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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-01-02

... Secretary must determine that the waiver--(1) is expected to increase organ donations; and (2) will assure...] Medicare and Medicaid Programs; Announcement of Application From a Hospital Requesting Waiver for Organ... require the hospital to enter into an agreement with its designated Organ Procurement Organization (OPO...

75 FR 43177 - Medicare and Medicaid Programs; Announcement of an Application From a Hospital Requesting Waiver...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-23

... waiver, the Secretary must determine that the waiver--(1) is expected to increase organ donations; and (2...] Medicare and Medicaid Programs; Announcement of an Application From a Hospital Requesting Waiver for Organ... require the hospital to enter into an agreement with its designated Organ Procurement Organization (OPO...

75 FR 21337 - Medicare and Medicaid Programs; Announcement of an Application From a Hospital Requesting Waiver...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-04-23

... waiver--(1) Is expected to increase organ donations; and (2) will ensure equitable treatment of patients...] Medicare and Medicaid Programs; Announcement of an Application From a Hospital Requesting Waiver for Organ... require the hospital to enter into an agreement with its designated Organ Procurement Organization (OPO...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-02-02

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part 489... & Medicaid Services (CMS), HHS. ACTION: Request for comments. SUMMARY: This request for comments addresses... comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-20

... on the Innovation Center Web site http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated... Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, Mail Stop S3-13-05, 7500... and Medicaid Innovation (Innovation Center). The Pioneer ACO Model is an Innovation Center initiative...

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

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-1587-N2... Submission of Applications AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice of... hospitals to apply to the Centers for Medicare & Medicaid Services (CMS) to receive St. Vincent's Medical...

Evaluation of an emergency department-based enrollment program for uninsured children.

PubMed

Mahajan, Prashant; Stanley, Rachel; Ross, Kevin W; Clark, Linda; Sandberg, Keisha; Lichtenstein, Richard

2005-03-01

We evaluate the effectiveness of an emergency department (ED)-based outreach program in increasing the enrollment of uninsured children. The study involved placing a full-time worker trained to enroll uninsured children into Medicaid or the State Children's Health Insurance Program in an inner-city academic children's hospital ED. Analysis was carried out for outpatient ED visits by insurance status, average revenue per patient from uninsured and insured children, proportion of patients enrolled in Medicaid and State Children's Health Insurance Program through this program, estimated incremental revenue from new enrollees, and program-specific incremental costs. A cost-benefit analysis and breakeven analysis was conducted to determine the impact of this intervention on ED revenues. Five thousand ninety-four uninsured children were treated during the 10 consecutive months assessed, and 4,667 were treated during program hours. One thousand eight hundred and three applications were filed, giving a program penetration rate of 39%. Eighty-four percent of applications filed were resolved (67% of these were Medicaid). Average revenue from each outpatient ED visit for Medicaid was US135.68 dollars, other insurance was US210.43 dollars, and uninsured was US15.03 dollars. Estimated incremental revenue for each uninsured patient converted to Medicaid was US120.65 dollars. Total annualized incremental revenue was US224,474 dollars, and the net incremental revenue, after accounting for program costs, was US157,414 dollars per year. A program enrolling uninsured children at an inner-city pediatric ED into government insurance was effective and generated revenue that paid for program costs.

42 CFR 435.1200 - Medicaid agency responsibilities.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Web site, any interactive kiosks and other information systems established by the State to support... application is submitted to any insurance affordability program. (c) Provision of Medicaid for individuals... eligibility; (2) Comply with the provisions of § 435.911 of this part to the same extent as if the application...

42 CFR 435.1200 - Medicaid agency responsibilities.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Web site, any interactive kiosks and other information systems established by the State to support... application is submitted to any insurance affordability program. (c) Provision of Medicaid for individuals... eligibility; (2) Comply with the provisions of § 435.911 of this part to the same extent as if the application...

42 CFR 435.1200 - Medicaid agency responsibilities.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Web site, any interactive kiosks and other information systems established by the State to support... application is submitted to any insurance affordability program. (c) Provision of Medicaid for individuals... eligibility; (2) Comply with the provisions of § 435.911 of this part to the same extent as if the application...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-09-28

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-3264-FN... Accreditation Program (AOA/HFAP) Application for Continuing CMS-Approval of Its Ambulatory Surgical Center (ASC... 6 years or sooner as determined by CMS. AOA/HFAP's current term of approval for their ASC...

Direct Verification of School Meal Applications with Medicaid Data: A Pilot Evaluation of Feasibility, Effectiveness and Costs

ERIC Educational Resources Information Center

Logan, Christopher W.; Cole, Nancy; Kamara, Sheku G.

2010-01-01

Purpose/Objectives: The Direct Verification Pilot tested the feasibility, effectiveness, and costs of using Medicaid and State Children's Health Insurance Program (SCHIP) data to verify applications for free and reduced-price (FRP) school meals instead of obtaining documentation from parents and guardians. Methods: The Direct Verification Pilot…

What The Oregon Health Study Can Tell Us About Expanding Medicaid

PubMed Central

Allen, Heidi; Baicker, Katherine; Finkelstein, Amy; Taubman, Sarah; Wright, Bill J.

2012-01-01

The recently enacted Patient Protection and Affordable Care Act includes a major expansion of Medicaid to low-income adults in 2014. This paper describes the Oregon Health Study, a randomized controlled trial that will be able to shed some light on the likely effects of such expansions. In 2008, Oregon randomly drew names from a waiting list for its previously closed public insurance program. Our analysis of enrollment into this program found that people who signed up for the waiting list and enrolled in the Oregon Medicaid program were likely to have worse health than those who did not. However, actual enrollment was fairly low, partly because many applicants did not meet eligibility standards. PMID:20679654

Stigma and Other Determinants of Participation in TANF and Medicaid

ERIC Educational Resources Information Center

Stuber, Jennifer; Kronebusch, Karl

2004-01-01

We developed a conceptual framework to examine the association between stigma, enrollment barriers (e.g., difficult application), knowledge, state policy, and participation in the Temporary Assistance to Needy Families (TANF) and adult Medicaid programs. Survey data from 901 community health center patients, who were potential and actual…

78 FR 19269 - Medicare and Medicaid Programs; Announcement of Application From a Hospital Requesting Waiver for...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-29

... Procurement Service Area AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice with... require the hospital to enter into an agreement with its designated Organ Procurement Organization (OPO... Organ Procurement Organizations (OPOs) are not-for-profit organizations that are responsible for the...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-31

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-1587-N... & Medicaid Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice announces the closure of St. Vincent's Medical Center and the initiation of an application process for hospitals to apply to the Centers for...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-02-24

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-3259-PN... Self-Management Training AGENCY: Centers for Medicare & Medicare Services (CMS), HHS. ACTION: Proposed... comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and...

Medicaid Integrity Program; eligible entity and contracting requirements for the Medicaid Integrity audit program. Final rule.

PubMed

2008-09-26

Section 1936 of the Social Security Act (the Act) (as added by section 6034 of the Deficit Reduction Act of 2005 (DRA) established the Medicaid Integrity Program to promote the integrity of the Medicaid program by requiring CMS to enter into contracts with eligible entities to: (1) Review the actions of individuals or entities furnishing items or services (whether on a fee-for-service, risk, or other basis) for which payment may be made under an approved State plan and/or any waiver of such plan approved under section 1115 of the Act; (2) audit claims for payment of items or services furnished, or administrative services rendered, under a State plan; (3) identify overpayments to individuals or entities receiving Federal funds; and (4) educate providers of services, managed care entities, beneficiaries, and other individuals with respect to payment integrity and quality of care. This final rule will provide requirements for an eligible entity to enter into a contract under the Medicaid integrity audit program. The final rule will also establish the contracting requirements for eligible entities. The requirements will include procedures for identifying, evaluating, and resolving organizational conflicts of interest that are generally applicable to Federal acquisition and procurement; competitive procedures to be used; and procedures under which a contract may be renewed.

78 FR 59121 - Basic Health Program: State Administration of Basic Health Programs; Eligibility and Enrollment...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-09-25

....305) 3. Application (Sec. 600.310) 4. Certified Application Counselors (Sec. 600.315) 5. Determination... application'' used by both Medicaid and the Exchange, and found in 42 CFR 431.907(b)(1) of this chapter and 45... [[Page 59126

Misperceptions of medicaid ineligibility persist among African American caregivers of Alzheimer's dementia care recipients.

PubMed

Kingsberry, Sheridan Quarless; Mindler, Philinda

2012-06-01

African American caregivers of the elderly, including those who care for patients with Alzheimer's and other forms of dementia, remain underserved by Medicaid Assistance Programs. The purpose of this exploratory study was to ascertain to what degree participants in an Alzheimer's Association program that primarily targeted African Americans applied for and received Medicaid assistance, in particular for adult day care, in-home care, and respite care. Secondary data from the Delaware Regional Office of the Alzheimer's Association's 2006 Caregiver Survey of 38 caregivers were reviewed using descriptive, chi-square, and logistic regression analysis. Results indicate that 20 caregivers applied for Medicaid services, 12 of whom were approved. However, 18 caregivers did not apply for Medicaid mainly because they perceived that they would not qualify for benefits, without investigating their eligibility. Clearly more education is needed in African American communities about the eligibility requirements and benefits of Medicaid Assistance Programs because services such as adult day care, in-home care, and respite care have been shown to reduce some of the burden, stress, and strain associated with caring for elderly patients with Alzheimer's dementia. However, a multisystem approach should be used in the outreach and education processes. Finally, the Medicaid application process should be streamlined to make it less cumbersome. More financial and support services are needed by African American caregivers of Alzheimer's care recipients.

76 FR 57807 - Medicaid Program; Recovery Audit Contractors

Federal Register 2010, 2011, 2012, 2013, 2014

2011-09-16

... for Medicare & Medicaid Services 42 CFR Part 455 Medicaid Program; Recovery Audit Contractors; Final... 42 CFR Part 455 [CMS-6034-F] RIN 0938-AQ19 Medicaid Program; Recovery Audit Contractors AGENCY... costs of Medicaid Recovery Audit Contractors (Medicaid RACs) and the payment methodology for State...

