medicare Supplemental Policies General Provisions §...

  6. 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…

  7. 42 CFR 423.462 - Medicare secondary payer procedures.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Coordination of Part D Plans With Other Prescription Drug Coverage § 423.462 Medicare secondary payer procedures. (a) General... to Part D sponsors and Part D plans (with respect to the offering of qualified prescription...

  8. 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...

  9. 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 §...

  10. 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 §...

  11. 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 §...

  12. 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 §...

  13. 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.

  14. 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.

  15. 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.

  16. 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

    ...This major proposed rule 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 would also implement provisions of the Affordable Care Act by establishing a face-to-face encounter as a condition of payment......

  17. 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......

  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. Medicare program: request for public comments on implementation of risk adjusted payment for the Medicare+Choice program and announcement of public meeting--HCFA. Solicitation of comments; announcement of meeting.

    PubMed

    1998-09-08

    This notice solicits further public comments on issues related to the implementation of risk adjusted payment of Medicare+Choice organizations. Section 1853(a)(3) of the Social Security Act (the Act) requires the Secretary to implement a risk adjustment methodology that accounts for variation in per capita costs based on health status and demographic factors for payments no later than January 1, 2000. The methodology is to apply uniformly to all Medicare+Choice plans. This notice outlines our proposed approach to implementing risk adjusted payment. In order to carry out risk adjustment, section 1853(a)(3) of the Act also requires Medicare+Choice organizations, as well as other organizations with risk sharing contracts, to submit encounter data. Inpatient hospital data are required for discharges on or after July 1, 1997. Other data, as the Secretary deems necessary, may be required beginning July 1998. The Medicare+Choice interim final rule published on June 26, 1998 (63 FR 34968) describes the general process for the collection of encounter data. We also included a schedule for the collection of additional encounter data. Physician, outpatient hospital, skilled nursing facility, and home health data will be collected no earlier than October 1, 1999, and all other data we deem necessary no earlier than October 1, 2000. Given any start date, comprehensive risk adjustment will be made about three years after the year of initial collection of outpatient hospital and physician encounter data. Comments on the process for encounter data collection are requested in that interim final rule. We intend to consider comments received in response to this solicitation as we develop the final methodology for implementation of risk adjustment. This notice also informs the public of a meeting on September 17, 1998, to discuss risk adjustment and the collection of encounter data. The meeting will be held at the Health Care Financing Administration headquarters, located at 7500

  20. 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

  1. 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.

  2. 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

  3. 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.

  4. 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

  5. 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.

  6. 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.

  7. 42 CFR 411.37 - Amount of Medicare recovery when a primary payment is made as a result of a judgment or settlement.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Amount of Medicare recovery when a primary payment is made as a result of a judgment or settlement. 411.37 Section 411.37 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE...

  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. 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.

  10. 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

  11. 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.

  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. 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.

  14. 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.

  15. Use and knowledge of the new enrollee "welcome to Medicare" physical examination benefit.

    PubMed

    Petroski, Cara A; Regan, Joseph F

    2009-01-01

    The Medicare Current Beneficiary Survey (MCBS) is a large survey utilizing a nationally representative sample of the Medicare population. The MCBS collects data on a whole host of topics including health status, health insurance coverage and financing, access to care, knowledge and understanding of the Medicare Program, as well as use and effectiveness of new program benefits and changes.

  16. 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…

  17. 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…

  18. Effect of medicare payment on rural health care systems.

    PubMed

    McBride, Timothy D; Mueller, Keith J

    2002-01-01

    Medicare payments constitute a significant share of patient-generated revenues for rural providers, more so than for urban providers. Therefore, Medicare payment policies influence the behavior of rural providers and determine their financial viability. Health services researchers need to contribute to the understanding of the implications of changes in fee-for-service payment policy, prospects for change because of the payment to Medicare+Choice risk plans, and implications for rural providers inherent in any restructuring of the Medicare program. This article outlines the basic policy choices, implications for rural providers and Medicare beneficiaries, impacts of existing research, and suggestions for further research. Topics for further research include implications of the Critical Access Hospital program, understanding how changes in payment to rural hospitals affect patient care, developing improved formulas for paying rural hospitals, determining the payment-to-cost ratio for physicians, measuring the impact of changes in the payment methodology used to pay for services delivered by rural health clinics and federally qualified health centers, accounting for the reasons for differences in historical Medicare expenditures across rural counties and between rural and urban counties, explicating all reasons for Medicare+Choice plans withdrawing from some rural areas and entering others, measuring the rural impact of proposals to add a prescription drug benefit to the Medicare program, and measuring the impact of Medicare payment policies on rural economies.

  19. Providing information to help Medicare beneficiaries choose a health plan.

    PubMed

    McCormack, L A; Burrus, B B; Garfinkel, S A; Gibbs, D; Harris-Kojetin, L D; Sangl, J A

    2001-01-01

    Many Medicare beneficiaries have limited knowledge of the Medicare program and related health insurance options. This is due in part to the complexity of the Medicare program and supplemental health insurance market. A recent congressional mandate through the Balanced Budget Act of 1997 called for broad dissemination of information to educate beneficiaries about their health plan options and to encourage informed health plan decision-making. In response, the Health Care Financing Administration (HCFA) launched the National Medicare Education Program (NMEP) to support the educational objectives of the BBA. This paper provides an overview of the components of the NMEP information campaign. We also review lessons learned from our experience in designing and testing a prototype consumer handbook that explains the different health plan options to Medicare beneficiaries. Through our discussion of the handbook, we highlight several ways to communicate information effectively about a complex publicly funded program to an older adult population.

  20. Medicare Advantage update: benefits, enrollment, and payments after the ACA.

    PubMed

    Linehan, Kathryn

    2013-07-19

    In 2012, the Medicare program paid private health plans $136 billion to cover about 13 million beneficiaries who received Part A and B benefits through the Medicare Advantage (MA) program rather than traditional fee-for-service (FFS) Medicare. Private plans have been a part of the program since the 1970s. Debate about the policy goals--Should they cost less per beneficiary than FFS Medicare? Should they be available to all beneficiaries? Should they be able to offer additional benefits?--has long accompanied Medicare's private plan option.This debate is reflected in the history of Medicare payment policy,and policy decisions over the years have affected plans' willingness to participate and beneficiaries' enrollment at different periods of the program. Recently, evidence that the Medicare program was paying more per beneficiary in MA relative to what would have been spent under FFS Medicare prompted policymakers to reduce MA payments in the Patient Protection and Affordable Care Act of 2010 (ACA). So far, plans continue to participate in MA and enrollment continues to grow, but payment reductions in 2012 through 2014 have been partially offset by payments made to plans through the quality bonus payment demonstration.This brief contains recent data on plan enrollment, availability, and benefits and discusses MA plan payment policy, including changes to MA payment made in the ACA and their actual and projected effects.

  1. Medicare privatization and the erosion of retirement security.

    PubMed

    Polivka, Larry; Kwak, Jung

    2008-01-01

    This paper describes initiatives to privatize the Medicare program over the last 10 years and the implications of these initiatives for the future of retirement security. Our analysis focuses on the privatization provisions of the Medicare Modernization Act, which is largely designed to benefit the corporate health care sector without containing costs or significantly reducing the threat of rising health care costs to the economic security of current and future retirees. In fact, as designed, the Medicare Modernization Act is likely to increase the threat to retirement security in the years ahead. We conclude with a series of policy alternatives to the neoliberal agenda for the privatization of Medicare.

  2. Public/Private Partnerships for Prescription Drug Coverage: Policy Formulation and Outcomes in Quebec's Universal Drug Insurance Program, with Comparisons to the Medicare Prescription Drug Program in the United States

    PubMed Central

    Pomey, Marie-Pascale; Forest, Pierre-Gerlier; Palley, Howard A; Martin, Elisabeth

    2007-01-01

    In January 1997, the government of Quebec, Canada, implemented a public/private prescription drug program that covered the entire population of the province. Under this program, the public sector collaborates with private insurers to protect all Quebecers from the high cost of drugs. This article outlines the principal features and history of the Quebec plan and draws parallels between the factors that led to its emergence and those that led to the passage of the Medicare Prescription Drug, Improvement and Modernization Act (MMA) in the United States. It also discusses the challenges and similarities of both programs and analyzes Quebec's ten years of experience to identify adjustments that may help U.S. policymakers optimize the MMA. PMID:17718665

  3. Medicare program; end-stage renal disease prospective payment system and quality incentive program; ambulance fee schedule; durable medical equipment; and competitive acquisition of certain durable medical equipment prosthetics, orthotics and supplies. Final rule.

    PubMed

    2011-11-10

    This final rule updates and makes certain revisions to the End-Stage Renal Disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2012. We are also finalizing the interim final rule with comment period published on April 6, 2011, regarding the transition budget-neutrality adjustment under the ESRD PPS,. This final rule also sets forth requirements for the ESRD quality incentive program (QIP) for payment years (PYs) 2013 and 2014. In addition, this final rule revises the ambulance fee schedule regulations to conform to statutory changes. This final rule also revises the definition of durable medical equipment (DME) by adding a 3-year minimum lifetime requirement (MLR) that must be met by an item or device in order to be considered durable for the purpose of classifying the item under the Medicare benefit category for DME. Finally, this final rule implements certain provisions of section 154 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) related to the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) Competitive Acquisition Program and responds to comments received on an interim final rule published January 16, 2009, that implemented these provisions of MIPPA effective April 18, 2009. (See the Table of Contents for a listing of the specific issues addressed in this final rule.)

  4. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. Final rule with comment period.

    PubMed

    2016-11-04

    The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repeals the Medicare sustainable growth rate (SGR) methodology for updates to the physician fee schedule (PFS) and replaces it with a new approach to payment called the Quality Payment Program that rewards the delivery of high-quality patient care through two avenues: Advanced Alternative Payment Models (Advanced APMs) and the Merit-based Incentive Payment System (MIPS) for eligible clinicians or groups under the PFS. This final rule with comment period establishes incentives for participation in certain alternative payment models (APMs) and includes the criteria for use by the Physician-Focused Payment Model Technical Advisory Committee (PTAC) in making comments and recommendations on physician-focused payment models (PFPMs). Alternative Payment Models are payment approaches, developed in partnership with the clinician community, that provide added incentives to deliver high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. This final rule with comment period also establishes the MIPS, a new program for certain Medicare-enrolled practitioners. MIPS will consolidate components of three existing programs, the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals (EPs), and will continue the focus on quality, cost, and use of certified EHR technology (CEHRT) in a cohesive program that avoids redundancies. In this final rule with comment period we have rebranded key terminology based on feedback from stakeholders, with the goal of selecting terms that will be more easily identified and understood by our stakeholders.

  5. 42 CFR 460.94 - Required services for Medicare participants.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE Services § 460.94 Required services for Medicare participants. (a)...

  6. 42 CFR 460.180 - Medicare payment to PACE organizations.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Payment § 460.180 Medicare payment to PACE organizations. (a) Principle...

  7. 42 CFR 460.94 - Required services for Medicare participants.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE Services § 460.94 Required services for Medicare participants. (a)...

  8. 42 CFR 460.180 - Medicare payment to PACE organizations.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Payment § 460.180 Medicare payment to PACE organizations. (a) Principle...

  9. 42 CFR 460.94 - Required services for Medicare participants.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE Services § 460.94 Required services for Medicare participants. (a)...

  10. 42 CFR 460.180 - Medicare payment to PACE organizations.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Payment § 460.180 Medicare payment to PACE organizations. (a) Principle...

  11. 42 CFR 460.94 - Required services for Medicare participants.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE Services § 460.94 Required services for Medicare participants. (a)...