78 FR 9457 - Medicare, Medicaid, Children's Health Insurance Programs; Transparency Reports and Reporting of...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-02-08

... applicable manufacturers of drugs, devices, biologicals, or medical supplies covered under title XVIII of the Act (Medicare) or a State plan under title XIX (Medicaid) or XXI of the Act (the Children's Health..., ``Conflict of Interest in Medical Research, Education and Practice.'' Given these recommendations and other...

42 CFR 441.100 - Basis and purpose.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Basis and purpose. 441.100 Section 441.100 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Medicaid for Individuals Age 65 or Over in Institutions...

42 CFR 441.100 - Basis and purpose.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Basis and purpose. 441.100 Section 441.100 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Medicaid for Individuals Age 65 or Over in Institutions...

42 CFR 441.100 - Basis and purpose.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Basis and purpose. 441.100 Section 441.100 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Medicaid for Individuals Age 65 or Over in Institutions...

42 CFR 441.100 - Basis and purpose.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Basis and purpose. 441.100 Section 441.100 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Medicaid for Individuals Age 65 or Over in Institutions...

42 CFR 441.100 - Basis and purpose.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 4 2013-10-01 2013-10-01 false Basis and purpose. 441.100 Section 441.100 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Medicaid for Individuals Age 65 or Over in Institutions...

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

...). We noted that research has extensively documented the pervasiveness of vulnerable populations which.... For example, if the State law requires the administrator of a NF participating in its State Medicaid...) would not be applicable. For example, if a facility's air conditioning failed during a heat wave, the...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-05-31

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-1459-N... Slots AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice announces the closure of two teaching hospitals and the initiation of an application process where hospitals...

Factors Related to Medicaid Payment Acceptance at Outpatient Substance Abuse Treatment Programs

PubMed Central

Terry-McElrath, Yvonne M; Chriqui, Jamie F; McBride, Duane C

2011-01-01

Objective To examine factors associated with Medicaid acceptance for substance abuse (SA) services by outpatient SA treatment programs. Data Sources Secondary analysis of 2003–2006 National Survey of Substance Abuse Treatment Services data combined with state Medicaid policy and usage measures and other publicly available data. Study Design We used cross-sectional analyses, including state fixed effects, to assess relationships between SA treatment program Medicaid acceptance and (1) program-level factors, (2) county-level sociodemographics and treatment program density, and (3) state-level population characteristics, SA treatment-related factors, and Medicaid policy and usage. Data Extraction Methods State Medicaid policy data were compiled based on reviews of state Medicaid-related statutes/regulations and Medicaid plans. Other data were publicly available. Principal Findings Medicaid acceptance was significantly higher for programs: (a) that were publicly funded and in states with Medicaid policy allowing SA treatment coverage; (b) with accreditation/licensure and nonprofit/government ownership, as well as mental- and general-health focused programs; and (c) in counties with lower household income. Conclusions SA treatment program Medicaid acceptance related to program-, county, and state-level factors. The data suggest the importance of state policy and licensure/accreditation requirements in increasing SA program Medicaid access. PMID:21105870

42 CFR 455.232 - Medicaid integrity audit program contractor functions.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Medicaid integrity audit program contractor functions. 455.232 Section 455.232 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid...

42 CFR 455.232 - Medicaid integrity audit program contractor functions.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Medicaid integrity audit program contractor functions. 455.232 Section 455.232 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid...

42 CFR 455.232 - Medicaid integrity audit program contractor functions.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Medicaid integrity audit program contractor functions. 455.232 Section 455.232 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid...

42 CFR 455.232 - Medicaid integrity audit program contractor functions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Medicaid integrity audit program contractor functions. 455.232 Section 455.232 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid...

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 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.

24 CFR 700.130 - Service coordinator.

Code of Federal Regulations, 2011 CFR

2011-04-01

... AND PUBLIC AND INDIAN HOUSING PROGRAMS) CONGREGATE HOUSING SERVICES PROGRAM § 700.130 Service...; (10) Educate grant recipient's program participants on such issues as benefits application procedures (e.g. SSI, food stamps, Medicaid), service availability, and program participant options and...

The Politics of Medicaid: Most Americans Are Connected to the Program, Support Its Expansion, and Do Not View It as Stigmatizing.

PubMed

Grogan, Colleen M; Park, Sunggeun Ethan

2017-12-01

Policy Points: More than half of Americans are connected to the Medicaid program-either through their own coverage or that of a family member or close friend-and are significantly more likely to view Medicaid as important and to support increases in spending, even among conservatives. This finding helps explain why Affordable Care Act repeal efforts faced (and will continue to face) strong public backlash. Policymakers should be aware that although renaming programs within Medicaid may have increased enrollment take-up, this destigmatization effort might have also increased program confusion and reduced support for Medicaid even among enrollees who say the program is important to them. Since the 1980s, Medicaid enrollment has expanded so dramatically that by 2015 two-thirds of Americans had some connection to the program in which either they themselves, a family member, or a close friend is currently or was previously enrolled. Utilizing a nationally representative survey-the Kaiser Family Foundation Poll: Medicare and Medicaid at 50 (n = 1,849)-and employing ordinal and logistic regression analyses, our study examines 3 questions: (1) are individuals with a connection to Medicaid more likely to view the program as important, (2) are they more likely to support an increase in Medicaid spending, and (3) are they more likely to support adoption of the Medicaid expansion offered under the Affordable Care Act? For each of these questions we examine whether partisanship and views of stigma also impact support for Medicaid and, if so, whether these factors overwhelm the impact of connection to the program. Controlling for the strong effect of partisanship, people with any connection to the Medicaid program are more likely to view the program as important than those with no connection. However, when it comes to increasing spending or expanding the program, the type of connection to the program matters. In particular, adults with current and previous Medicaid coverage and those with a family member or close friend with Medicaid coverage are more likely to support increases in spending and the Medicaid expansion; but, those connected to Medicaid only through coverage of a child are no more likely to support Medicaid than those with no connection. Future research should probe more deeply into whether people with different types of connection to Medicaid view the program differently, and, if so, how and why. Moreover, future research should also explore whether state-level attempts to destigmatize Medicaid by renaming the program also serves to reduce knowledge and support for Medicaid. © 2017 Milbank Memorial Fund.

Medicaid/CHIP Program; Medicaid Program and Children's Health Insurance Program (CHIP); Changes to the Medicaid Eligibility Quality Control and Payment Error Rate Measurement Programs in Response to the Affordable Care Act. Final rule.

PubMed

2017-07-05

This final rule updates the Medicaid Eligibility Quality Control (MEQC) and Payment Error Rate Measurement (PERM) programs based on the changes to Medicaid and the Children's Health Insurance Program (CHIP) eligibility under the Patient Protection and Affordable Care Act. This rule also implements various other improvements to the PERM program.

Cost-effectiveness of preventive oral health care in medical offices for young Medicaid enrollees.

PubMed

Stearns, Sally C; Rozier, R Gary; Kranz, Ashley M; Pahel, Bhavna T; Quiñonez, Rocio B

2012-10-01

To estimate the cost-effectiveness of a medical office-based preventive oral health program in North Carolina called Into the Mouths of Babes (IMB). Observational study using Medicaid claims data (2000-2006). Medical staff delivered IMB services in medical offices, and dentists provided dental services in offices or hospitals. A total of 209 285 children enrolled in Medicaid at age 6 months. Into the Mouths of Babes visits included screening, parental counseling, topical fluoride application, and referral to dentists, if needed. The cost-effectiveness analysis used the Medicaid program perspective and a propensity score-matched sample with regression analysis to compare children with 4 or more vs 0 IMB visits. Dental treatments and Medicaid payments for children up to age 6 years enabled assessment of the likelihood of whether IMB was cost-saving and, if not, the additional payments per hospital episode avoided. Into the Mouths of Babes is 32% likely to be cost-saving, with discounting of benefits and payments. On average, IMB visits cost $11 more than reduced dental treatment payments per person. The program almost breaks even if future benefits from prevention are not discounted, and it would be cost-saving with certainty if IMB services could be provided at $34 instead of $55 per visit. The program is cost-effective with 95% certainty if Medicaid is willing to pay $2331 per hospital episode avoided. Into the Mouths of Babes improves dental health for additional payments that can be weighed against unmeasured hospitalization costs.

42 CFR 425.204 - Content of the application.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Content of the application. 425.204 Section 425.204 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE SHARED SAVINGS PROGRAM Application Procedures and Participation Agreement § 425.204 Content of the...

Reimbursement rates and policies for primary molar pit-and-fissure sealants across state Medicaid programs.

PubMed

Chi, Donald L; Singh, Jennifer

2013-11-01

Little is known about Medicaid policies regarding reimbursement for placement of sealants on primary molars. The authors identified Medicaid programs that reimbursed dentists for placing primary molar sealants and hypothesized that these programs had higher reimbursement rates than did state programs that did not reimburse for primary molar sealants. The authors obtained Medicaid reimbursement data from online fee schedules and determined whether each state Medicaid program reimbursed for primary molar sealants (no or yes). The outcome measure was the reimbursement rate for permanent tooth sealants (calculated in 2012 U.S. dollars). The authors compared mean reimbursement rates by using the t test (α = .05). Seventeen Medicaid programs reimbursed dentists for placing primary molar sealants (34 percent), and the mean reimbursement rate was $27.57 (range, $16.00 [Maine] to $49.68 [Alaska]). All 50 programs reimbursed dentists for placement of sealants on permanent teeth. The mean reimbursement for permanent tooth sealants was significantly higher in programs that reimbursed for primary molar sealants than in programs that did not ($28.51 and $23.67, respectively; P = .03). Most state Medicaid programs do not reimburse dentists for placing sealants on primary molars, but programs that do so have significantly higher reimbursement rates. Medicaid reimbursement rates are related to dentists' participation in Medicaid and children's dental care use. Reimbursement for placement of sealants on primary molars is a proxy for Medicaid program generosity.

42 CFR 455.236 - Renewal of a contract.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid Integrity Program § 455.236 Renewal of a contract. (a) CMS specifies the initial contract term in the Medicaid integrity audit program...

76 FR 60050 - Medicaid Program: Money Follows the Person Rebalancing Demonstration Program

Federal Register 2010, 2011, 2012, 2013, 2014

2011-09-28

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid Program: Money Follows the Person Rebalancing Demonstration Program AGENCY: Centers for Medicare & Medicaid..., particularly given the complexity and vulnerability of the populations being served in MFP and the Congress...

42 CFR 455.14 - Preliminary investigation.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid Agency Fraud Detection and Investigation Program § 455.14 Preliminary investigation. If the agency receives a complaint of Medicaid fraud...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-11-30

... Radiation Therapy (IMRT) (APC 0305) f. Computed Tomography of Abdomen/Pelvic (APCs 0331 and 0334) g. Complex Interstitial Radiation Source Application (APC 0651) h. Radioelement Applications (APC 0312) 8. Respiratory...

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

...] Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on Outreach and... Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). This meeting is open to the public... eligible for, Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). Enhancing the Federal...

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

...] Medicare, Medicaid, and Children's Health Insurance Programs; Renewal of the Advisory Panel on Outreach and... Medicaid and the Children's Health Insurance Program (CHIP), and also expanded the availability of other... are eligible for Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) about options...

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

...] Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on Outreach and... Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). This meeting is open to the public... eligible for, Medicare, Medicaid and the Children's Health Insurance Program (CHIP). Enhancing the Federal...

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

...] Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on Outreach and... the Medicare, Medicaid, and Children's Health Insurance (CHIP) programs. This meeting is open to the... outreach programs for individuals enrolled in, or eligible for, Medicare, Medicaid, and the Children's...

42 CFR 455.16 - Resolution of full investigation.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 455.16 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid Agency Fraud Detection and... further action; (2) Suspending or terminating the provider from participation in the Medicaid program; (3...

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

PubMed

2018-01-30

This document announces the extension of statewide temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance providers and suppliers and Medicare home health agencies, subunits, and branch locations in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey, as applicable, to prevent and combat fraud, waste, and abuse. This extension also applies to the enrollment of new non-emergency ground ambulance suppliers and home health agencies, subunits, and branch locations in Medicaid and the Children's Health Insurance Program in those states. For purposes of these moratoria, providers that were participating as network providers in one or more Medicaid managed care organizations prior to January 1, 2018 will not be considered "newly enrolling" when they are required to enroll with the State Medicaid agency pursuant to a new statutory requirement, and thus will not be subject to the moratoria.

75 FR 69037 - Medicaid Program; Recovery Audit Contractors

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-10

... [CMS-6034-P] RIN 0938-AQ19 Medicaid Program; Recovery Audit Contractors AGENCY: Centers for Medicare... Recovery Audit Contractors (Medicaid RACs) and the payment methodology for State payments to Medicaid RACs... RACs coordinate with other contractors and entities auditing Medicaid providers and with State and...

42 CFR 495.350 - State Medicaid agency attestations.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false State Medicaid agency attestations. 495.350 Section 495.350 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.350 State Medicaid agency attestations...

42 CFR 455.21 - Cooperation with State Medicaid fraud control units.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Cooperation with State Medicaid fraud control units. 455.21 Section 455.21 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid Agency Fraud...

42 CFR 495.332 - State Medicaid health information technology (HIT) plan requirements.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 5 2014-10-01 2014-10-01 false State Medicaid health information technology (HIT... HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.332 State Medicaid health information technology (HIT) plan requirements. Each State Medicaid HIT plan must include...

42 CFR 495.332 - State Medicaid health information technology (HIT) plan requirements.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 5 2013-10-01 2013-10-01 false State Medicaid health information technology (HIT... HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.332 State Medicaid health information technology (HIT) plan requirements. Each State Medicaid HIT plan must include...

42 CFR 495.332 - State Medicaid health information technology (HIT) plan requirements.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 5 2012-10-01 2012-10-01 false State Medicaid health information technology (HIT... HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.332 State Medicaid health information technology (HIT) plan requirements. Each State Medicaid HIT plan must include...

42 CFR 495.332 - State Medicaid health information technology (HIT) plan requirements.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 5 2011-10-01 2011-10-01 false State Medicaid health information technology (HIT... HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.332 State Medicaid health information technology (HIT) plan requirements. Each State Medicaid HIT plan must include...

42 CFR 495.332 - State Medicaid health information technology (HIT) plan requirements.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false State Medicaid health information technology (HIT... HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.332 State Medicaid health information technology (HIT) plan requirements. Each State Medicaid HIT plan must include...

Medicaid Program; Disproportionate Share Hospital Payments--Treatment of Third Party Payers in Calculating Uncompensated Care Costs. Final rule.

PubMed

2017-04-03

This final rule addresses the hospital-specific limitation on Medicaid disproportionate share hospital (DSH) payments under section 1923(g)(1)(A) of the Social Security Act (Act), and the application of such limitation in the annual DSH audits required under section 1923(j) of the Act, by clarifying that the hospital-specific DSH limit is based only on uncompensated care costs. Specifically, this rule makes explicit in the text of the regulation, an existing interpretation that uncompensated care costs include only those costs for Medicaid eligible individuals that remain after accounting for payments made to hospitals by or on behalf of Medicaid eligible individuals, including Medicare and other third party payments that compensate the hospitals for care furnished to such individuals. As a result, the hospital-specific limit calculation will reflect only the costs for Medicaid eligible individuals for which the hospital has not received payment from any source.

78 FR 42159 - Medicaid and Children's Health Insurance Programs: Essential Health Benefits in Alternative...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-07-15

...This final rule implements provisions of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act. This final rule finalizes new Medicaid eligibility provisions; finalizes changes related to electronic Medicaid and the Children's Health Insurance Program (CHIP) eligibility notices and delegation of appeals; modernizes and streamlines existing Medicaid eligibility rules; revises CHIP rules relating to the substitution of coverage to improve the coordination of CHIP coverage with other coverage; and amends requirements for benchmark and benchmark- equivalent benefit packages consistent with sections 1937 of the Social Security Act (which we refer to as ``alternative benefit plans'') to ensure that these benefit packages include essential health benefits and meet certain other minimum standards. This rule also implements specific provisions including those related to authorized representatives, notices, and verification of eligibility for qualifying coverage in an eligible employer-sponsored plan for Affordable Insurance Exchanges. This rule also updates and simplifies the complex Medicaid premium and cost sharing requirements, to promote the most effective use of services, and to assist states in identifying cost sharing flexibilities. It includes transition policies for 2014 as applicable.

Medicaid program; correction and reduction plans for intermediate care facilities for the mentally retarded--HCFA. Final rule.

PubMed

1988-01-25

These final regulations provide States options under which an intermediate care facility for the mentally retarded (ICF/MR) found to have substantial deficiencies only in physical plant and staffing (or physical plant, staffing, and other minor deficiencies) that do not pose an immediate threat to the clients' health and safety may remedy those deficiencies. The regulations provide the State Medicaid agency with options to submit written plans either to correct the necessary staff and physical plant deficiencies, and all other minor deficiencies, within 6 months of the approval date of the plan, or to reduce permanently the number of beds in certified units within 36 months of the approval date of the plan. These regulations implement section 9516 of the Consolidated Omnibus Budget Reconciliation Act of 1985 and section 4217 of the Omnibus Budget Reconciliation Act of 1987. The purpose of the correction plan provision is to promote correction of deficiencies without having to exclude ICFs/MR from the Medicaid program. The reduction plan provision is intended to move Medicaid clients out of deficient ICFs/MR into licensed or certified (as applicable) community settings while maintaining the clients' quality of life and retaining their Medicaid eligibility.

76 FR 26341 - Medicaid Program; Methods for Assuring Access to Covered Medicaid Services

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-06

... Medicare & Medicaid Services 42 CFR Part 447 Medicare Program; Methods for Assuring Access to Covered... Services 42 CFR Part 447 [CMS 2328-P] RIN 0938-AQ54 Medicaid Program; Methods for Assuring Access to... design the procedures for enrolling providers of such care, and to set the methods for establishing...

42 CFR 431.810 - Basic elements of the Medicaid eligibility quality control (MEQC) program.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Basic elements of the Medicaid eligibility quality control (MEQC) program. 431.810 Section 431.810 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES... elements of the Medicaid eligibility quality control (MEQC) program. (a) General requirements. The agency...

42 CFR 431.810 - Basic elements of the Medicaid eligibility quality control (MEQC) program.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Basic elements of the Medicaid eligibility quality control (MEQC) program. 431.810 Section 431.810 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES... GENERAL ADMINISTRATION Quality Control Medicaid Eligibility Quality Control (meqc) Program § 431.810 Basic...

The Medicaid School Program: An Effective Public School and Private Sector Partnership

ERIC Educational Resources Information Center

Mallett, Christopher A.

2013-01-01

Privatized service delivery within Medicaid has greatly increased over the past two decades. This public program-private sector collaboration is quite common today, with a majority of Medicaid recipients receiving services in this fashion; yet controversy remains. This article focuses on just one program within Medicaid, school-based services for…

Enrolling in Medicaid through the National School Lunch Program: outcome of a pilot project in California schools.

PubMed

Cousineau, Michael R; Wada, Eriko O; Hogan, Laura

2007-01-01

California has several health insurance programs for children. However, the system for enrolling into these programs is complex and difficult to manage for many families. Express Lane Eligibility is designed to streamline the Medicaid (called Medi-Cal in California) enrollment process by linking it to the National School Lunch Program. If a child is eligible for free lunch and the parents consent, the program provides two months of presumptive eligibility for Medi-Cal and a simplified application process for continuation in Medi-Cal. For those who are ineligible, it provides a referral to other programs. An evaluation of Express Lane shows that while many children were presumptively enrolled, nearly half of the applicants were already enrolled in Medi-Cal. Many Express Enrolled children failed to complete the full Medi-Cal enrollment process. Few were referred to the State Children's Health Insurance Program or county programs. Express Lane is less useful as a broad screening strategy, but can be one of many tools that communities use to enroll children in health insurance.

42 CFR 495.320 - FFP for payments to Medicaid providers.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false FFP for payments to Medicaid providers. 495.320 Section 495.320 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.320 FFP for payments to Medicaid...

42 CFR 456.437 - Notification of adverse decision.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Intermediate Care... qualified mental retardation professional, if applicable; (d) The Medicaid agency; (e) The recipient; and (f...

Care coordination for children with special needs in Medicaid: lessons from Medicare.