  12. Medicare Hospice Benefits

    MedlinePlus

    ... 4 Care for a condition other than your terminal illness ......................................... 4 How your Medicare hospice benefit works ..................................................... ... care, counseling, drugs, equipment, and supplies for the terminal illness and related conditions. ■■ Care is generally provided ...

  13. Medicare and Rural Health

    MedlinePlus

    ... health maintenance organization, preferred provider organization, or private fee-for-service plan. Part D (Prescription Drug Coverage) ... provisions and their effects through 2013: Medicare Physician Fee Schedule Update – the Geographic Practice Cost Indices were ...

  14. Claims and Appeals (Medicare)

    MedlinePlus

    ... gov Medicare forms Advance directives & long-term care Electronic prescribing Electronic Health Records (EHRs) Download claims with Medicare’s Blue ... to Disclose Personal Health Information form Access an electronic form so that someone who helps you with ...

  15. Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System--Update for Fiscal Year Beginning October 1, 2015 (FY 2016). Final rule.

    PubMed

    2015-08-05

    This final rule updates the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs) (which are freestanding IPFs and psychiatric units of an acute care hospital or critical access hospital). These changes are applicable to IPF discharges occurring during fiscal year (FY) 2016 (October 1, 2015 through September 30, 2016). This final rule also implements: a new 2012-based IPF market basket; an updated IPF labor-related share; a transition to new Core Based Statistical Area (CBSA) designations in the FY 2016 IPF Prospective Payment System (PPS) wage index; a phase-out of the rural adjustment for IPF providers whose status changes from rural to urban as a result of the wage index CBSA changes; and new quality measures and reporting requirements under the IPF quality reporting program. This final rule also reminds IPFs of the October 1, 2015 implementation of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), and updates providers on the status of IPF PPS refinements.

  16. 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 Alternative Payment Models in dermatology.

    PubMed

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

    2017-03-30

    With the introduction of the Medicare Access and Children's Health Insurance Program Reauthorization Act, clinicians who are not eligible for an exemption must choose to participate in 1 of 2 new reimbursement models: the Merit-based Incentive Payment System or Alternative Payment Models (APMs). Although most dermatologists are expected to default into the Merit-based Incentive Payment System, some may have an interest in exploring APMs, which have associated financial incentives. However, for dermatologists interested in the APM pathway, there are currently no options other than joining a qualifying Accountable Care Organization, which make up only a small subset of Accountable Care Organizations overall. As a result, additional APMs relevant to dermatologists are needed to allow those interested in the APMs to explore this pathway. Fortunately, the Medicare Access and Children's Health Insurance Program Reauthorization Act establishes a process for new APMs to be approved and the creation of bundled payments for skin diseases may represent an opportunity to increase the number of APMs available to dermatologists. In this article, we will provide a detailed review of APMs under the Medicare Access and Children's Health Insurance Program Reauthorization Act and discuss the development and introduction of APMs as they pertain to dermatology.

  17. 42 CFR 407.11 - Forms used to apply for enrollment under Medicare Part B.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Forms used to apply for enrollment under Medicare Part B. 407.11 Section 407.11 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM SUPPLEMENTARY MEDICAL INSURANCE (SMI) ENROLLMENT AND ENTITLEMENT Individual Enrollment and Entitlement...

  18. 42 CFR 406.15 - Special provisions applicable to Medicare qualified government employment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... government employment. 406.15 Section 406.15 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM HOSPITAL INSURANCE ELIGIBILITY AND ENTITLEMENT Hospital Insurance Without Monthly Premiums § 406.15 Special provisions applicable to Medicare...

  19. 42 CFR 403.206 - General standards for Medicare supplemental policies.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false General standards for Medicare supplemental policies. 403.206 Section 403.206 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS SPECIAL PROGRAMS AND PROJECTS Medicare Supplemental...

  20. 42 CFR 420.405 - Rewards for information relating to Medicare fraud and abuse.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Rewards for information relating to Medicare fraud... Rewards for Information Relating to Medicare Fraud and Abuse, and Establishment of a Program to Collect... Rewards for information relating to Medicare fraud and abuse. (a) General rule. CMS pays a monetary...

  1. 42 CFR 420.405 - Rewards for information relating to Medicare fraud and abuse.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Rewards for information relating to Medicare fraud... Rewards for Information Relating to Medicare Fraud and Abuse, and Establishment of a Program to Collect... Rewards for information relating to Medicare fraud and abuse. (a) General rule. CMS pays a monetary...

  2. 42 CFR 420.405 - Rewards for information relating to Medicare fraud and abuse.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Rewards for information relating to Medicare fraud... Rewards for Information Relating to Medicare Fraud and Abuse, and Establishment of a Program to Collect... Rewards for information relating to Medicare fraud and abuse. (a) General rule. CMS pays a monetary...

  3. 42 CFR 412.108 - Special treatment: Medicare-dependent, small rural hospitals.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Special treatment: Medicare-dependent, small rural hospitals. 412.108 Section 412.108 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL...

  4. Medicare. Indirect Medical Education Payments Are Too High. GAO Report to Congressional Committees.

    ERIC Educational Resources Information Center

    Zimmerman, Michael; And Others

    A report to the Congressional Committees examines the variation in Medicare costs and payments among teaching and nonteaching hospitals and identifies factors explaining the variation. Three chapters are as follows: (1) introduction (i.e., the Medicare Program, Medicare payments for inpatient hospital services, objectives, scope, and methodology);…

  5. 42 CFR 420.405 - Rewards for information relating to Medicare fraud and abuse.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Rewards for information relating to Medicare fraud... Information Relating to Medicare Fraud and Abuse, and Establishment of a Program to Collect Suggestions for... information relating to Medicare fraud and abuse. (a) General rule. CMS pays a monetary reward for...

  6. Medicare and Medicaid programs; modifications to the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program for 2014 and other changes to EHR Incentive Program; and health information technology: revision to the certified EHR technology definition and EHR certification changes related to standards. Final rule.

    PubMed

    2014-09-04

    This final rule changes the meaningful use stage timeline and the definition of certified electronic health record technology (CEHRT) to allow options in the use of CEHRT for the EHR reporting period in 2014. It also sets the requirements for reporting on meaningful use objectives and measures as well as clinical quality measure (CQM) reporting in 2014 for providers who use one of the CEHRT options finalized in this rule for their EHR reporting period in 2014. In addition, it finalizes revisions to the Medicare and Medicaid EHR Incentive Programs to adopt an alternate measure for the Stage 2 meaningful use objective for hospitals to provide structured electronic laboratory results to ambulatory providers; to correct the regulation text for the measures associated with the objective for hospitals to provide patients the ability to view online, download, and transmit information about a hospital admission; and to set a case number threshold exemption for CQM reporting applicable for eligible hospitals and critical access hospitals (CAHs) beginning with FY 2013. Finally, this rule finalizes the provisionally adopted replacement of the Data Element Catalog (DEC) and the Quality Reporting Document Architecture (QRDA) Category III standards with updated versions of these standards.

  7. Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Organ Procurement Organization Reporting and Communication; Transplant Outcome Measures and Documentation Requirements; Electronic Health Record (EHR) Incentive Programs; Payment to Nonexcepted Off-Campus Provider-Based Department of a Hospital; Hospital Value-Based Purchasing (VBP) Program; Establishment of Payment Rates Under the Medicare Physician Fee Schedule for Nonexcepted Items and Services Furnished by an Off-Campus Provider-Based Department of a Hospital. Final rule with comment period and interim final rule with comment period.

    PubMed

    2016-11-14

    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 2017 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this final rule with comment period updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program. Further, in this final rule with comment period, we are making changes to tolerance thresholds for clinical outcomes for solid organ transplant programs; to Organ Procurement Organizations (OPOs) definitions, outcome measures, and organ transport documentation; and to the Medicare and Medicaid Electronic Health Record Incentive Programs. We also are removing the HCAHPS Pain Management dimension from the Hospital Value-Based Purchasing (VBP) Program. In addition, we are implementing section 603 of the Bipartisan Budget Act of 2015 relating to payment for certain items and services furnished by certain off-campus provider-based departments of a provider. In this document, we also are issuing an interim final rule with comment period to establish the Medicare Physician Fee Schedule payment rates for the nonexcepted items and services billed by a nonexcepted off-campus provider-based department of a hospital in accordance with the provisions of section 603.

  8. HOW MUCH FAVORABLE SELECTION IS LEFT IN MEDICARE ADVANTAGE?

    PubMed

    Newhouse, Joseph P; Price, Mary; McWilliams, J Michael; Hsu, John; McGuire, Thomas G

    2015-01-01

    The health economics literature contains two models of selection, one with endogenous plan characteristics to attract good risks and one with fixed plan characteristics; neither model contains a regulator. Medicare Advantage, a principal example of selection in the literature, is, however, subject to anti-selection regulations. Because selection causes economic inefficiency and because the historically favorable selection into Medicare Advantage plans increased government cost, the effectiveness of the anti-selection regulations is an important policy question, especially since the Medicare Advantage program has grown to comprise 30 percent of Medicare beneficiaries. Moreover, similar anti-selection regulations are being used in health insurance exchanges for those under 65. Contrary to earlier work, we show that the strengthened anti-selection regulations that Medicare introduced starting in 2004 markedly reduced government overpayment attributable to favorable selection in Medicare Advantage. At least some of the remaining selection is plausibly related to fixed plan characteristics of Traditional Medicare versus Medicare Advantage rather than changed selection strategies by Medicare Advantage plans.

  9. HOW MUCH FAVORABLE SELECTION IS LEFT IN MEDICARE ADVANTAGE?

    PubMed Central

    PRICE, MARY; MCWILLIAMS, J. MICHAEL; HSU, JOHN; MCGUIRE, THOMAS G.

    2015-01-01

    The health economics literature contains two models of selection, one with endogenous plan characteristics to attract good risks and one with fixed plan characteristics; neither model contains a regulator. Medicare Advantage, a principal example of selection in the literature, is, however, subject to anti-selection regulations. Because selection causes economic inefficiency and because the historically favorable selection into Medicare Advantage plans increased government cost, the effectiveness of the anti-selection regulations is an important policy question, especially since the Medicare Advantage program has grown to comprise 30 percent of Medicare beneficiaries. Moreover, similar anti-selection regulations are being used in health insurance exchanges for those under 65. Contrary to earlier work, we show that the strengthened anti-selection regulations that Medicare introduced starting in 2004 markedly reduced government overpayment attributable to favorable selection in Medicare Advantage. At least some of the remaining selection is plausibly related to fixed plan characteristics of Traditional Medicare versus Medicare Advantage rather than changed selection strategies by Medicare Advantage plans. PMID:26389127

  10. 42 CFR 405.425 - Effects of opting-out of Medicare.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Effects of opting-out of Medicare. 405.425 Section 405.425 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED Private Contracts § 405.425 Effects of opting-out of Medicare. If a...

  11. 78 FR 57857 - Medicare and Medicaid Programs; Application from the Compliance Team for Initial CMS-Approval of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-20

    ... the Compliance Team for Initial CMS-Approval of its Rural Health Clinic Accreditation Program AGENCY... below, no later than 5 p.m. on October 21, 2013. ADDRESSES: In commenting, please refer to file code CMS... Services, Attention: CMS-3287-PN, P.O. Box 8016, Baltimore, MD 21244-8010. Please allow sufficient time...

  12. 77 FR 31359 - Medicare and Medicaid Programs; Announcement of the Re-Approval of the Joint Commission as an...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-25

    ... the Re-Approval of the Joint Commission as an Accreditation Organization Under the Clinical Laboratory.... SUMMARY: This notice announces the application of the Joint Commission for re-approval as an accreditation...) program for all specialty and subspecialty areas under CLIA. We have determined that the Joint...

  13. Medicare program; revisions to the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) supplier safeguards. Final rule.

    PubMed

    2012-03-14

    This final rule removes the definition of "direct solicitation'' and allows DMEPOS suppliers, including DMEPOS competitive bidding program contract suppliers, to contract with licensed agents to provide DMEPOS supplies, unless prohibited by State law. It also removes the requirement for compliance with local zoning laws and modifies certain State licensure requirement exceptions.

  14. 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

    ...This proposed rule would update and make certain revisions to the End-Stage Renal Disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2012. This proposed rule would also set forth proposed requirements for the ESRD quality incentive program (QIP) for payment years (PYs) 2013 and 2014. In addition, this proposed rule would revise the ambulance fee schedule regulations to......

  15. Centers for Medicare & Medicaid Services

    MedlinePlus

    ... Regulations & Guidance Research, Statistics, Data & Systems Outreach & Education CMS.gov Covering more Americans Making Americans healthier by ... Medicare coverage database CMS forms Transmittals MLN Homepage CMS covers 100 million people... ...through Medicare, Medicaid, the ...

  16. Clinical and Economic Impact of a Digital, Remotely-Delivered Intensive Behavioral Counseling Program on Medicare Beneficiaries at Risk for Diabetes and Cardiovascular Disease

    PubMed Central

    Chen, Fang; Su, Wenqing; Becker, Shawn H.; Payne, Mike; Peters, Anne L.; Dall, Timothy M.

    2016-01-01

    Background Type 2 diabetes and cardiovascular disease impose substantial clinical and economic burdens for seniors (age 65 and above) and the Medicare program. Intensive Behavioral Counseling (IBC) interventions like the National Diabetes Prevention Program (NDPP), have demonstrated effectiveness in reducing excess body weight and lowering or delaying morbidity onset. This paper estimated the potential health implications and medical savings of a digital version of IBC modeled after the NDPP. Methods and Findings Participants in this digital IBC intervention, the Omada program, include 1,121 overweight or obese seniors with additional risk factors for diabetes or heart disease. Weight changes were objectively measured via participant use of a networked weight scale. Participants averaged 6.8% reduction in body weight within 26 weeks, and 89% of participants completed 9 or more of the 16 core phase lessons. We used a Markov-based microsimulation model to simulate the impact of weight loss on future health states and medical expenditures over 10 years. Cumulative per capita medical expenditure savings over 3, 5 and 10 years ranged from $1,720 to 1,770 (3 years), $3,840 to $4,240 (5 years) and $11,550 to $14,200 (10 years). The range reflects assumptions of weight re-gain similar to that seen in the DPP clinical trial (lower bound) or minimal weight re-gain aligned with age-adjusted national averages (upper bound). The estimated net economic benefit after IBC costs is $10,250 to $12,840 cumulative over 10 years. Simulation outcomes suggest reduced incidence of diabetes by 27–41% for participants with prediabetes, and stroke by approximately 15% over 5 years. Conclusions A digital, remotely-delivered IBC program can help seniors at risk for diabetes and cardiovascular disease achieve significant weight loss, reduces risk for diabetes and cardiovascular disease, and achieve meaningful medical cost savings. These findings affirm recommendations for IBC coverage by the

  17. Medicare reimbursement for clinical trial services: understanding Medicare coverage in establishing a clinical trial budget.

    PubMed

    Barnes, Mark; Korn, Jerald

    2005-01-01

    In designing and setting up a clinical trial, investigators and private sponsors must take into account what costs will or will not be covered by third-party insurers and government payment programs like Medicare and Medicaid. Failure to "cost out" the clinical trials accurately can yield one of two results: either third-party payors are billed improperly, or even illegally, for experimental care, or significant research-related care is not billed, with either the investigating institution, or the research subjects themselves, shouldering the cost. Unfortunately, because Medicare has established different coverage principles to be applied depending on the type of trial being conducted, costing out the trial is not an easy task. This Article looks at the various Medicare coverage principles as they apply to clinical trials, including the 2000 National Coverage Decision and the recent expansion in coverage for Class A Investigational Devices created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. The Article then examines how the Medicare secondary payor rule, which states that providers may not bill Medicare for items or services when another party has primary responsibility for those services, relates to clinical trails in light of recent commentary. The Article concludes with the presentation of a general framework that investigators can use to establish a clinical trial budgeting and billing system.

  18. Medicare and Medicaid programs; physicians' referrals to health care entities with which they have financial relationships. Health Care Financing Administration (HCFA), HHS. Final rule with comment period.

    PubMed

    2001-01-04

    This final rule with 90-day comment period (Phase I of this rulemaking) incorporates into regulations the provisions in paragraphs (a), (b), and (h) of section 1877 of the Social Security Act (the Act). Under section 1877, if a physician or a member of a physician's immediate family has a financial relationship with a health care entity, the physician may not make referrals to that entity for the furnishing of designated health services (DHS) under the Medicare program, unless an exception applies. The following services are DHS: clinical laboratory services; physical therapy services; occupational therapy services; radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services; radiation therapy services and supplies; durable medical equipment and supplies; parenteral and enteral nutrients, equipment, and supplies; prosthetics, orthotics, and prosthetic devices and supplies; home health services; outpatient prescription drugs; and inpatient and outpatient hospital services. In addition, section 1877 of the Act provides that an entity may not present or cause to be presented a Medicare claim or bill to any individual, third party payer, or other entity for DHS furnished under a prohibited referral, nor may we make payment for a designated health service furnished under a prohibited referral. Paragraph (a) of section 1877 of the Act includes the general prohibition. Paragraph (b) of the Act includes exceptions that pertain to both ownership and compensation relationships, including an in-office ancillary services exception. Paragraph (h) includes definitions that are used throughout section 1877 of the Act, including the group practice definition and the definitions for each of the DHS. We intend to publish a second final rule with comment period (Phase II of this rulemaking) shortly addressing, to the extent necessary, the remaining sections of the Act. Phase II of this rulemaking will address comments

  19. Physician profiling: can Medicare paint an accurate picture?

    PubMed

    Dummit, Laura A

    2007-09-10

    Physician profiling, that is, the comparison of the health care services used by a physician's patients to average service use or another benchmark, has been proposed as a way to improve Medicare. It has been used by private health plans and physician groups to identify both efficient practice patterns and the physicians who practice efficiently. The Medicare Payment Advisory Commission (MedPAC) and the Government Accountability Office (GAO) have recommended that Medicare adopt physician profiling to slow spending growth and improve efficiency. Recent legislation would mandate that Medicare employ profiling. This issue brief reviews MedPAC and GAO's analyses of profiling, concerns about using this type of information, and the obstacles in incorporating profiling in the Medicare program.

  20. Medicare Prescription Drug Coverage

    MedlinePlus

    ... people also have to pay an additional monthly cost. Private companies provide Medicare prescription drug coverage. You choose the drug plan you like best. Whether or not you should sign up depends on how good your current coverage is. You need to sign up as ...

  1. Medicare: Physician Compare

    MedlinePlus

    ... You” Handbook Help with file formats & plug-ins CMS & HHS Websites HealthCare.gov STOPMedicareFraud.gov InsureKidsNow.gov MyMedicare.gov Medicaid.gov CMS.gov HHS.gov Get Involved with Us Twitter ...

  2. Medicare Advantage Plans

    MedlinePlus

    ... You” Handbook Help with file formats & plug-ins CMS & HHS Websites HealthCare.gov STOPMedicareFraud.gov InsureKidsNow.gov MyMedicare.gov Medicaid.gov CMS.gov HHS.gov Get Involved with Us Twitter ...

  3. Health and Health Care of Medicare Beneficiaries in 2030.

    PubMed

    Gaudette, Étienne; Tysinger, Bryan; Cassil, Alwyn; Goldman, Dana P

    2015-12-01

    On Medicare's 50th anniversary, we use the Future Elderly Model (FEM) - a microsimulation model of health and economic outcomes for older Americans - to generate a snapshot of changing Medicare demographics and spending between 2010 and 2030. During this period, the baby boomers, who began turning 65 and aging into Medicare in 2011, will drive Medicare demographic changes, swelling the estimated US population aged 65 or older from 39.7 million to 67.0 million. Among the risks for Medicare sustainability, the size of the elderly population in the future likely will have the highest impact on spending but is easiest to forecast. Population health and the proportion of the future elderly with disabilities are more uncertain, though tools such as the FEM can provide reasonable forecasts to guide policymakers. Finally, medical technology breakthroughs and their effect on longevity are most uncertain and perhaps riskiest. Policymakers will need to keep these risks in mind if Medicare is to be sustained for another 50 years. Policymakers may also want to monitor the equity of Medicare financing amid signs that the program's progressivity is declining, resulting in higher-income people benefiting relatively more from Medicare than lower-income people.

  4. Medicare, Medicaid, and Maternal and Child Health Services Block Grant programs; civil money penalties and assessments for false or improper claims--Department of Health and Human Services. Notice of proposed rulemaking.

    PubMed

    1982-12-30

    These proposed regulations are intended to strengthen the Department's ability to protect the health care financing programs against persons and organizations who defraud and abuse those programs. The regulations would specify procedures for implementing the authority provided to the Department by section 2105 of the Omnibus Budget Reconciliation Act of 1981 (Pub. L. 97-35), as amended by section 137(b)(26) of the Tax Equity and Fiscal Responsibility Act of 1982 (Pub. L. 97-248), to impose civil money penalties and assessments administratively for the filing of false or certain other improper claims in the Medicare, Medicaid, or Maternal and Child Health Services Block Grant programs. The statute also permits an individual upon whom the Department imposes a civil money penalty or assessment to be suspended from participation in the Medicare and Medicaid programs. Until enactment of the civil money penalties legislation, the federal government had to rely upon litigation under the False Claims Act or criminal proceedings in order to compel restitution of funds falsely or improperly claimed under HHS health care financing programs.

  5. Medicare Program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system changes and FY2011 rates; provider agreements and supplier approvals; and hospital conditions of participation for rehabilitation and respiratory care services; Medicaid program: accreditation for providers of inpatient psychiatric services. Final rules and interim final rule with comment period.