PubMed

Stewart, Kate A; Bradley, Katharine W V; Zickafoose, Joseph S; Hildrich, Rachel; Ireys, Henry T; Brown, Randall S

2018-04-01

To provide actionable recommendations for improving care coordination programs for children with special healthcare needs (CSHCN) in Medicaid managed care.  Literature review and interviews with stakeholders and policy experts to adapt lessons learned from Medicare care coordination programs for CSHCN in Medicaid managed care. We reviewed syntheses of research on Medicare care coordination programs to identify lessons learned from successful programs. We adapted findings from Medicare to CSHCN in Medicaid based on an environmental scan and discussions with experts. The scan focused on Medicaid financing and eligibility for care coordination and how these intersect with Medicaid managed care. The expert discussions included pediatricians, Medicaid policy experts, Medicaid medical directors, and a former managed care executive, all experienced in care coordination for CSHCN. We found 6 elements that are consistently associated with improved outcomes from Medicare care coordination programs and relevant to CSHCN in Medicaid: 1) identifying and targeting high-risk patients, 2) clearly articulating what outcomes programs are likely to improve, 3) encouraging active engagement between care coordinators and primary care providers, 4) requiring some in-person contact between care coordinators and patients, 5) facilitating information sharing among providers, and 6) supplementing care coordinators' expertise with that of other clinical experts. States and Medicaid managed care organizations have many options for designing effective care coordination programs for CSHCN. Their choices should account for the diversity of conditions among CSHCN, families' capacity to coordinate care, and social determinants of health.

42 CFR 408.205 - Application procedures.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Application procedures. 408.205 Section 408.205 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PREMIUMS FOR SUPPLEMENTARY MEDICAL INSURANCE Supplementary Medical Insurance Premium Surcharge...

42 CFR 408.205 - Application procedures.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 2 2011-10-01 2011-10-01 false Application procedures. 408.205 Section 408.205 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PREMIUMS FOR SUPPLEMENTARY MEDICAL INSURANCE Supplementary Medical Insurance Premium Surcharge...

Medicaid: A Primer - Key Information on the Nation's Health Coverage Program for Low-Income People

MedlinePlus

... nearly 40% of all Medicaid spending. Through the economic downturn, the main driver of Medicaid spending was ... Medicaid is a countercyclical program that expands during economic downturns, when states’ fiscal capacity is also most ...

Diagnostic Risk Adjustment for Medicaid: The Disability Payment System

PubMed Central

Kronick, Richard; Dreyfus, Tony; Lee, Lora; Zhou, Zhiyuan

1996-01-01

This article describes a system of diagnostic categories that Medicaid programs can use for adjusting capitation payments to health plans that enroll people with disability. Medicaid claims from Colorado, Michigan, Missouri, New York, and Ohio are analyzed to demonstrate that the greater predictability of costs among people with disabilities makes risk adjustment more feasible than for a general population and more critical to creating health systems for people with disability. The application of our diagnostic categories to State claims data is described, including estimated effects on subsequent-year costs of various diagnoses. The challenges of implementing adjustment by diagnosis are explored. PMID:10172665

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

... Respiratory Care Services; Medicaid Program: Accreditation for Providers of Inpatient Psychiatric Services... Conditions of Participation for Rehabilitation and Respiratory Care Services; Medicaid Program: Accreditation... Participation for Rehabilitation and Respiratory Care Services; Medicaid Program: Accreditation for Providers of...

Design and development of a mobile exercise application for home care aides and older adult medicaid home and community-based clients.

PubMed

Danilovich, Margaret K; Diaz, Laura; Saberbein, Gustavo; Healey, William E; Huber, Gail; Corcos, Daniel M

2017-01-01

We describe a community-engaged approach with Medicaid home and community-based services (HCBS), home care aide (HCA), client, and physical therapist stakeholders to develop a mobile application (app) exercise intervention through focus groups and interviews. Participants desired a short exercise program with modification capabilities, goal setting, and mechanisms to track progress. Concerns regarding participation were training needs and feasibility within usual care services. Technological preferences were for simple, easy-to-use, and engaging content. The app was piloted with HCA-client dyads (n = 5) to refine the intervention and evaluate content. Engaging stakeholders in intervention development provides valuable user-feedback on both desired exercise program contents and mobile technology preferences for HCBS recipients.

Assessing the present state and potential of Medicaid controlled substance lock-in programs.

PubMed

Roberts, Andrew W; Skinner, Asheley Cockrell

2014-05-01

Nonmedical use of prescription medications--particularly controlled substances--has risen dramatically in recent decades, resulting in alarming increases in overdose-related health care utilization, costs, and mortality. The Centers for Disease Control and Prevention estimate that 80% of abused and misused controlled substances originate as legal prescriptions. As such, policymakers and payers have the opportunity to combat nonmedical use by regulating controlled substance accessibility within legal prescribing and dispensing processes. One common policy strategy is found in Medicaid controlled substance lock-in programs. Lock-in programs identify Medicaid beneficiaries exhibiting high-risk controlled substance seeking behavior and "lock in" these patients to, typically, a single prescriber and pharmacy from which they may obtain Medicaid-covered controlled substance prescriptions. Lock-in restrictions are intended to improve care coordination between providers, reduce nonmedical use behaviors, and limit Medicaid costs stemming from nonmedical use and diversion. Peer-reviewed and gray literature have been examined to assess the current prevalence and design of Medicaid lock-in programs, as well as the current evidence base for informing appropriate program design and understanding program effectiveness. Forty-six state Medicaid agencies currently operate lock-in programs. Program design varies widely between states in terms of defining high-risk controlled substance use, the scope of actual lock-in restrictions, and length of program enrollment. Additionally, there is a remarkable dearth of peer-reviewed literature evaluating the design and effectiveness of Medicaid lock-in programs. Nearly all outcomes evidence stemmed from publicly accessible internal Medicaid program evaluations, which largely investigated cost savings to the state. Lock-in programs are highly prevalent and poised to play a meaningful role in curbing the prescription drug abuse epidemic. However, achieving these ends requires a concerted effort from the academic and policy communities to rigorously evaluate the effect of lock-in programs on patient outcomes, determine optimal program design, and explore opportunities to enhance lock-in program impact through coordination with parallel controlled substance policy efforts, namely prescription drug-monitoring programs.

42 CFR 600.700 - Basis, scope, and applicability.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 5 2014-10-01 2014-10-01 false Basis, scope, and applicability. 600.700 Section 600.700 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) BASIC HEALTH PROGRAM ADMINISTRATION, ELIGIBILITY, ESSENTIAL HEALTH BENEFITS...

42 CFR 423.774 - Eligibility determinations, redeterminations, and applications.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Eligibility determinations, redeterminations, and applications. 423.774 Section 423.774 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-11-29

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-3285-FN] Medicare and Medicaid Programs; Continued Approval of American Osteopathic Association/Healthcare... Medicare & Medicaid Services, HHS. ACTION: Final notice. SUMMARY: This final notice announces our decision...

42 CFR 455.13 - Methods for identification, investigation, and referral.

Code of Federal Regulations, 2010 CFR

2010-10-01

... referral. 455.13 Section 455.13 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid... referral. The Medicaid agency must have— (a) Methods and criteria for identifying suspected fraud cases; (b...

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

...] Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on Outreach and... strategies concerning Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). This meeting is... Health Insurance Program (CHIP). Enhancing the Federal government's effectiveness in informing Medicare...

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

...] Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on Outreach and... Medicare, Medicaid and the Children's Health Insurance Program (CHIP). This meeting is open to the public... Health Insurance Program (CHIP). Enhancing the federal government's effectiveness in informing Medicare...

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

...] Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on Outreach and... Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). This meeting is open to the public... Health Insurance Program (CHIP). Enhancing the federal governments effectiveness in informing Medicare...

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

...] Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on Outreach and..., Medicaid and the Children's Health Insurance Program (CHIP). This meeting is open to the public. DATES... Children's Health Insurance Program (CHIP). Enhancing the federal government's effectiveness in informing...

Michigan dentists' attitudes toward Medicaid and an alternative public dental insurance system for children.

PubMed

Nebeker, Cordell D; Briskie, Daniel M; Maturo, Raymond A; Piskorowski, Wilhelm A; Sohn, Woosung; Boynton, James R

2014-01-01

Healthy Kids Dental (HKD) was created as a pilot program of the Michigan State Medicaid program to increase access to care for Medicaid-eligible children. The purpose of this study was to evaluate dentist's attitudes toward Healthy Kids Dental and Medicaid in Michigan. An online survey was sent to practitioners with an e-mail address registered with the Michigan Dental Association (N=4,285). Surveys were returned from 965 practitioners (~23 percent). Although practitioners were not fully satisfied with the HKD, their satisfaction with the program was significantly higher than their satisfaction with the traditional Medicaid program (P<.001). Sixty-four percent of providers that accept Medicaid limit the number of children seen in some manner, while 28 percent of providers that accept HKD limit the number of children seen. Families with traditional Medicaid who contact an office are significantly less likely to receive treatment for their child than families with HKD insurance who contact the same office (P<.001). Practitioners were more satisfied with programmatic and patient-related factors of the Healthy Kids Dental program than they were with Medicaid. Dentists were more likely to treat children with HKD than children with Medicaid when the parent contacts a dentist in Michigan.

Medicaid and Children's Health Insurance Programs: essential health benefits in alternative benefit plans, eligibility notices, fair hearing and appeal processes, and premiums and cost sharing; exchanges: eligibility and enrollment. Final rule.

PubMed

2013-07-15

This final rule implements provisions of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act. This final rule finalizes new Medicaid eligibility provisions; finalizes changes related to electronic Medicaid and the Children's Health Insurance Program (CHIP) eligibility notices and delegation of appeals; modernizes and streamlines existing Medicaid eligibility rules; revises CHIP rules relating to the substitution of coverage to improve the coordination of CHIP coverage with other coverage; and amends requirements for benchmark and benchmark-equivalent benefit packages consistent with sections 1937 of the Social Security Act (which we refer to as ``alternative benefit plans'') to ensure that these benefit packages include essential health benefits and meet certain other minimum standards. This rule also implements specific provisions including those related to authorized representatives, notices, and verification of eligibility for qualifying coverage in an eligible employer-sponsored plan for Affordable Insurance Exchanges. This rule also updates and simplifies the complex Medicaid premium and cost sharing requirements, to promote the most effective use of services, and to assist states in identifying cost sharing flexibilities. It includes transition policies for 2014 as applicable.

Commentary: Medicaid reform issues affecting the Indian health care system.