    PubMed

    2010-08-16

    : We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems and to implement certain provisions of the Affordable Care Act and other legislation. In addition, we describe the changes to the amounts and factors used to determine the rates for Medicare acute care hospital inpatient services for operating costs and capital-related costs. We also are setting forth the update 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. We are updating the payment policy and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) and setting forth the changes to the payment rates, factors, and other payment rate policies under the LTCH PPS. In addition, we are finalizing the provisions of the August 27, 2009 interim final rule that implemented statutory provisions relating to payments to LTCHs and LTCH satellite facilities and increases in beds in existing LTCHs and LTCH satellite facilities under the LTCH PPS. We are making changes affecting the: Medicare conditions of participation for hospitals relating to the types of practitioners who may provide rehabilitation services and respiratory care services; and determination of the effective date of provider agreements and supplier approvals under Medicare. We are also setting forth provisions that offer psychiatric hospitals and hospitals with inpatient psychiatric programs increased flexibility in obtaining accreditation to participate in the Medicaid program. Psychiatric hospitals and hospitals with inpatient psychiatric programs will have the choice of undergoing a State survey or of obtaining accreditation from a national accrediting organization whose hospital accreditation

  6. Urban-Rural Differences in the Effect of a Medicare Health Promotion and Disease Self-Management Program on Physical Function and Health Care Expenditures

    ERIC Educational Resources Information Center

    Meng, Hongdao; Wamsley, Brenda; Liebel, Diane; Dixon, Denise; Eggert, Gerald; Van Nostrand, Joan

    2009-01-01

    Purpose: To evaluate the impact of a multicomponent health promotion and disease self-management intervention on physical function and health care expenditures among Medicare beneficiaries. To determine if these outcomes vary by urban or rural residence. Design and Methods: We analyzed data from a 22-month randomized controlled trial of a health…

  7. Patents, Innovation, and the Welfare Effects of Medicare Part D*

    PubMed Central

    Gailey, Adam; Lakdawalla, Darius; Sood, Neeraj

    2013-01-01

    Purpose To evaluate the efficiency consequences of the Medicare Part D program. Methods We develop and empirically calibrate a simple theoretical model to examine the static and dynamic welfare effects of Medicare Part D. Findings We show that Medicare Part D can simultaneously reduce static deadweight loss from monopoly pricing of drugs and improve incentives for innovation. We estimate that even after excluding the insurance value of the program, the welfare gain of Medicare Part D roughly equals its social costs. The program generates $5.11 billion of annual static deadweight loss reduction, and at least $3.0 billion of annual value from extra innovation. Implications Medicare Part D and other public prescription drug programs can be welfare-improving, even for risk-neutral and purely self-interested consumers. Furthermore, negotiation for lower branded drug prices may further increase the social return to the program. Originality This study demonstrates that pure efficiency motives, which do not even surface in the policy debate over Medicare Part D, can nearly justify the program on their own merits. PMID:20575239

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

    PubMed

    2016-08-03

    This document announces the extension of temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance suppliers and Medicare home health agencies (HHAs), subunits, and branch locations in specific locations within designated metropolitan areas in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey to prevent and combat fraud, waste, and abuse. It also announces the implementation of temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance suppliers and Medicare HHAs, subunits, and branch locations in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey on a statewide basis. In addition, it announces the lifting of the moratoria on all Part B emergency ground ambulance suppliers. These moratoria, and the changes described in this document, also apply to the enrollment of HHAs and non-emergency ground ambulance suppliers in Medicaid and the Children's Health Insurance Program.

  9. Does Medicare Advantage Cost Less Than Traditional Medicare?

    PubMed

    Biles, Brian; Casillas, Giselle; Guterman, Stuart

    2016-01-01

    The costs of providing benefits to enrollees in private Medicare Advantage (MA) plans are slightly less, on average, than what traditional Medicare spends per beneficiary in the same county. However, MA plans that are able to keep their costs comparatively low are concen­trated in a fairly small number of U.S. counties. In the 25 counties where the cost differences between MA plans and traditional Medicare are largest, MA plans spent a total of $5.2 billion less than what traditional Medicare would have been expected to spend on the same benefi­ciaries, with health maintenance organizations (HMOs) accounting for all of that difference. In the rest of the country, MA plans spent $4.8 billion above the expected costs under tradi­tional Medicare. Broad determinations about the relative efficiency of MA plans and traditional Medicare can therefore be misleading, as they fail to take into account local conditions and individual plans' performance.

  10. Setting Physicians' Prices in FFS Medicare: An Economic Perspective

    PubMed Central

    Dowd, Bryan; Feldman, Roger; Nyman, John; Town, Bob

    2006-01-01

    Recent policy discussions by the Medicare Payment Advisory Commission (MedPAC) regarding physician prices in the traditional fee-for-service (FFS) Medicare Program reflect movement toward a market pricing model. Earlier objectives such as sustainable levels of spending have given way to concerns over the relationship between fees and actual costs, access to care, and the importance of demand and supply in local markets. An important objective in other policy settings is economically efficient distribution of services. We explain the meaning of economic efficiency for Medicare physician prices and explore difficulties one might encounter in pursuing economic efficiency, as well as the cost of not pursuing it. PMID:17427848

  11. Population-based disease management under fee-for-service Medicare.

    PubMed

    Foote, Sandra M

    2003-01-01

    Medicare policymakers are considering testing population-based disease management (PDM) programs under fee-for-service (FFS) Medicare as a way to improve health and cost outcomes for selected subgroups of chronically ill beneficiaries. This paper provides a brief overview of how PDM programs are evolving in the private sector and describes how they differ from other approaches already being tested in Medicare disease management demonstrations. It also discusses some key opportunities and issues to be considered in adapting PDM programs for testing in the FFS Medicare context.

  12. 42 CFR 405.211 - Procedures for Medicare contractors in making coverage decisions for a non-experimental...

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Procedures for Medicare contractors in making coverage decisions for a non-experimental/investigational (Category B) device. 405.211 Section 405.211 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE...

  13. 42 CFR 413.82 - Direct GME payments: Special rules for States that formerly had a waiver from Medicare...

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Direct GME payments: Special rules for States that... FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PRINCIPLES... Direct GME payments: Special rules for States that formerly had a waiver from Medicare...

  14. Examining Measures of Income and Poverty in Medicare Administrative Data.

    PubMed

    Samson, Lok Wong; Finegold, Kenneth; Ahmed, Azeem; Jensen, Matthew; Filice, Clara E; Joynt, Karen E

    2016-07-29

    Disparities by economic status are observed in the health status and health outcomes of Medicare beneficiaries. For health services and health policy researchers, one barrier to addressing these disparities is the ability to use Medicare data to ascertain information about an individual's income level or poverty, because Medicare administrative data contains limited information about individual economic status. Information gleaned from other sources-such as the Medicaid and Supplemental Security Income programs-can be used in some cases to approximate the income of Medicare beneficiaries. However, such information is limited in its availability and applicability to all beneficiaries. Neighborhood-level measures of income can be used to infer individual-level income, but level of neighborhood aggregation impacts accuracy and usability of the data. Community-level composite measures of economic status have been shown to be associated with health and health outcomes of Medicare beneficiaries and may capture neighborhood effects that are separate from individual effects, but are not readily available in Medicare data and do not serve to replace information about individual economic status. There is no single best method of obtaining income data from Medicare files, but understanding strengths and limitations of different approaches to identifying economic status will help researchers choose the best method for their particular purpose, and help policymakers interpret studies using measures of income.

  15. A Political History of Medicare and Prescription Drug Coverage

    PubMed Central

    Oliver, Thomas R; Lee, Philip R; Lipton, Helene L

    2004-01-01

    This article examines the history of efforts to add prescription drug coverage to the Medicare program. It identifies several important patterns in policymaking over four decades. First, prescription drug coverage has usually been tied to the fate of broader proposals for Medicare reform. Second, action has been hampered by divided government, federal budget deficits, and ideological conflict between those seeking to expand the traditional Medicare program and those preferring a greater role for private health care companies. Third, the provisions of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 reflect earlier missed opportunities. Policymakers concluded from past episodes that participation in the new program should be voluntary, with Medicare beneficiaries and taxpayers sharing the costs. They ignored lessons from past episodes, however, about the need to match expanded benefits with adequate mechanisms for cost containment. Based on several new circumstances in 2003, the article demonstrates why there was a historic opportunity to add a Medicare prescription drug benefit and identify challenges to implementing an effective policy. PMID:15225331

  16. 2014: Rural Medicare Advantage Enrollment Update.

    PubMed

    Kemper, Leah; Barker, Abigail; McBride, Timothy; Mueller, Keith

    2015-01-01

    Key Data Findings. (1) Reclassification of rural and urban county designations (due to the switch from 2000 census data to 2010 census data) resulted in a 10 percent decline in the number of Medicare eligible Americans living in rural counties in 2014 (from roughly 10.7 million to 9.6 million). These changes also resulted in a decline in the number of MA enrollees considered to be living in a rural area, from 2.19 million to 1.95 million. However, the percentage of Medicare beneficiaries enrolled in MA and prepaid plans in rural areas declined only slightly from 20.6 percent to 20.3 percent. (2) Rural Medicare Advantage (MA) and other prepaid plan enrollment in March 2014 was nearly 1.95 million, or 20.3 percent of all rural Medicare beneficiaries, an increase of more than 216,000 from March 2013. Enrollment increased to 1.99 million (20.4 percent) in October 2014. (3) In March 2014, 56 percent of rural MA enrollees were enrolled in Preferred Provider Organization (PPO) plans, 29 percent were enrolled in Health Maintenance Organization (HMO) or Point-of-Service (POS) plans, 7 percent were enrolled in Private Fee-for-Service (PFFS) plans, and 8 percent were enrolled in other prepaid plans, including Cost plans and Program of All-Inclusive Care for the Elderly (PACE) plans. (4) States with the highest percentage of rural Medicare beneficiaries enrolled in MA and other prepaid plans include Minnesota (49.1 percent), Hawaii (41.1 percent), Pennsylvania (35.4 percent), Wisconsin (34.3 percent), New York (30.4 percent), and Ohio (30.1 percent).

  17. 42 CFR 136.30 - Payment to Medicare-participating hospitals for authorized Contract Health Services.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... prospective payment system (PPS) will be based on that PPS. For example, payment for inpatient hospital services shall be made per discharge based on the applicable PPS used by the Medicare program to pay for... based on a PPS used in the Medicare program to pay for similar hospital services under 42 CFR part...

  18. Improving the design of competitive bidding in Medicare Advantage.

    PubMed

    Cawley, John H; Whitford, Andrew B

    2007-04-01

    In 2003, Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act, which required that in 2006 the Centers for Medicare and Medicaid Services (CMS) implement a system of competitive bids to set payments for the Medicare Advantage program. Managed care plans now bid for the right to enroll Medicare beneficiaries. Data from the first year of bidding suggest that imperfect competition is limiting the success of the bidding system. This article offers suggestions to improve this system based on findings from auction theory and previous government-run auctions. In particular, CMS can benefit by adjusting its system of competitive bids in four ways: credibly committing to regulations governing bidding; limiting the scope for collusion, entry deterrence, and predatory behavior among bidders; adjusting how benchmark reimbursement rates are set; and accounting for asymmetric information among bidders.

  19. Medicare depreciation; useful life guidelines--HCFA. Proposed rule.

    PubMed

    1982-09-30

    We are proposing to amend Medicare regulations to clarify which useful life guidelines providers of health care services may use to determine the useful life of a depreciable asset for Medicare reimbursement purposes. Current regulations state that providers must utilize HHS useful life guidelines or, if none have been published by HHS, the American Hospital Association (AHA) useful life guidelines of 1973 or IRS guidelines. We are proposing to eliminate the reference to IRS guidelines because those previously acceptable for Medicare purposes are outdated and have been made obsolete by the IRS or by statutory change. We would also delete the specific reference to the 1973 AHA guidelines. In addition, we intend this amendment to clarify that certain tax legislation on accelerated depreciation, recently passed by Congress, does not apply to the Medicare program.

  20. Medicare financial status, budget impact, and sustainability--which concept is which?

    PubMed

    Foster, Richard S; Clemens, M Kent

    2009-01-01

    Medicare is continually undergoing change, as it must in order to reflect advances in medical technology, new health care delivery systems, financial pressures, and other developments. Modifications to the program are debated by policymakers in Congress and the administration, together with academic experts and others. These debates would be improved if policymakers and the public had a clearer understanding of Medicare and certain commonly cited views of the program's overall status. Three such concepts--the financial status of the Medicare trust funds, the impact of Medicare on the Federal budget, and the long-run sustainability of Medicare-are often confused with each other and are sometimes used interchangeably. Each concept is important but needs to be used for its own purpose. This article clarifies the differences among these three views of Medicare and provides examples of each.

  1. Medicare financial status, budget impact, and sustainability--which concept is which?

    PubMed

    Foster, Richard S; Clemens, M Kent

    Medicare is continually undergoing change, as it must in order to reflect advances in medical technology, new health care delivery systems, financial pressures, and other developments. Modifications to the program are debated by policymakers in Congress and the administration, together with academic experts and others. These debates would be improved if policymakers and the public had a clearer understanding of Medicare and certain commonly cited views of the program's overall status. Three such concepts--the financial status of the Medicare trust funds, the impact of Medicare on the Federal budget, and the long-run sustainability of Medicare--are often confused with each other and are sometimes used interchangeably. Each concept is important but needs to be used for its own purpose. This article clarifies the differences among these three views of Medicare and provides examples of each.

  2. Medicare program; end-stage renal disease prospective payment system, quality incentive program, and durable medical equipment, prosthetics, orthotics, and supplies.

    PubMed

    2013-12-02

    This rule updates and makes revisions to the End-Stage Renal Disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2014. This rule also sets forth requirements for the ESRD quality incentive program (QIP), including for payment year (PY) 2016 and beyond. In addition, this rule clarifies the grandfathering provision related to the 3-year minimum lifetime requirement (MLR) for Durable Medical Equipment (DME), and provides clarification of the definition of routinely purchased DME. This rule also implements budget-neutral fee schedules for splints and casts, and intraocular lenses (IOLs) inserted in a physician's office. Finally, this rule makes a few technical amendments and corrections to existing regulations related to payment for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items and services.

  3. Medicare prescription drug coverage: Consumer information and preferences

    PubMed Central

    Winter, Joachim; Balza, Rowilma; Caro, Frank; Heiss, Florian; Jun, Byung-hill; Matzkin, Rosa; McFadden, Daniel

    2006-01-01

    We investigate prescription drug use, and information and enrollment intentions for the new Medicare Part D drug insurance program, using a sample of Medicare-eligible subjects surveyed before open enrollment began for this program. We find that, despite the complexity of competing plans offered by private insurers under Part D, a majority of the Medicare population had information on this program and a substantial majority planned to enroll. We find that virtually all elderly, even those with no current prescription drug use, can expect to benefit from enrollment in a Part D Standard plan at the low premiums available in the current market. However, there is a significant risk that many eligible seniors, particularly low-income elderly with poor health or cognitive impairment, will make poor enrollment and plan choices. PMID:16682629

  4. Three decades of Medicare: what the numbers tell us.

    PubMed

    Davis, M H; Burner, S T

    1995-01-01

    The Medicare program was first implemented to meet a critical need in American society, and over its thirty-year history it has evolved into an integral part of the U.S. health care system. This DataWatch provides a broad overview of the program, outlining both historical and current trends in coverage, financing, payment mechanisms, beneficiary status, benefits, and spending.

  5. 42 CFR 460.90 - PACE benefits under Medicare and Medicaid.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE Services § 460.90 PACE benefits under Medicare and Medicaid. If a...

  6. 42 CFR 460.90 - PACE benefits under Medicare and Medicaid.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE Services § 460.90 PACE benefits under Medicare and Medicaid. If a...

  7. 42 CFR 460.90 - PACE benefits under Medicare and Medicaid.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE Services § 460.90 PACE benefits under Medicare and Medicaid. If a...

  8. 42 CFR 460.90 - PACE benefits under Medicare and Medicaid.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE Services § 460.90 PACE benefits under Medicare and Medicaid. If a...

  9. Staying Healthy: Medicare's Preventive Services

    MedlinePlus

    ... counseling in a primary care setting. Bone Mass Measurement These tests help to see if you’re ... Medicare. You need a flu shot for the current virus each year. Glaucoma Tests These tests help ...

  10. Medicare Financing of Graduate Medical Education

    PubMed Central

    Rich, Eugene C; Liebow, Mark; Srinivasan, Malathi; Parish, David; Wolliscroft, James O; Fein, Oliver; Blaser, Robert

    2002-01-01

    The past decade has seen ongoing debate regarding federal support of graduate medical education, with numerous proposals for reform. Several critical problems with the current mechanism are evident on reviewing graduate medical education (GME) funding issues from the perspectives of key stakeholders. These problems include the following: substantial interinstitutional and interspecialty variations in per-resident payment amounts; teaching costs that have not been recalibrated since 1983; no consistent control by physician educators over direct medical education (DME) funds; and institutional DME payments unrelated to actual expenditures for resident education or to program outcomes. None of the current GME reform proposals adequately address all of these issues. Accordingly, we recommend several fundamental changes in Medicare GME support. We propose a re-analysis of the true direct costs of resident training (with appropriate adjustment for local market factors) to rectify the myriad problems with per-resident payments. We propose that Medicare DME funds go to the physician organization providing resident instruction, keeping DME payments separate from the operating revenues of teaching hospitals. To ensure financial accountability, we propose that institutions must maintain budgets and report expenditures for each GME program. To establish educational accountability, Residency Review Committees should establish objective, annually measurable standards for GME program performance; programs that consistently fail to meet these minimum standards should lose discretion over GME funds. These reforms will solve several long-standing, vexing problems in Medicare GME funding, but will also uncover the extent of undersupport of GME by most other health care payers. Ultimately, successful reform of GME financing will require “all-payer” support. PMID:11972725

  11. Medicare financing of graduate medical education.

    PubMed

    Rich, Eugene C; Liebow, Mark; Srinivasan, Malathi; Parish, David; Wolliscroft, James O; Fein, Oliver; Blaser, Robert

    2002-04-01

    The past decade has seen ongoing debate regarding federal support of graduate medical education, with numerous proposals for reform. Several critical problems with the current mechanism are evident on reviewing graduate medical education (GME) funding issues from the perspectives of key stakeholders. These problems include the following: substantial interinstitutional and interspecialty variations in per-resident payment amounts; teaching costs that have not been recalibrated since 1983; no consistent control by physician educators over direct medical education (DME) funds; and institutional DME payments unrelated to actual expenditures for resident education or to program outcomes. None of the current GME reform proposals adequately address all of these issues. Accordingly, we recommend several fundamental changes in Medicare GME support. We propose a re-analysis of the true direct costs of resident training (with appropriate adjustment for local market factors) to rectify the myriad problems with per-resident payments. We propose that Medicare DME funds go to the physician organization providing resident instruction, keeping DME payments separate from the operating revenues of teaching hospitals. To ensure financial accountability, we propose that institutions must maintain budgets and report expenditures for each GME program. To establish educational accountability, Residency Review Committees should establish objective, annually measurable standards for GME program performance; programs that consistently fail to meet these minimum standards should lose discretion over GME funds. These reforms will solve several long-standing, vexing problems in Medicare GME funding, but will also uncover the extent of undersupport of GME by most other health care payers. Ultimately, successful reform of GME financing will require "all-payer" support.

  12. Medicare and durable medical equipment.

    PubMed

    Coviello, Amy

    2002-01-01

    Medicare coverage of wheelchairs, hospital beds and other durable medical equipment (DME) is a major source of confusion for people with Medicare, their families and the professionals who work with them. Yet, consumer publications rarely touch on it. In this brief we offer an overview of DME coverage issues and payment policies, including potential costs for consumers and their rights to appeal denials of payment.

  13. Funding a Health Disparities Research Agenda: The Case of Medicare Home Health Care

    ERIC Educational Resources Information Center

    Davitt, Joan K.

    2014-01-01

    Medicare home health care provides critical skilled nursing and therapy services to patients in their homes, generally after a period in an inpatient facility or nursing home. Disparities in access to, or outcomes of, home health care can result in patient deterioration and increased cost to the Medicare program if patient care needs intensify.…

  14. 42 CFR 403.322 - Termination of agreements for Medicare recognition of State systems.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Termination of agreements for Medicare recognition of State systems. 403.322 Section 403.322 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS SPECIAL PROGRAMS AND PROJECTS Recognition of...

  15. Medicare fraud in the United States: can it ever be stopped?

    PubMed

    Hill, Chelsea; Hunter, Alex; Johnson, Leslie; Coustasse, Alberto

    2014-01-01

    The majority of the United States health care fraud has been focused on the major public program, Medicare. The yearly financial loss from Medicare fraud has been estimated at about $54 billion. The purpose of this research study was to explore the current state of Medicare fraud in the United States, identify current policies and laws that foster Medicare fraud, and determine the financial impact of Medicare fraud. The methodology for this study was a literature review. Research was conducted using a scholarly online database search and government Web sites. The number of individuals charged with criminal fraud increased from 797 cases in fiscal year 2008 to 1430 cases in fiscal year 2011-an increase of more than 75%. According to 2010 data, of the 7848 subjects investigated for criminal fraud, 25% were medical facilities, and 16% were medical equipment suppliers. In 2009 and 2010, the Health Care Fraud and Abuse Control Program recovered approximately $25.2 million of taxpayers' money. Educating providers about the policies and laws designed to prevent fraud would help them to become partners. Many new programs and partnerships with government agencies have also been developed to combat Medicare fraud. Medicare fraud has been a persistent crime, and laws and policies alone have not been enough to control the problem. With investments in governmental partnerships and new systems, the United States can reduce Medicare fraud but probably will not stop it altogether.

  16. Paying medicare advantage plans: To level or tilt the playing field.

    PubMed

    Glazer, Jacob; McGuire, Thomas G

    2016-12-29

    Medicare beneficiaries are eligible for health insurance through the public option of traditional Medicare (TM) or may join a private Medicare Advantage (MA) plan. Both are highly subsidized but in different ways. Medicare pays for most of costs directly in TM, and subsidizes MA plans based on a "benchmark" for each beneficiary choosing a private plan. The level of this benchmark is arguably the most important policy decision Medicare makes about the MA program. Many analysts recommend equalizing Medicare's subsidy across the options - referred to in policy circles as a "level playing field." This paper studies the normative question of how to set the level of the benchmark, applying the versatile model developed by Einav and Finkelstein (EF) to Medicare. The EF framework implies unequal subsidies to counteract risk selection across plan types. We also study other reasons to tilt the field: the relative efficiency of MA vs. TM, market power of MA plans, and institutional features of the way Medicare determines subsidies and premiums. After review of the empirical and policy literature, we conclude that in areas where the MA market is competitive, the benchmark should be set below average costs in TM, but in areas characterized by imperfect competition in MA, it should be raised in order to offset output (enrollment) restrictions by plans with market power. We also recommend specific modifications of Medicare rules to make demand for MA more price elastic.

  17. Medicare program; reissuance of the wage index in the 1981 schedule of limits on hospital per diem inpatient general routine operating costs--HCFA. Proposed notice.

    PubMed

    1984-02-17

    We are reissuing for public comment the change in the types of data that were used to calculate the wage index that was contained in the schedules of limits on hospital per diem inpatient general routine operating costs reimbursable under Medicare that were applicable to cost reporting periods beginning on or after July 1, 1981 and for cost reporting periods ending after September 30, 1981. The cost limits for cost reporting periods beginning on or after October 1, 1982 are governed by the notice published in the Federal Register on September 30, 1982 (47 FR 43296) and August 30, 1983 (48 FR 39426) and are not affected by this reissuance. The wage index was originally issued as part of the schedule of limits published on June 30, 1981 (46 FR 33637) and September 30, 1981 (46 FR 48010) and is being reissued as the result of the April 29, 1983 decision of the United States District Court for the District of Columbia in the case of District of Columbia Hospital Association, et al. v Heckler, et al. (No. 82-2520 DDC). The District Court held that the 1981 schedule of hospital cost limits was invalid for failure to comply with the Administrative Procedure Act insofar as the schedule incorporated or was formulated by using a wage index that was calculated by excluding Federal government hospital wage data.