PubMed Central

Wellever, A; Hill, G; Casey, M

1998-01-01

Substantial numbers of Indian people rely on Medicaid for their primary health insurance coverage. When state Medicaid programs enroll Indians in managed care programs, several unintended consequences may ensue. This paper identifies some of the perverse consequences of Medicaid reform for Indians and the Indian health care system and suggests strategies for overcoming them. It discusses the desire of Indian people to receive culturally appropriate services, the need to maintain or improve Indian health care system funding, and the duty of state governments to respect tribal sovereignty. Because of their relatively small numbers, Indians may be treated differently under Medicaid managed care systems without significantly endangering anticipated program savings. Failure of Medicaid programs to recognize the uniqueness of Indian people, however, may severely weaken the Indian health care system. PMID:9491006

42 CFR 417.484 - Requirement applicable to related entities.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Requirement applicable to related entities. 417.484 Section 417.484 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL...

42 CFR 417.484 - Requirement applicable to related entities.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Requirement applicable to related entities. 417.484 Section 417.484 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL...

42 CFR 455.230 - Eligibility requirements.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Eligibility requirements. 455.230 Section 455.230 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid Integrity Program § 455.230...

42 CFR 455.2 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID § 455.2 Definitions. As used in this part unless the context... medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for...

77 FR 47375 - Applications for New Awards; Assistive Technology Alternative Financing Program

Federal Register 2010, 2011, 2012, 2013, 2014

2012-08-08

... (AT) they need. In addition, programs such as Medicaid, Medicare, and vocational rehabilitation cannot... sources. Competitive Preference Priorities: Within this absolute priority, we give competitive preference... comment on the proposed absolute and competitive preference priorities under section 437(d)(1)of GEPA. The...

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

... skilled nursing facilities, in the Medicare program, and nursing facilities, in the Medicaid program, that... skilled nursing facilities (SNFs) for Medicare and nursing facilities (NFs) for Medicaid. The Federal... services provided by a nursing home are important, Congressional intent about what constitutes ``quality of...

42 CFR 431.151 - Scope and applicability.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Scope and applicability. 431.151 Section 431.151 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STATE ORGANIZATION AND GENERAL ADMINISTRATION Appeals Process for NFs and ICFs/MR § 431.151 Scope and applicability...

42 CFR 431.151 - Scope and applicability.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Scope and applicability. 431.151 Section 431.151 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STATE ORGANIZATION AND GENERAL ADMINISTRATION Appeals Process for NFs and ICFs/MR § 431.151 Scope and applicability...

2014 QuickCompaof TRICARE Child Beneficiaries: Utilization of Medicaid Waivered Services

DTIC Science & Technology

2015-02-12

Utilization of Medicaid Waivered Services 5b. GRANT NUMBER 5c. PROGRAM ELEMENT NUMBER 6. AUTHORISI Sd. PROJECT NUMBER Tinney, R., Dr. Se. TASK...from the 2014 QuickCompass ofTRlCARE Child Beneficiaries: Utilization of Medicaid Waivered Services (2014 QTCB). The 2014 QTCB survey was...Family Member Program (EFMP), TRICARE Extended Care Health Option (ECHO), Medicaid , and Medicaid Home and Community Based Services (HCBS) Waivers. 16

42 CFR 430.60 - Scope.

Code of Federal Regulations, 2010 CFR

2010-10-01

... FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS Hearings on Conformity of State Medicaid... Federal funds (under § 430.35), because the State plan or State practice in the Medicaid program is not in...

Improving medicaid health incentives programs: lessons from substance abuse treatment research.

PubMed

Hand, Dennis J; Heil, Sarah H; Sigmon, Stacey C; Higgins, Stephen T

2014-06-01

This commentary addresses the efforts of Medicaid programs in several US states to employ financial incentives to increase healthy behavior among their beneficiaries. While these Medicaid incentive programs have been successful at boosting rates of less effortful behaviors, like semiannual dental visits, they have fallen short in promoting more complex behaviors, like smoking cessation, drug abstinence, and weight management. Incentives have been extensively studied as a treatment for substance use disorders for over 20years, with good success. We identify two variables shown by meta-analysis to moderate the efficacy of incentive interventions in substance abuse treatment, the immediacy of incentive delivery and size (or magnitude) of the incentive, that are lacking in current Medicaid incentive program. We also offer some guidance on how these moderating variables could be addressed within Medicaid programs. This is a critical time for such analysis, as more than 10 states are employing incentives in their Medicaid programs, and some are currently reevaluating their incentive strategies. Copyright © 2014 Elsevier Inc. All rights reserved.

Contrary To Popular Belief, Medicaid Hospital Admissions Are Often Profitable Because Of Additional Medicare Payments.

PubMed

Stensland, Jeffrey; Gaumer, Zachary R; Miller, Mark E

2016-12-01

It is generally believed that most hospitals lose money on Medicaid admissions. The data suggest otherwise. Medicaid admissions are often profitable for hospitals because of payments from both the Medicaid program and the Medicare program, including payments for uncompensated care and from the Medicare disproportionate-share hospital program. On average, adding a single Medicaid patient day in fiscal year 2017 will increase most hospitals' Medicare payments by more than $300. When added to Medicaid payments, these payments often cause Medicaid patients to be profitable for hospitals. In contrast, adding a single charity care day in the same year will decrease overall Medicare payments by about $20 on average. The Centers for Medicare and Medicaid Services recently announced a proposal to shift some Medicare payments from supporting hospitals' costs for Medicaid patients to directly supporting their costs for uncompensated care. If that proposal is adopted, hospitals' profits on Medicaid patients would decrease, but their losses on care for the uninsured would be reduced. Project HOPE—The People-to-People Health Foundation, Inc.

42 CFR 436.909 - Automatic entitlement to Medicaid following a determination of eligibility under other programs.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Automatic entitlement to Medicaid following a... & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS... Islands § 436.909 Automatic entitlement to Medicaid following a determination of eligibility under other...

76 FR 61103 - Medicare Program; Comprehensive Primary Care Initiative

Federal Register 2010, 2011, 2012, 2013, 2014

2011-10-03

... interest by November 15, 2011 using the LOI template provided on the Innovation Center Web site at http://www.innovation.cms.gov /. Application Submission Deadline: Applications must be received through an... practice redesign in primary care through payment reform. The Center for Medicare & Medicaid Innovation...

42 CFR 403.312 - Submittal of application.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Submittal of application. 403.312 Section 403.312 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS SPECIAL PROGRAMS AND PROJECTS Recognition of State Reimbursement Control Systems § 403.312...

78 FR 6275 - Medicaid, Children's Health Insurance Programs, and Exchanges: Essential Health Benefits in...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-01-30

... Medicaid, Children's Health Insurance Programs, and Exchanges: Essential Health Benefits in Alternative...'s Health Insurance Programs, and Exchanges: Essential Health Benefits in Alternative Benefit Plans... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 430...

A predictive model of hospitalization risk among disabled medicaid enrollees.

PubMed

McAna, John F; Crawford, Albert G; Novinger, Benjamin W; Sidorov, Jaan; Din, Franklin M; Maio, Vittorio; Louis, Daniel Z; Goldfarb, Neil I

2013-05-01

To identify Medicaid patients, based on 1 year of administrative data, who were at high risk of admission to a hospital in the next year, and who were most likely to benefit from outreach and targeted interventions. Observational cohort study for predictive modeling. Claims, enrollment, and eligibility data for 2007 from a state Medicaid program were used to provide the independent variables for a logistic regression model to predict inpatient stays in 2008 for fully covered, continuously enrolled, disabled members. The model was developed using a 50% random sample from the state and was validated against the other 50%. Further validation was carried out by applying the parameters from the model to data from a second state's disabled Medicaid population. The strongest predictors in the model developed from the first 50% sample were over age 65 years, inpatient stay(s) in 2007, and higher Charlson Comorbidity Index scores. The areas under the receiver operating characteristic curve for the model based on the 50% state sample and its application to the 2 other samples ranged from 0.79 to 0.81. Models developed independently for all 3 samples were as high as 0.86. The results show a consistent trend of more accurate prediction of hospitalization with increasing risk score. This is a fairly robust method for targeting Medicaid members with a high probability of future avoidable hospitalizations for possible case management or other interventions. Comparison with a second state's Medicaid program provides additional evidence for the usefulness of the model.

Medicaid and Children's Health Insurance Programs: Eligibility Notices, Fair Hearing and Appeal Processes for Medicaid and Other Provisions Related to Eligibility and Enrollment for Medicaid and CHIP. Final rule.

PubMed

2016-11-30

This final rule implements provisions of the Affordable Care Act that expand access to health coverage through improvements in Medicaid and coordination between Medicaid, CHIP, and Exchanges. This rule finalizes most of the remaining provisions from the "Medicaid, Children's Health Insurance Programs, and Exchanges: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes for Medicaid and Exchange Eligibility Appeals and Other Provisions Related to Eligibility and Enrollment for Exchanges, Medicaid and CHIP, and Medicaid Premiums and Cost Sharing; Proposed Rule" that we published in the January 22, 2013, Federal Register. This final rule continues our efforts to assist states in implementing Medicaid and CHIP eligibility, appeals, and enrollment changes required by the Affordable Care Act.

Medicaid Managed Care and Cost Containment in the Adult Disabled Population

PubMed Central

Burns, Marguerite E.

2010-01-01

Background Despite the increasing enrollment of adult disabled beneficiaries into Medicaid managed care organizations (MCOs) there is little evidence of its (hoped for) effectiveness at reducing Medicaid expenditures. Objective To evaluate the impact of Medicaid MCOs on health care expenditures for adults with disabilities. Research Design I employ a repeated observations design comparing individual monthly Medicaid expenditures across beneficiaries who reside in counties with mandatory, voluntary, and no MCOs. County-level Medicaid MCO program status for adults with disabilities was merged with the Medical Expenditure Panel Survey and the Area Resource File for 1996–2004. Two-part regression models are used to estimate the probability and level of Medicaid expenditure. Subjects Working age Medicaid beneficiaries who receive Supplement Security Income for disability comprise the sample of 1,613 individuals. Measures Outcome measures include total and service-specific Medicaid expenditures. Results On average, total monthly Medicaid expenditures per beneficiary do not differ between FFS and MCO counties although some service-specific spending differs. Relative to FFS counties, average monthly Medicaid spending per beneficiary is higher for prescription medications in voluntary ($24) and mandatory ($25) MCO counties. Average Medicaid monthly spending for other medical care and dental care is $4 – $11 higher per beneficiary in MCO relative to FFS counties. Conclusions Medicaid MCO programs as implemented are not associated with lower Medicaid spending; thus, state Medicaid programs should consider additional policy tools to contain health care expenditures in this population. PMID:19820613

Child Health Assessment Act and Increased Medicaid Funding for Puerto Rico. Hearing Before the Subcommittee on Health of the Committee on Finance, United States Senate, Ninety-Fifth Congress, Second Session on H.R. 9434 and S. 1392.

ERIC Educational Resources Information Center

Congress of the U.S., Washington, DC. Senate Committee on Finance.

This Congressional hearing records the testimony of administration and public witnesses on H.R. 9434 and S. 1392 and includes the texts of the legislation. H.R. 9434 is an act to amend the social security act to increase the dollar limitation and federal medical assistance percentages applicable to the medicaid programs of Puerto Rico, the Virgin…

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-09-23

... use in enforcement activities; monitoring procedures for provider entities found not in compliance... pertaining to activities relating to the survey and certification of facilities are at 42 CFR part 488. The... complaints against accredited facilities. ++ CHAP's processes and procedures for monitoring HHAs found out of...

42 CFR 423.800 - Administration of subsidy program.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Administration of subsidy program. 423.800 Section 423.800 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... track the application of the subsidies under this subpart to be applied to the out-of-pocket threshold...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-09-23

...-service (FFS) program, we require that Medicare contractors review State licensing board data on a monthly... professional review actions and malpractice from the National Practitioner Data Bank (NPDB), accreditation... verify data submitted on, and as part of, the Medicare provider/supplier enrollment application, our...

42 CFR 455.23 - Withholding of payments in cases of fraud or willful misrepresentation.

Code of Federal Regulations, 2010 CFR

2010-10-01

... willful misrepresentation. 455.23 Section 455.23 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid Agency Fraud Detection and Investigation Program § 455.23 Withholding of payments in cases of...

76 FR 10735 - Medicaid Program; Community First Choice Option

Federal Register 2010, 2011, 2012, 2013, 2014

2011-02-25

... Vol. 76 Friday, No. 38 February 25, 2011 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Part 441 Medicaid Program; Community First Choice Option...; [[Page 10736

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

... 42 Public Health 5 2010-10-01 2010-10-01 false Exclusion from participation in Medicare, Medicaid..., ASSESSMENTS AND EXCLUSIONS § 1003.105 Exclusion from participation in Medicare, Medicaid and all Federal... the Medicare and Medicaid programs, he or she will, at the same time he or she notifies the respondent...

Economic impacts of Medicaid in North Carolina.

PubMed

Dumas, Christopher; Hall, William; Garrett, Patricia

2008-01-01

The purpose of this study is to provide estimates of the economic impacts of Medicaid program expenditures in North Carolina in state fiscal year (SFY) 2003. The study uses input-output analysis to estimate the economic impacts of Medicaid expenditures. The study uses North Carolina Medicaid program expenditure data for SFY 2003 as submitted by the North Carolina Division of Medical Assistance to the federal Centers for Medicare and Medicaid Services (CMS). Industry structure data from 2002 that are part of the IMPLAN input-output modeling software database are also used in the analysis. In SFY 2003 $6.307 billion in Medicaid program expenditures occurred within the state of North Carolina-$3.941 billion federal dollars, $2.014 billion state dollars, and $351 million in local government funds. Each dollar of state and local government expenditures brought $1.67 in federal Medicaid cost-share to the state. The economic impacts within North Carolina of the 2003 Medicaid expenditures included the following: 182,000 jobs supported (including both full-time and some part-time jobs); $6.1 billion in labor income (wages, salaries, sole proprietorship/partnership profits); and $1.9 billion in capital income (rents, interest payments, corporate dividend payments). If the Medicaid program were shut down and the funds returned to taxpayers who saved/spent the funds according to typical consumer expenditure patterns, employment in North Carolina would fall by an estimated 67,400 jobs, and labor income would fall by $2.83 billion, due to the labor-intensive nature of Medicaid expenditures. Medicaid expenditure and economic impact results do not capture the economic value of the improved health and well-being of Medicaid recipients. Furthermore, the results do not capture the savings to society from increased preventive care and reduced uncompensated care resulting from Medicaid. State and local government expenditures do not fully capture the economic consequences of Medicaid in North Carolina. This study finds that Medicaid makes a large contribution to state and local economic activity by creating jobs, income, and profit in North Carolina. Any changes to the Medicaid program should be made with caution. The rising costs of health care and the appropriate role of government health insurance programs are the object of current policy debates. Informed discussion of these issues requires good information on the economic and health consequences of alternative policy choices. This is the first systematic study of the broader economic impacts of Medicaid expenditures in North Carolina.

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

PubMed

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

2018-02-01

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

Improving access for Medicaid-insured children: focus on front-office personnel.

PubMed

Lam, M; Riedy, C A; Milgrom, P

1999-03-01

Access to dental services for low-income children is limited. Front-office personnel play a role regarding dentists' participation in the Medicaid program. Subjects (N = 24) represented general dental offices in Spokane County, Wash., and included participants and nonparticipants in the Access to Baby and Child Dentistry, or ABCD, program, a dental society/community program aimed at expanding dental services provided to Medicaid-insured children. The authors stratified the participants according to the number of claims their practices submitted to Medicaid for ABCD children: non-ABCD, low-ABCD and high-ABCD. Five two-hour focus group sessions were conducted to determine participants' beliefs about, attitudes toward and experiences in serving this population. The authors' data analysis consisted of a comprehensive content review of participants' responses from transcripted audiotapes. They synthesized frequently mentioned concepts and ideas into relevant themes. The major factors affecting practices' participation in Medicaid were office policy on seeing Medicaid-insured patients; staff members' personal connection to Medicaid-insured patients; staff members' attitudes about Medicaid-insured patients; and staff members' perceptions of Medicaid-insured patients' barriers to care. The data suggest that factors affecting dentists' participation in the Medicaid program are more complex than the often-stated dissatisfactions with low reimbursement fees and hassles with paperwork. Efforts to increase dentist participation in serving Medicaid-insured patients will continue to be relatively ineffective until many of the concerns raised by this study's subjects are better understood and addressed.

Leveraging The Affordable Care Act To Enroll Justice-Involved Populations In Medicaid: State And Local Efforts

PubMed Central

Bandara, Sachini N.; Huskamp, Haiden A.; Riedel, Lauren E.; McGinty, Emma E.; Webster, Daniel; Toone, Robert E.; Barry, Colleen L.

2016-01-01

The Affordable Care Act provides an unprecedented opportunity to enroll criminal justice–involved populations in health insurance, particularly Medicaid. As a result, many state and county corrections departments have launched programs that incorporate Medicaid enrollment in discharge planning. Our study characterizes the national landscape of programs enrolling criminal justice–involved populations in Medicaid as of January 2015. We provide an overview of sixty-four programs operating in jails, prisons, or community probation and parole systems that enroll individuals during detention, incarceration, and the release process. We describe the variation among the programs in terms of settings, personnel, timing of eligibility screening, and target populations. Seventy-seven percent of the programs are located in jails, and 56 percent use personnel from public health or social service agencies. We describe four practices that have facilitated the Medicaid enrollment process: suspending instead of terminating Medicaid benefits upon incarceration, presuming that an individual is eligible for Medicaid before the process is completed, allowing enrollment during incarceration, and accepting alternative forms of identification for enrollment. The criminal justice system is a complex one that requires a variety of approaches to enroll individuals in Medicaid. Future research should examine how these approaches influence health and criminal justice outcomes. PMID:26643624

42 CFR 405.455 - Application to Medicare+Choice contracts.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Application to Medicare+Choice contracts. 405.455 Section 405.455 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 § 405.455...

42 CFR 405.2410 - Application of Part B deductible and coinsurance.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Application of Part B deductible and coinsurance. 405.2410 Section 405.2410 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED Rural Health...

77 FR 11677 - Medicaid Program; Review and Approval Process for Section 1115 Demonstrations

Federal Register 2010, 2011, 2012, 2013, 2014

2012-02-27

... experimental, pilot, and demonstration projects approved under section 1115 of the Social Security Act relating... selected provisions of section 1902 of the Act for experimental, pilot, or demonstration projects... application, and recommended that CMS allow the State to not post a complete application. The commenters noted...

77 FR 17068 - Medicare and Medicaid Programs; Approval of the Application by the American Association for...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-23

... of Ambulatory Surgery Facilities for Deeming Authority for Rural Health Clinics AGENCY: Centers for... decision to approve the American Association for Accreditation of Ambulatory Surgery Facilities [[Page...

Utilization of the medical librarian in a state Medicaid program to provide information services geared to health policy and health disparities

PubMed Central

Droese, Peter; Peterson, Nancy

2006-01-01

Objective: The role of two solo medical librarians in supporting Medicaid programs by functioning as information specialists at regional and state levels is examined. Setting: A solo librarian for the Massachusetts Medicaid (MassHealth) program and a solo librarian for the New England States Consortium Systems Organization (NESCSO) functioned as information specialists in context to support Medicaid policy development and clinical, administrative, and program staff for state Medicaid programs. Brief Description: The librarian for MassHealth initially focused on acquiring library materials and providing research support on culturally competent health care and outreach, as part of the United States Department of Health and Human Services Culturally and Linguistically Appropriate Services in Health Care Standards. The NESCSO librarian focused on state Medicaid system issues surrounding the implementation of the Health Insurance Portability and Accountability Act. The research focus expanded for both the librarians, shaping their roles to more directly support clinical and administrative policy development. Of note, the availability and dissemination of information to policy leaders facilitated efforts to reduce health disparities. In Massachusetts, this led to a state legislative special commission to eliminate health disparities, which released a report in November 2005. On a regional level, the NESCSO librarian provided opportunities for states in New England to share ideas and Medicaid program information. The Centers for Medicaid and Medicare are working with NESCSO to explore the potential for using the NESCSO model for collaboration for other regions of the United States. Results/Outcomes: With the increased attention on evidence-based health care and reduction of health disparities, medical librarians are called on to support a variety of health care information needs. Nationally, state Medicaid programs are being called on to provide coverage and make complex medical decisions regarding the delivery of benefits. Increasing numbers of beneficiaries and shrinking Medicaid budgets demand effective and proactive decision making to provide quality care and to accomplish the missions of state Medicaid programs. In this environment, the opportunities for information professionals to provide value and knowledge management are increasing. PMID:16636710

Between welfare medicine and mainstream entitlement: Medicaid at the political crossroads.