  18. Patient-centered care: an opportunity to accomplish the "Three Aims" of the National Quality Strategy in the Medicare ESRD program.

    PubMed

    O'Hare, Ann M; Armistead, Nancy; Schrag, Wendy L Funk; Diamond, Louis; Moss, Alvin H

    2014-12-05

    In light of mounting federal government debt and levels of Medicare spending that are widely viewed as unsustainable, commentators have called for a transformation of the United States health care system to deliver better care at lower costs. This article presents the priorities of the Coalition for Supportive Care of Kidney Patients for how clinicians might achieve this transformation for patients with advanced CKD and their families. The authors suspect that much of the high-intensity, high-cost care currently delivered to patients with advanced kidney disease may be unwanted and that the "Three Aims" put forth by the National Quality Strategy of better care for the individual, better health for populations, and reduced health care costs may be within reach for patients with CKD and ESRD. This work describes the coalition's vision for a more patient-centered approach to the care of patients with kidney disease and argues for more concerted efforts to align their treatments with their goals, values, and preferences. Key priorities to achieve this vision include using improved prognostic models and decision science to help patients, their families, and their providers better understand what to expect in the future; engaging patients and their families in shared decision-making before the initiation of dialysis and during the course of dialysis treatment; and tailoring treatment strategies throughout the continuum of their care to address what matters most to individual patients.

  19. Steps to reduce favorable risk selection in medicare advantage largely succeeded, boding well for health insurance exchanges.

    PubMed

    Newhouse, Joseph P; Price, Mary; Huang, Jie; McWilliams, J Michael; Hsu, John

    2012-12-01

    Within Medicare, the Medicare Advantage program has historically attracted better risks-healthier, lower-cost patients-than has traditional Medicare. The disproportionate enrollment of lower-cost patients and avoidance of higher-cost ones during the 1990s-known as favorable selection-resulted in Medicare's spending more per beneficiary who enrolled in Medicare Advantage than if the enrollee had remained in traditional Medicare. We looked at two measures that can indicate whether favorable selection is taking place-predicted spending on beneficiaries and mortality-and studied whether policies that Medicare implemented in the past decade succeeded in reducing favorable selection in Medicare Advantage. We found that these policies-an improved risk adjustment formula and a prohibition on monthly disenrollment by beneficiaries-largely succeeded. Differences in predicted spending between those switching from traditional Medicare to Medicare Advantage relative to those who remained in traditional Medicare markedly narrowed, as did adjusted mortality rates. Because insurance exchanges set up under the Affordable Care Act will employ similar policies to combat risk selection, our results give reason for optimism about managing competition among health plans.

  20. Medicare payment system for hospital inpatients: diagnosis-related groups.

    PubMed

    Baker, Judith J

    2002-01-01

    Diagnosis-Related Groups (DRGs) are categories of patient conditions that demonstrate similar levels of hospital resources required to treat the conditions. Each inpatient that is discharged from an acute care hospital can be classified into one of the 506 DRGs currently utilized by the Medicare program. The Medicare DRG prospective payment methodology has been in use for almost two decades and is used by hospital managers for planning and decisionmaking. The viability of DRGs for future prospective payment depends on the ability to keep up with the times through updates of the current methodology.

  1. Medicare Advantage: Issues, Insights, and Implications for the Future

    PubMed Central

    Cotton, Paul; Newhouse, Joseph P.; Volpp, Kevin G.; Fendrick, A. Mark; Oesterle, Susan Lynne; Oungpasuk, Pat; Aggarwal, Ruchi; Wilensky, Gail; Sebelius, Kathleen

    2016-01-01

    Medicare Advantage: Issues, Insights, and Implications for the Future Paul Cotton, Joseph P. Newhouse, PhD, Kevin G. Volpp, MD, PhD, A. Mark Fendrick, MD, Susan Lynne Oesterle, Pat Oungpasuk, Ruchi Aggarwal, Gail Wilensky, PhD, and Kathleen Sebelius Editorial   S-2 D.B. Nash, and A.Y. Schwartz The History, Impact, and Future of the Medicare Advantage Star Ratings System   S-3 P. Cotton Medicare Advantage and Traditional Fee-For-Service Medicare   S-4 J.P. Newhouse Behavioral Economics: Key to Effective Care Management Programs for Patients, Payers, and Providers   S-5 K.G. Volpp Value-Based Insurance Design: A Promising Strategy for Medicare Advantage   S-6 A.M. Fendrick, S.L. Oesterle, P. Oungpasuk, and R. Aggarwal Two Perspectives on the Future of Medicare Advantage   S-7 G. Wilensky and K. Sebelius PMID:27834576

  2. The Medicare Prospective Payment System: Intent and Future Direction

    PubMed Central

    Dobson, Allen

    1984-01-01

    Increases in health care expenditures, especially for hospital care, have been a persistent and growing problem for the Medicare program and the Nation for nearly two decades. Recognizing its potential as a pragmatic yet immediate solution to spiralling costs, Congress recently enacted the Prospective Payment System (PPS) for most inpatient hospital services covered by Medicare. The PPS legislation represents a fundamental change in the way hospitals are paid for care delivered to Medicare beneficiaries. Hospitals can be expected to respond to behavioral incentives created by the new payment approach with both immediate and long-term adjustments. Changes in the ways hospitals will manage themselves and conduct their business — present and future — are examined, and some initial data trends are presented. Significant future policy issues related to the PPS and the health care delivery system are lastly discussed.

  3. Plan selection in Medicare Part D: Evidence from administrative data

    PubMed Central

    Heiss, Florian; Leive, Adam; McFadden, Daniel; Winter, Joachim

    2014-01-01

    We study the Medicare Part D prescription drug insurance program as a bellwether for designs of private, non-mandatory health insurance markets, focusing on the ability of consumers to evaluate and optimize their choices of plans. Our analysis of administrative data on medical claims in Medicare Part D suggests that fewer than 25 percent of individuals enroll in plans that are ex ante as good as the least cost plan specified by the Plan Finder tool made available to seniors by the Medicare administration, and that consumers on average have expected excess spending of about $300 per year, or about 15 percent of expected total out-of-pocket cost for drugs and Part D insurance. These numbers are hard to reconcile with decision costs alone; it appears that unless a sizeable fraction of consumers place large values on plan features other than cost, they are not optimizing effectively. PMID:24308882

  4. The impact of weight loss among seniors on Medicare spending

    PubMed Central

    2013-01-01

    Objective To examine the impact of temporary and permanent weight loss of 10% and 15% on 10-year and lifetime Medicare spending among adults with overweight and obesity aged 65 years and older. Weight loss of this magnitude is consistent with next generation anti-obesity medications recently approved by the Food and Drug Administration. Methods We follow the approach of a longitudinal dynamic aging process model developed by our research team. This model considers the dynamic relationships between weight, chronic disease, acute medical events, functional status, mortality, health care utilization and spending among Medicare beneficiaries from age 65 until death. Using this model, we estimate baseline Medicare spending over the next decade and then over the lifetime of seniors with a body mass index (BMI) ≥ 27 with at least one weight-related comorbidity (overweight), and seniors with obesity having a BMI ≥ 30 and ≥ 35. We then estimate Medicare spending for this population between ages 65 and 70 over the course of a year, assuming 10% and 15% weight loss under alternative scenarios: with and without weight regain. (Weight regain is assumed to be 90% over a 10-year period.) The difference in spending between baseline (no weight-loss intervention) and the alternative scenarios represent potential gross savings to the Medicare program. Results Permanent weight loss of 10 to 15% will yield $9,445 to $15,987 in gross per capita savings throughout their lifetime, and $8,070 to $13,474 over ten years. Similarly, initial weight loss of 10 to 15% followed by 90% weight regain will result in gross per capita savings of $7,556 to $11,109 over their lifetime, and $6,456 to $8,911 over ten years. Targeting weight loss medications to adults with obesity (BMI ≥ 30) produces greater savings to the Medicare program. Conclusion Medicare can realize significant cost savings through anti-obesity medications that produce substantial weight loss, and as a result, reduce the

  5. Medicare's risk-adjusted capitation method.

    PubMed

    Grimaldi, Paul L

    2002-01-01

    Since 1997, the method to establish capitation rates for Medicare beneficiaries who are members of risk-bearing managed care plans has undergone several important developments. This includes the factoring of beneficiary health status into the rate-setting calculations. These changes were expected to increase the number of participating health plans, accelerate Medicare enrollment growth, and slice Medicare spending.

  6. Medicare beneficiary out-of-pocket costs: are Medicare Advantage Plans a better deal?

    PubMed

    Biles, Brian; Hersch Nicholas, Lauren; Guterman Stuart, Stuart

    2006-05-01

    The creators of the Medicare Advantage (MA) program envisioned that seniors would opt out of fee-for-service Medicare to take advantage of the lower premiums, lower cost-sharing, and additional benefits available in private plans. Earlier research, however, indicates that out-of-pocket costs for MA enrollees vary widely by health status and plan benefit package. This issue brief examines out-of-pocket costs for beneficiaries in good, fair, and poor health throughout the country. In 2005, annual out-of-pocket costs for plan members ranged from under $100 for beneficiaries in good health to over $6,000 for those in poor health. Costs for beneficiaries in poor health would actually have been higher than fee-for-service in 19 of the 88 MA plans examined. Despite the high payments, relative to fee-for-service costs, that MA plans receive from Medicare to enrich enrollee benefits, these plans may not always be a good deal for sicker beneficiaries who use more health services.

  7. Geography and destiny: local-market perspectives on developing Medicare Advantage regional plans.

    PubMed

    Hurley, Robert E; Strunk, Bradley C; Grossman, Joy M

    2005-01-01

    The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 established regional preferred provider organizations (PPOs) as a new private-plan option for beneficiaries in the Medicare Advantage (MA) program, starting in 2006. Developing network-based Medicare products uniformly priced across statewide or multistate regions presents unprecedented challenges and opportunities for health insurers. We held discussions with local health plan and hospital informants in six of the twelve Community Tracking Study (CTS) communities to obtain their perspectives on key considerations in evaluating whether they can and will offer regional PPO products under the MA program.

  8. The Star Rating System and Medicare Advantage Plans.

    PubMed

    Sprague, Lisa

    2015-05-05

    With nearly 30 percent of Medicare beneficiaries opting to enroll in Medicare Advantage (MA) plans instead of fee-for-service Medicare, it's safe to say the MA program is quite popular. The Centers for Medicare & Medicaid Services (CMS) administers a Star Ratings program for MA plans, which offers measures of quality and service among the plans that are used not only to help beneficiaries choose plans but also to award additional payments to plans that meet high standards. These additional payments, in turn, are used by plans to provide additional benefits to beneficiaries or to reduce cost sharing--added features that are likely to factor into beneficiaries' choice of MA plans. The Star Ratings program is also meant to drive improvements in the quality of plans, and this secondary effort seems to have been successful. Despite this success, issues with the Star Ratings system remain, including: how performance metrics are developed, chosen, and maintained; how differences among beneficiary populations (particularly with regard to the dually eligible and those receiving low-income subsidies) should be recognized; and the extent to which health plans can control the variables on which they are being measured. Because the Star Ratings approach has been extended to providers of health care as well--hospitals, nursing homes, and dialysis facilities--these issues are worth exploring as CMS fine-tunes its methods of measurement.