PubMed

Grogan, Colleen; Patashnik, Eric

2003-10-01

As the new century begins, the Medicaid program is arguably at a political crossroads. Over the 1980s and 1990s, policy makers enacted major expansions in Medicaid coverage, offering significant new health benefits to poor women and children and other constituencies. In elite rhetoric and political framing, Medicaid was increasingly cast as a broad-based social welfare entitlement of value to all Americans, including middle-class citizens. Some health care advocates began viewing Medicaid expansions as a potential path to achieving universal coverage in the United States. Yet Medicaid remains a means-tested program that has been repeatedly threatened with policy retrenchment. In this essay, we scrutinize Medicaid's current status and future possibilities from a historical-institutional perspective by tracing its complex evolution since its enactment in the Social Security Amendments of 1965. Our core claim is that decisions made at the time of Medicaid's original adoption have fundamentally set the matrix for struggles over the program's unfolding development. We demonstrate that key ambiguities embedded in the 1965 act created largely unintended opportunities for policy entrepreneurs to broaden Medicaid's scale and scope as well as foreseeable vulnerabilities that must be overcome if Medicaid is to realize its full potential.

An explanatory model for state Medicaid per capita prescription drug expenditures.

PubMed

Roy, Sanjoy; Madhavan, S Suresh

2012-01-01

Rising prescription drug expenditure is a growing concern for publicly funded drug benefit programs like Medicaid. To be able to contain drug expenditures in Medicaid, it is important that cause(s) for such increases are identified. This study attempts to establish an explanatory model for Medicaid prescription drugs expenditure based on the impacts of key influencers/predictors identified using a comprehensive framework of drug utilization. A modified Andersen's behavior model of health services utilization is employed to identify potential determinants of pharmaceutical expenditures in state Medicaid programs. Level of federal matching funds, access to primary care, severity of diseases, unemployment, and education levels were found to be key influencers of Medicaid prescription drug expenditure. Increases in all, except education levels, were found to result in increases in drug expenditures. Findings from this study could better inform intervention policies and cost-containment strategies for state Medicaid drug benefit programs.

42 CFR 431.636 - Coordination of Medicaid with the Children's Health Insurance Program (CHIP).

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Coordination of Medicaid with the Children's Health Insurance Program (CHIP). 431.636 Section 431.636 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES...'s Health Insurance Program (CHIP). (a) Statutory basis. This section implements— (1) Section 2102(b...

42 CFR 431.636 - Coordination of Medicaid with the Children's Health Insurance Program (CHIP).

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Coordination of Medicaid with the Children's Health Insurance Program (CHIP). 431.636 Section 431.636 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES...'s Health Insurance Program (CHIP). (a) Statutory basis. This section implements— (1) Section 2102(b...

An economic model of large Medicaid practices.

PubMed Central

Cromwell, J; Mitchell, J B

1984-01-01

Public attention given to Medicaid "mills" prompted this more general investigation of the origins of large Medicaid practices. A dual market demand model is proposed showing how Medicaid competes with private insurers for scarce physician time. Various program parameters--fee schedules, coverage, collection costs--are analyzed along with physician preferences, specialties, and other supply-side characteristics. Maximum likelihood techniques are used to test the model. The principal finding is that in raising Medicaid fees, as many physicians opt into the program as expand their Medicaid caseloads to exceptional levels, leaving the maldistribution of patients unaffected while notably improving access. Still, the fact that Medicaid fees are lower than those of private insurers does lead to reduced access to more qualified practitioners. Where anti-Medicaid sentiment is stronger, access is also reduced and large Medicaid practices more likely to flourish. PMID:6376426

Medicaid program; deduction of incurred medical expenses (spenddown)--HCFA. Final rule with comment period.

PubMed

1994-01-12

This final rule with comment period permits States flexibility to revise the process by which incurred medical expenses are considered to reduce an individual's or family's income to become Medicaid eligible. This process is commonly referred to as "spenddown." Only States which cover the medically needy, and States which use more restrictive criteria to determine eligibility of the aged, blind, and disabled, than the criteria used to determine eligibility for Supplemental Security Income (SSI) benefits (section 1902(f) States) have a spenddown. These revisions permit States to: Consider as incurred medical expenses projected institutional expenses at the Medicaid reimbursement rate, and deduct those projected expenses from income in determining eligibility; combine the retroactive and prospective medically needy budget periods; either include or exclude medical expenses incurred earlier than the third month before the month of application (States must, however, deduct current payments on old bills not previously deducted in any budget period); and deduct incurred medical expenses from income in the order in which the services were provided, in the order each bill is submitted to the agency, by type of service. All States with medically needy programs using the criteria of the SS program may implement any of the provisions. States using more restrict criteria than the SSI program under section 1902(f) of the Social Security Act may implement all of these provisions except for the option to exclude medical expenses incurred earlier than the third month before the month of application.

How Readable are Spanish-Language Medicaid Applications?

PubMed Central

Hansen, Julie S.; DeVoe, Jennifer E.

2015-01-01

Nationally, Hispanics comprise nearly one-quarter of all non-elderly Medicaid recipients. We evaluated readability, layout characteristics, and document complexity of state-issued Spanish-language Medicaid enrollment applications. We located and analyzed Internet-based Spanish enrollment applications from 37 states and the District of Columbia. We calculated the readability of each Medicaid enrollment application “Signature” page using the Spanish Lexile Analyzer. We assessed application layout characteristics utilizing the User-Friendliness Tool, and we evaluated document complexity using the PMOSE/IKIRSCH scale. The average Lexile score estimated an 11th–12th grade reading level (M = 1184, SD = 192) for “Signature” pages of enrollment applications. Most applications used small font size and lacked adequate white space. Document complexity ranged from level 3 (moderate) to level 5 (very high); the majority of applications ranked at level 4 (high). Spanish-language Medicaid enrollment applications should be revised to adhere to low-literacy guidelines, which may improve the accessibility of Medicaid coverage for eligible Spanish-speaking families. PMID:21213122

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

PubMed

2017-07-28

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

Medicaid home and community-based waivers for acquired immunodeficiency syndrome patients

PubMed Central

Lindsey, Phoebe A.; Jacobson, Peter D.; Pascal, Anthony H.

1990-01-01

Acquired immunodeficiency syndrome (AIDS), an increasingly significant health problem, presents a special challenge to Medicaid programs. Analyzed in this article is one particular approach to providing services for Medicaid-eligible AIDS patients: the Medicaid home and community-based (section 2176) waiver program, authorized by the 1981 Omnibus Budget Reconciliation Act and amended in 1985 to include persons with AIDS. The authors conclude that the AIDS-specific waiver is an attractive program for the States, but that changes in program administration and in how cost effectiveness is determined would likely facilitate broader acceptance by the States. PMID:10113487

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

.... Regulations concerning provider agreements are at 42 CFR part 489 and those pertaining to activities relating...; resources for conducting required surveys; capacity to furnish information for use in enforcement activities; monitoring procedures for provider entities found not in compliance with the conditions or requirements; and...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-13

... furnish information for use in enforcement activities; monitoring procedures for provider entities found... agreements are at 42 CFR part 489 and those pertaining to activities relating to the survey and certification... for monitoring CAHs found out of compliance with the Joint Commission's program requirements. These...

42 CFR 455.17 - Reporting requirements.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Reporting requirements. 455.17 Section 455.17 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid Agency Fraud Detection and...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-07-09

... [CMS-1450-CN] RIN 0938-AR52 Medicare and Medicaid Programs; Home Health Prospective Payment System Rate Update for CY 2014, Home Health Quality Reporting Requirements, and Cost Allocation of Home Health Survey... period titled ``Medicare and Medicaid Programs; Home Health Prospective Payment System Rate Update for CY...

42 CFR 455.20 - Recipient verification procedure.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Recipient verification procedure. 455.20 Section 455.20 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid Agency Fraud Detection and...

42 CFR 455.12 - State plan requirement.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false State plan requirement. 455.12 Section 455.12 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid Agency Fraud Detection and...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-28

... care issues. Frank Szeflinski, (303) 844-7119, Medicare Advantage issues. SUPPLEMENTARY INFORMATION... MCO Managed Care Organization MITA Medicaid Information Technology Architecture MMIS Medicaid... Payment Calculation for Eligible Hospitals c. Medicare Share d. Charity Care e. Transition Factor f...

Factors Affecting Dentist Participation in a State Medicaid Program.

ERIC Educational Resources Information Center

Damiano, Peter C.; And Others

1990-01-01

Telephone interviews with 92 dentists in California identified low fees, denial of payment, and broken appointments by patients as the 3 most important problems with the Medicaid program. Results suggest reasons for the decreasing participation in Medicaid by dentists. (Author/DB)

A successful program for training parent mentors to provide assistance with obtaining health insurance for uninsured children.

PubMed

Flores, Glenn; Walker, Candy; Lin, Hua; Lee, Michael; Fierro, Marco; Henry, Monica; Massey, Kenneth; Portillo, Alberto

2015-01-01

Seven million US children lack health insurance. Community health workers are effective in insuring uninsured children, and parent mentors (PMs) in improving asthmatic children's outcomes. It is unknown, however, whether a training program can result in PMs acquiring knowledge/skills to insure uninsured children. The study aim was to determine whether a PM training program results in improved knowledge/skills regarding insuring uninsured minority children. Minority parents in a primary-care clinic who already had Medicaid/Children's Health Insurance Program (CHIP)-covered children were selected as PMs, attending a 2-day training session addressing 9 topics. A 33-item pretraining test assessed knowledge/skills regarding Medicaid/CHIP, the application process, and medical homes. A 46-item posttest contained the same 33 pretest items (ordered differently) and 13 Likert-scale questions on training satisfaction. All 15 PMs were female and nonwhite, 60% were unemployed, and the mean annual income was $20,913. After training, overall test scores (0-100 scale) significantly increased, from a mean of 62 (range 39-82) to 88 (range 67-100) (P < .01), and the number of wrong answers decreased (mean reduction 8; P < .01). Significant improvements occurred in 6 of 9 topics, and 100% of PMs reported being very satisfied (86%) or satisfied (14%) with the training. Preliminary data indicate PMs are significantly more effective than traditional Medicaid/CHIP outreach/enrollment in insuring uninsured minority children. A PM training program resulted in significant improvements in knowledge and skills regarding outreach to and enrollment of uninsured, Medicaid/CHIP-eligible children, with high levels of satisfaction with the training. This PM training program might be a useful model for training Patient Protection and Affordable Care Act navigators. Copyright © 2015 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Creative payment strategy helps ensure a future for teaching hospitals.