  9. Competitive bidding in Medicare Advantage: effect of benchmark changes on plan bids.

    PubMed

    Song, Zirui; Landrum, Mary Beth; Chernew, Michael E

    2013-12-01

    Bidding has been proposed to replace or complement the administered prices that Medicare pays to hospitals and health plans. In 2006, the Medicare Advantage program implemented a competitive bidding system to determine plan payments. In perfectly competitive models, plans bid their costs and thus bids are insensitive to the benchmark. Under many other models of competition, bids respond to changes in the benchmark. We conceptualize the bidding system and use an instrumental variable approach to study the effect of benchmark changes on bids. We use 2006-2010 plan payment data from the Centers for Medicare and Medicaid Services, published county benchmarks, actual realized fee-for-service costs, and Medicare Advantage enrollment. We find that a $1 increase in the benchmark leads to about a $0.53 increase in bids, suggesting that plans in the Medicare Advantage market have meaningful market power.

  10. 77 FR 31618 - Medicaid Program; Announcement of Requirements and Registration for CMS Provider Screening...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-29

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services (CMS) Medicaid Program; Announcement of Requirements and Registration for CMS Provider Screening Innovator Challenge AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice. SUMMARY: The Centers for Medicare & Medicaid Services...

  11. Medicare disease management in policy context.

    PubMed

    Linden, Ariel; Adler-Milstein, Julia

    2008-01-01

    Interim results of the Medicare health support (MHS) demonstration projects suggest that commercial disease management (DM) is unable to deliver short-term medical cost savings. This is not surprising given the current DM program focus on compliance with process measures that may only lead to cost savings in the long-term. A program focused on reducing near-term hospitalizations is more likely to deliver savings during the initial 3-year phase of MHS. If the early trends in MHS are indicative of the final results, CMS will face the decision of whether to abandon commercial DM in favor of other chronic care management strategies. This article supports the upcoming assessment by describing the characteristics of the current commercial DM model that limit its ability to deliver short-term medical cost savings and the changes required to overcome these limitations.

  12. The continuing cost of privatization: extra payments to Medicare Advantage plans jump to $11.4 billion in 2009.

    PubMed

    Biles, Brian; Pozen, Jonah; Guterman, Stuart

    2009-05-01

    The Medicare Modernization Act of 2003 explicitly increased Medicare payments to private Medicare Advantage (MA) plans. As a result, MA plans have, for the past six years, been paid more for their enrollees than they would be expected to cost in traditional fee-for-service Medicare. Payments to MA plans in 2009 are projected to be 13 percent greater than the corresponding costs in traditional Medicare--an average of $1,138 per MA plan enrollee, for a total of $11.4 billion. Although the extra payments are used to provide enrollees additional benefits, those benefits are not available to all beneficiaries-- but they are financed by general program funds. If payments to MA plans were instead equal to the spending level under traditional Medicare, the more than $150 billion in savings over 10 years could be used to finance improved benefits for the low-income elderly and disabled, or for expanding health-insurance coverage.

  13. Medicare Advantage: options for standardizing benefits and information to improve consumer choice.

    PubMed

    O'Brien, Ellen; Hoadley, Jack

    2008-04-01

    The Medicare Advantage (MA) program offers beneficiaries a choice of private health plans as alternatives to the traditional fee-for-service Medicare program. MA plans potentially provide additional value, but as plan choices have proliferated, consumers contemplating their options have had difficulty understanding how they differ. Through "standardization" more consistent types of information and a limited number of dimensions along which plans vary--MA plans could reduce complexity and improve beneficiaries' ability to make informed choices. Such standardization steps would offer more meaningful variation in the health coverage options available to beneficiaries, Medicare officials and their community partners would find it far easier to educate beneficiaries about their health plan choices, and beneficiaries would better understand what they were buying. Standardization might also strengthen the ability of the market-based Medicare Advantage program to incorporate beneficiary preferences.

  14. New Medicare-approved prescription drug discount card.

    PubMed

    James, John S

    2004-05-28

    Patients who are on Medicare and have income under 135% of Federal poverty level and are not on Medicaid probably should obtain one of the new Medicare discount cards that became available on June 1, 2004, because all these cards include $600 annual credit for prescription-drug purchases for persons within that income limit. Unfortunately this program is complex, no one yet knows how it will work in practice, and after choosing a card one is locked in and cannot change cards until November 15. The most difficult part of the choice of which card to get may involve how it interacts with other programs, including ADAP, and pharmaceutical company patient assistance programs.

  15. Extending U.S. Medicare to Mexico

    PubMed Central

    Haims, Marla C.; Dick, Andrew W.

    2012-01-01

    Abstract There is a lack of hard data on the exact number of Medicare-eligible retirees residing in Mexico, but it is at least in the tens of thousands and is certainly rising as the baby boom generation reaches retirement. Because Medicare does not cover health services received outside the United States, these retirees must travel to the United States for health care or purchase alternative coverage for health services received in Mexico. There are several arguments for extending Medicare to Mexico—that is, allowing Medicare-eligible beneficiaries to receive their Medicare benefits in Mexico. Medicare-eligible retirees living in Mexico would certainly benefit, and Mexico might benefit from improved quality of care and an expanded health economy. Moreover, American taxpayers might benefit from a reduced total cost of Medicare: To the extent that extending Medicare to Mexico induces Medicare beneficiaries to substitute higher-cost U.S. health care services with lower-cost Mexican services, overall Medicare expenditures might be reduced. The authors outline four options for how this policy change might be implemented and describe a conceptual model that could be used to assess the effects of each option. PMID:28083264

  16. 75 FR 6360 - Federal Advisory Committee; DoD Medicare-Eligible Retiree Health Care Board of Actuaries

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-02-09

    ... of the Secretary Federal Advisory Committee; DoD Medicare-Eligible Retiree Health Care Board of... that the DoD Medicare-Eligible Retiree Health Care Board of Actuaries will meet on August 18, 2010... used in the valuation of benefits under DoD retiree health care programs for...

  17. 78 FR 9890 - DoD Medicare-Eligible Retiree Health Care Board of Actuaries; Notice of Federal Advisory...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-12

    ... of the Secretary DoD Medicare-Eligible Retiree Health Care Board of Actuaries; Notice of Federal... that the following Federal Advisory Committee meeting of the DoD Medicare-Eligible Retiree Health Care... in the valuation of benefits under DoD retiree health care programs for...

  18. Fixing flaws in Medicare drug coverage that prompt insurers to avoid low-income patients.

    PubMed

    Hsu, John; Fung, Vicki; Huang, Jie; Price, Mary; Brand, Richard; Hui, Rita; Fireman, Bruce; Dow, William H; Bertko, John; Newhouse, Joseph P

    2010-12-01

    Since 2006 numerous insurers have stopped serving the low-income segment of the Medicare Part D program, forcing millions of beneficiaries to change prescription drug plans. Using data from participating plans, we found that Medicare payments do not sufficiently reimburse insurers for the relatively high medication use among this population, creating perverse incentives for plans to avoid this part of the Part D market. Plans can accomplish this by increasing their premiums for all beneficiaries to an amount above regional benchmarks. We demonstrate that improving the accuracy of Medicare's risk and subsidy adjustments could mitigate these perverse incentives.

  19. 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 providers and for ambulatory surgical centers. final rule.

    PubMed

    2012-08-31

    (ASCs) that are participating in Medicare. We are establishing requirements for the Hospital Value-Based Purchasing (VBP) Program and the Hospital Readmissions Reduction Program.

  20. Conference report: APA conference of experts on medicare legislation for psychiatric disorders august 9-10, 1965, washington, D.C

    PubMed

    2000-04-01

    Editor's Note: The report on an American Psychiatric Association conference on Medicare legislation reprinted below was published in the October 1965 issue of Mental Hospitals. The conference was convened to draft recommendations to be used in setting standards for care in psychiatric facilities that wished to participate in the Medicare program. Richard G. Frank, Ph.D., discusses the dramatic impact of the Medicare and Medicaid programs on mental health care in a commentary and analysis beginning on page 465.

  1. Medicare Telehealth Services and Nephrology: Policies for Eligibility and Payment.

    PubMed

    Frilling, Stephanie

    2017-01-01

    The criteria for Medicare payment of telehealth nephrology services, and all other Medicare telehealth services, are set forth in section 1834(m) of the Social Security Act. There are just over 80 professional physician or practitioner services that may be furnished via telehealth and paid under Medicare Part B, when an interactive audio and video telecommunication system that permits real-time communication between a beneficiary at the originating site and the physician or practitioner at the distant site substitutes for an in-person encounter. These services include 16 nephrology billing codes for furnishing ESRD services for monthly monitoring and assessment and two billing codes for chronic kidney disease education. In recent years, many mobile health devices and other web-based tools have been developed in support of monitoring, observation, and collaboration for people living with chronic disease. This article reviews the statutory and program guidance that governs Medicare telehealth services, defines payment policy terms (e.g., originating site and distant site), and explains payment policies when telehealth services are furnished.

  2. MEDICARE PAYMENTS AND SYSTEM-LEVEL HEALTH-CARE USE

    PubMed Central

    ROBBINS, JACOB A.

    2015-01-01

    The rapid growth of Medicare managed care over the past decade has the potential to increase the efficiency of health-care delivery. Improvements in care management for some may improve efficiency system-wide, with implications for optimal payment policy in public insurance programs. These system-level effects may depend on local health-care market structure and vary based on patient characteristics. We use exogenous variation in the Medicare payment schedule to isolate the effects of market-level managed care enrollment on the quantity and quality of care delivered. We find that in areas with greater enrollment of Medicare beneficiaries in managed care, the non–managed care beneficiaries have fewer days in the hospital but more outpatient visits, consistent with a substitution of less expensive outpatient care for more expensive inpatient care, particularly at high levels of managed care. We find no evidence that care is of lower quality. Optimal payment policies for Medicare managed care enrollees that account for system-level spillovers may thus be higher than those that do not. PMID:27042687

  3. 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

    ... of Contents I. Background II. Provisions of the Final Regulations and Analysis of and Responses to....107, and Sec. 422.152) a. Adding a Definition of Fully Integrated Dual Eligible SNP (Sec. 422.2) b... Department Services (Sec. 422.113) 6. Clarify Language Related to Submission of a Valid Application (Sec....

  4. 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

    .... 423.44) 9. Translated Marketing Materials (Sec. 422.2264 and Sec. 423.2264) E. Strengthening Our... Organizations (Sec. 422.4) 2. Cost Plan Enrollment Mechanisms (Sec. 417.430) 3. Fast-Track Appeals of Service... Organizations (Sec. 422.100 and Sec. 422.262) V. ICRs Regarding Translated Marketing Materials (Sec....

  5. Predictable Unpredictability: the Problem with Basing Medicare Policy on Long-Term Financial Forecasting.

    PubMed

    Glied, Sherry; Zaylor, Abigail

    2015-07-01

    The authors assess how Medicare financing and projections of future costs have changed since 2000. They also assess the impact of legislative reforms on the sources and levels of financing and compare cost forecasts made at different times. Although the aging U.S. population and rising health care costs are expected to increase the share of gross domestic product devoted to Medicare, changes made in the program over the past decade have helped stabilize Medicare's financial outlook--even as benefits have been expanded. Long-term forecasting uncertainty should make policymakers and beneficiaries wary of dramatic changes to the program in the near term that are intended to alter its long-term forecast: the range of error associated with cost forecasts rises as the forecast window lengthens. Instead, policymakers should focus on the immediate policy window, taking steps to reduce the current burden of Medicare costs by containing spending today.

  6. Viva la Vida: helping Latino Medicare beneficiaries with diabetes live their lives to the fullest.

    PubMed

    Olson, Rebecca; Sabogal, Fabio; Perez, Ana

    2008-02-01

    Viva la Vida (Live Your Life) is a call to action for older Latinos to take charge of their diabetes and live life to the fullest. Lumetra, California's federally designated Medicare quality improvement organization, developed the Viva la Vida project to improve diabetes care among Latino Medicare beneficiaries in 4 Southern California counties. After researching barriers to good diabetes care among Latino seniors, Lumetra designed a multifaceted program targeting health care providers and Medicare beneficiaries through bilingual, low-literacy health education materials and tools, community and provider partnerships, and the mass media. The project succeeded in helping to reduce the disparity in glycosylated hemoglobin testing between White and Latino Medicare beneficiaries in the 4 program counties.

  7. Viva La Vida: Helping Latino Medicare Beneficiaries With Diabetes Live Their Lives to the Fullest

    PubMed Central

    Olson, Rebecca; Sabogal, Fabio; Perez, Ana

    2008-01-01

    Viva la Vida (Live Your Life) is a call to action for older Latinos to take charge of their diabetes and live life to the fullest. Lumetra, California’s federally designated Medicare quality improvement organization, developed the Viva la Vida project to improve diabetes care among Latino Medicare beneficiaries in 4 Southern California counties. After researching barriers to good diabetes care among Latino seniors, Lumetra designed a multifaceted program targeting health care providers and Medicare beneficiaries through bilingual, low-literacy health education materials and tools, community and provider partnerships, and the mass media. The project succeeded in helping to reduce the disparity in glycosylated hemoglobin testing between White and Latino Medicare beneficiaries in the 4 program counties. PMID:18172150

  8. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2015 rates; quality reporting requirements for specific providers; reasonable compensation equivalents for physician services in excluded hospitals and certain teaching hospitals; provider administrative appeals and judicial review; enforcement provisions for organ transplant centers; and electronic health record (EHR) incentive program. Final rule.

    PubMed

    2014-08-22

    are participating in Medicare. 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. In addition, we are making technical corrections to the regulations governing provider administrative appeals and judicial review; updating the reasonable compensation equivalent (RCE) limits, and revising the methodology for determining such limits, for services furnished by physicians to certain teaching hospitals and hospitals excluded from the IPPS; making regulatory revisions to broaden the specified uses of Medicare Advantage (MA) risk adjustment data and to specify the conditions for release of such risk adjustment data to entities outside of CMS; and making changes to the enforcement procedures for organ transplant centers. We are aligning the reporting and submission timelines for clinical quality measures for the Medicare HER Incentive Program for eligible hospitals and critical access hospitals (CAHs) with the reporting and submission timelines for the Hospital IQR Program. In addition, we provide guidance and clarification of certain policies for eligible hospitals and CAHs such as our policy for reporting zero denominators on clinical quality measures and our policy for case threshold exemptions. In this document, we are finalizing two interim final rules with comment period relating to criteria for disproportionate share hospital uncompensated care payments and extensions of temporary changes to the payment adjustment for low-volume hospitals and of the Medicare-Dependent, Small Rural Hospital (MDH) Program.

  9. Experiments Have Not Demonstrated Success of Competitive Fixed-Price Contracting in Medicare.

    DTIC Science & Technology

    1981-12-01

    Claims Processingr (HRD-79-76). As requested, our review focused principally on the experimental contract in Illinois. We also addressed the Health Care ...fixed-price contracting on the Medi- care program. (See pp. 8 to 10.) The results of Medicare’s three fixed-price experiments have varied. Contractor...year of its fixed-price contract to process Medicare part B claims in Maine on September 30, 1981. The Health Care Financing Administration (HCFA

  10. Measuring coverage for seniors in Medicare Part A and estimating the cost of making it universal.

    PubMed

    Birnbaum, Michael; Patchias, Elizabeth M

    2010-02-01

    That Medicare is universal for seniors is widely accepted by leading analysts. But in the context of developing detailed policies that seek to cover as many people as possible, it is inaccurate to make Medicare eligibility sound so simple and inclusive. To estimate the number of seniors without full federal Medicare Part A coverage, we examined data for uninsured seniors, seniors with Medicaid and no Medicare coverage of any kind, seniors with Medicare Part B but without Part A, and seniors bought into Part A by their state Medicaid programs. We found that in 2005, 1.6 million seniors--or 5 percent of the elderly U.S. population--were without a full federal Part A premium subsidy. The share of seniors without this benefit was notably higher in the nation's two largest states--California (12 percent) and New York (8 percent). We estimate that reforming Medicare Part A to make the benefit truly universal and fully federal would cost the federal government $6 billion in new spending in federal fiscal year 2011, an increase in baseline federal Medicare expenditures of 1.1 percent.

  11. Your Guide to Medicare Special Needs Plans (SNPs)

    MedlinePlus

    ... are approved by Medicare and run by private companies. When you join a Medicare SNP, you get ... available in different parts of the country. Insurance companies decide where they will do business, so Medicare ...

  12. Medicare: Comparison of Catastropic Health Insurance Proposals--an Update.

    DTIC Science & Technology

    1987-10-01

    elderly’s health care bills; VA paid about 3 percent. Even with government programs, the elderly can face high out-of- pocket health care costs...the Congress, and others have introduced bills to relieve the elderly from the burden of catastrophic health care expenses. METHODOLOGY We updated our...GAO and other reports to identify the types and amounts of out-of- pocket expenses incurred by the elderly , (2) reviewing Medicare law and regulations

  13. Medicare and Medicaid Programs; CY 2017 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements. Final rule.

    PubMed

    2016-11-03

    This final rule updates the Home Health Prospective Payment System (HH PPS) payment rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor; effective for home health episodes of care ending on or after January 1, 2017. This rule also: Implements the last year of the 4-year phase-in of the rebasing adjustments to the HH PPS payment rates; updates the HH PPS case-mix weights using the most current, complete data available at the time of rulemaking; implements the 2nd-year of a 3-year phase-in of a reduction to the national, standardized 60-day episode payment to account for estimated case-mix growth unrelated to increases in patient acuity (that is, nominal case-mix growth) between CY 2012 and CY 2014; finalizes changes to the methodology used to calculate payments made under the HH PPS for high-cost "outlier" episodes of care; implements changes in payment for furnishing Negative Pressure Wound Therapy (NPWT) using a disposable device for patients under a home health plan of care; discusses our efforts to monitor the potential impacts of the rebasing adjustments; includes an update on subsequent research and analysis as a result of the findings from the home health study; and finalizes changes to the Home Health Value-Based Purchasing (HHVBP) Model, which was implemented on January 1, 2016; and updates to the Home Health Quality Reporting Program (HH QRP).

  14. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and Fiscal Year 2014 rates; quality reporting requirements for specific providers; hospital conditions of participation; payment policies related to patient status. Final rules.

    PubMed

    2013-08-19

    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 Act of 2010 (collectively known as the Affordable Care Act) and other legislation. These changes will be applicable to discharges occurring on or after October 1, 2013, unless otherwise specified in this final rule. We also are updating the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits. The updated rate-of-increase limits will be effective for cost reporting periods beginning on or after October 1, 2013. 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) and implementing certain statutory changes that were applied to the LTCH PPS by the Affordable Care Act. Generally, these updates and statutory changes will be applicable to discharges occurring on or after October 1, 2013, unless otherwise specified in this final rule. In addition, we are making a number of changes relating to direct graduate medical education (GME) and indirect medical education (IME) payments. We are establishing new requirements or have revised requirements for quality reporting by specific providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities (IPFs)) that are participating in Medicare. We are updating policies relating to the Hospital Value-Based Purchasing (VBP) Program and the Hospital Readmissions Reduction Program. In addition, we are revising the conditions of participation (CoPs) for hospitals relating to the

  15. March 2013: Medicare Advantage update.

    PubMed

    Sayavong, Sarah; Kemper, Leah; Barker, Abigail; McBride, Timothy

    2013-09-01

    Key Data Findings. (1) From March 2012 to March 2013, rural enrollment in Medicare Advantage (MA) and other prepaid plans increased by over 200,000 enrollees, to more than 1.9 million. (2) Preferred provider organization (PPO) plan enrollment increased to nearly one million enrollees, accounting for more than 51% of the rural MA market (up from 48% in March 2012). (3) Health maintenance organization (HMO) enrollment continued to grow in 2013, with over 31% of the rural MA market, while private fee-for-service (PFFS) plan enrollment decreased to less than 10% of market share. (4) Despite recent changes to MA payment, rural MA enrollment continues to increase.

  16. Medicare program; prospective payment system for long-term care hospitals RY 2009: annual payment rate updates, policy changes, and clarifications; and electronic submission of cost reports: revision to effective date of cost reporting period. Final rule.

    PubMed

    2008-05-09

    This final rule updates the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs). We are also consolidating the annual July 1 update for payment rates and the October 1 update for Medicare severity long-term care diagnosis-related group (MS-LTC-DRG) weights to a single rulemaking cycle that coincides with the Federal fiscal year (FFY). In addition, we are clarifying various policy issues. This final rule also finalizes the provisions from the Electronic Submission of Cost Reports: Revision to Effective Date of Cost Reporting Period interim final rule with comment period that was published in the May 27, 2005 Federal Register which revises the existing effective date by which all organ procurement organizations (OPOs), rural health clinics (RHCs), Federally qualified health centers (FQHCs), and community mental health centers (CMHCs) are required to submit their Medicare cost reports in a standardized electronic format from cost reporting periods ending on or after December 31, 2004 to cost reporting periods ending on or after March 31, 2005. This final rule does not affect the current cost reporting requirement for hospices and end-stage renal disease (ESRD) facilities. Hospices and ESRD facilities are required to continue to submit cost reports under the Medicare regulations in a standardized electronic format for cost reporting periods ending on or after December 31, 2004.

  17. Medicare: Better Controls Needed for Peer Review Organizations’ Evaluations.

    DTIC Science & Technology

    1987-10-01

    Peer Review Organizations’ performance during the 1984-86 contract period. It also discusses HCFA’S process for determining program funding for the 1986-88 contract period. The report contains recommendations to the Secretary of Health and Human Services. Professional Review Organizations (PROS) contract with the Medicare program to review the necessity, appropriateness, and quality of inpatient hospital services received by the program’s beneficiaries. From February through July 1986, the Department of Health and Human Services’ (HHS’S) Health

  18. Secret weapon: the "new" Medicare as a route to health security.

    PubMed

    Schlesinger, Mark; Hacker, Jacob S

    2007-04-01

    Over the past twenty years, Medicare has been transformed from a single-payer insurer into a hybrid of complementary public and private insurance arrangements. Despite creating ongoing controversy, these changes have resulted in an ironic and largely overlooked strategic potential: Medicare's evolving hybrid form makes it the most promising vehicle for overcoming the historical obstacles to universal health insurance in the United States. To make this surprising case, we first explore the distinctive political dynamics of programs that, like today's Medicare, are hybrids of public and private arrangements. We then consider how these political dynamics might circumvent past barriers to universal health insurance. Finally, we discuss the strengths and weaknesses of alternative pathways through which Medicare could be expanded to promote health security.

  19. Your Guide to Medicare's Preventive Services

    MedlinePlus

    ... primary care setting (like a doctor’s office). Your costs if you have Original Medicare You pay nothing if the doctor or other qualified primary care provider accepts PS assignment. Bone mass measurements Medicare covers bone mass measurements to see if ...

  20. Medicare Resources That You Should Use

    PubMed Central

    Schaum, Kathleen Dianne

    2013-01-01

    Wound care scientists, manufacturers, and wound care professionals should take time to visit the Centers for Medicare & Medicaid Services' website. It is easy to navigate and contains information for all wound care stakeholders. This article reviews some of the most popular Medicare website pages that should prove useful to wound care stakeholders. The links to those pages are also provided. PMID:24761329