PubMed

Vancil, D R; Shroyer, A L

1998-11-01

The Colorado Medicaid Program in years past relied on disproportionate share hospital (DSH) payment programs to increase access to hospital care for Colorado citizens, ensure the future financial viability of key safety-net hospitals, and partially offset the state's cost of funding the Medicaid program. The options to finance Medicaid care using DSH payments, however, recently have been severely limited by legislative and regulatory changes. Between 1991 and 1997, a creative Medicaid refinancing strategy called the major teaching hospital (MTH) payment program enabled $131 million in net payments to be distributed to the two major teaching hospitals in Colorado to provide enhanced funding related to their teaching programs and to address the ever-expanding healthcare needs of their low-income patients. This new Medicaid payment mechanism brought the state $69.5 million in Federal funding that otherwise would not have been received.

Exercise programming and counseling preferences of breast cancer survivors during or after radiation therapy.

PubMed

Karvinen, Kristina H; Raedeke, Thomas D; Arastu, Hyder; Allison, Ron R

2011-09-01

To explore exercise programming and counseling preferences and exercise-related beliefs in breast cancer survivors during and after radiation therapy, and to compare differences based on treatment and insurance status. Cross-sectional survey. Ambulatory cancer center in a rural community in eastern North Carolina. 91 breast cancer survivors during or after radiation therapy. The researchers administered the questionnaire to participants. Exercise programming and counseling preferences and exercise beliefs moderated by treatment status (on-treatment, early, and late survivors) and insurance status (Medicaid, non-Medicaid). Chi-square analyses indicated that fewer Medicaid users were physically active and reported health benefits as an advantage of exercise compared to non-Medicaid users (p < 0.05). In addition, more Medicaid users preferred exercise programming at their cancer center compared to non-Medicaid users (p < 0.05). More on-treatment and early survivors listed health benefits as advantages to exercise, but fewer indicated weight control as an advantage compared to late survivors (p < 0.05). Early survivors were more likely than on-treatment survivors to indicate that accessible facilities would make exercising easier for them (p < 0.05). Medicaid users are less active, less likely to identify health benefits as an advantage for exercising, and more likely to prefer cancer center-based exercise programming compared to non-Medicaid users. In addition, on-treatment and early survivors are more likely to list health benefits and less likely to indicate weight control as advantages of exercising compared to late survivors. The low activity levels of Medicaid users may be best targeted by providing cancer center-based exercise programming. Exercise interventions may be most effective if tailored to the unique needs of treatment status.

75 FR 21314 - Medicaid Program; Final FY 2008, Revised Preliminary FY 2009, and Preliminary FY 2010...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-04-23

... Federal share) IMD and other mental health facility DSH expenditures applicable to the State's FY 1995 DSH... State's total computable DSH expenditures attributable to the FY 1995 DSH allotment for mental health... DSH expenditures (mental health facility plus inpatient hospital) applicable to the FY 1995 DSH...

42 CFR 431.151 - Scope and applicability.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Scope and applicability. 431.151 Section 431.151 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STATE ORGANIZATION AND GENERAL ADMINISTRATION Appeals Process for NFs and ICFs/IID § 431.151 Scope and applicabilit...

42 CFR 431.151 - Scope and applicability.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 4 2013-10-01 2013-10-01 false Scope and applicability. 431.151 Section 431.151 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STATE ORGANIZATION AND GENERAL ADMINISTRATION Appeals Process for NFs and ICFs/IID § 431.151 Scope and applicabilit...

42 CFR 431.151 - Scope and applicability.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Scope and applicability. 431.151 Section 431.151 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STATE ORGANIZATION AND GENERAL ADMINISTRATION Appeals Process for NFs and ICFs/IID § 431.151 Scope and applicabilit...

A Basic Vocabulary of Federal Social Program Applications and Forms.

ERIC Educational Resources Information Center

Afflerbach, Peter P.; And Others

A study of the application forms for Social Security, Supplemental Security Income, public assistance, food stamps, Medicaid, and Medicare was conducted to examine the frequently occurring unfamiliar, specialized vocabulary words. It was found that 76 such words occurred at least ten times in the documents studied. A large number of other…

The effect of a telephone-based health coaching disease management program on Medicaid members with chronic conditions.

PubMed

Lin, Wen-Chieh; Chien, Hung-Lun; Willis, Georgianna; O'Connell, Elizabeth; Rennie, Kate Staunton; Bottella, Heather M; Ferris, Timothy G

2012-01-01

Despite the growing popularity of disease management programs for chronic conditions, evidence regarding the effect of these programs has been mixed. In addition, few peer-reviewed studies have examined the effect of these programs on publicly insured populations. To examine the effect of a telephone-based health coaching disease management program on healthcare utilization and expenditures in Medicaid members with chronic conditions. Using a difference-in-differences analysis, we examined changes in hospitalizations, emergency department (ED) visits, ambulatory care visits, and Medicaid expenditures among program members for 1 year before and 2 years after their enrollment compared with a matched comparison group. Medicaid members aged 18 to 64 with a diagnosis of qualifying chronic conditions and 2 acute health service events of hospitalizations and/or ED visits within a 12-month period. Changes in acute hospitalizations, ambulatory care visits, and Medicaid expenditures before and after program enrollment were similar between the 2 study groups. However, during the second year after enrollment, program members had a significantly smaller decrease in ED visits than the comparisons (8% in program members and 23% in comparisons, P value=0.03). Compared with a matched comparison group, the telephone-based health coaching disease management program did not demonstrate significant effects on healthcare utilization and expenditures in Medicaid members with chronic conditions.

42 CFR 455.19 - Provider's statement on check.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Provider's statement on check. 455.19 Section 455.19 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid Agency Fraud Detection and...

42 CFR 455.18 - Provider's statements on claims forms.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Provider's statements on claims forms. 455.18 Section 455.18 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid Agency Fraud...

Intermediate Care Facilities for Persons with Mental Retardation (ICFs-MR): Program Utilization and Resident Characterstics. Project Report #31.

ERIC Educational Resources Information Center

Minnesota Univ., Minneapolis. Center for Residential and Community Services.

This report on the Intermediate Care Facility for the Mentally Retarded (ICF-MR) and related programs under Title XIX (Medicaid) of the Social Security Act aims to assist in consideration of improvements to Medicaid services. The report begins with a background description of the key Medicaid programs of interest, discussing: federal involvement…

Intergenerational enrollment and expenditure changes in Medicaid: trends from 1991 to 2005

PubMed Central

2012-01-01

Background From its inception, Medicaid was aimed at providing insurance coverage for low income children, elderly, and disabled. Since this time, children have become a smaller proportion of the US population and Medicaid has expanded to additional eligibility groups. We sought to evaluate relative growth in spending in the Medicaid program between children and adults from 1991-2005. We hypothesize that this shifting demographic will result in fewer resources being allocated to children in the Medicaid program. Methods We utilized retrospective enrollment and expenditure data for children, adults and the elderly from 1991 to 2005 for both Medicaid and Children’s Health Insurance Program Medicaid expansion programs. Data were obtained from the Centers for Medicare and Medicaid Services using their Medicaid Statistical Information System. Results From 1991 to 2005, the number of enrollees increased by 83% to 58.7 million. This includes increases of 33% for children, 100% for adults and 50% for the elderly. Concurrently, total expenditures nationwide rose 150% to $273 billion. Expenditures for children increased from $23.4 to $65.7 billion, adults from $46.2 to $123.6 billion, and elderly from $39.2 to $71.3 billion. From 1999 to 2005, Medicaid spending on long-term care increased by 31% to $84.3 billion. Expenditures on the disabled grew by 61% to $119 billion. In total, the disabled account for 43% and long-term care 31%, of the total Medicaid budget. Conclusion Our study did not find an absolute decrease in the overall resources being directed toward children. However, increased spending on adults on a per-capita and absolute basis, particularly disabled adults, is responsible for much of the growth in spending over the past 15 years. Medicaid expenditures have grown faster than inflation and overall national health expenditures. A national strategy is needed to ensure adequate coverage for Medicaid recipients while dealing with the ongoing constraints of state and federal budgets. PMID:22992389

The Impact of the Medicaid Health Care-Associated Condition Program on Mediastinitis Following Coronary Artery Bypass Graft

PubMed Central

Hsu, Heather; Kawai, Alison Tse; Wang, Rui; Jentzsch, Maximilian S.; Rhee, Chanu; Horan, Kelly; Jin, Robert; Goldmann, Donald; Lee, Grace M.

2018-01-01

Objective In 2012, the Centers for Medicare and Medicaid Services expanded a 2008 program that eliminated additional Medicare payment for mediastinitis following coronary artery bypass graft (CABG) to include Medicaid. We aimed to evaluate the impact of this Medicaid program on mediastinitis rates reported by the National Healthcare Safety Network (NHSN) compared with rates of a condition not targeted by the program (deep space surgical site infection [SSI] after knee replacement). Design interrupted time series with comparison group. Methods We included surveillance data from non-federal acute care hospitals participating in NHSN and reporting CABG or knee replacement outcomes from 1/2009–6/2017. We examined the Medicaid program’s impact on NHSN-reported infection rates, adjusting for secular trends. Data analysis used generalized estimating equations with robust sandwich variance estimators. Results During the study period, 196 study hospitals reported 273,984 CABGs to NHSN, resulting in 970 mediastinitis cases (0.35%); 294 hospitals reported 555,395 knee replacements, with 1,751 resultant deep space SSIs (0.32%). There were no significant changes in incidence of either condition during the study. Mediastinitis models showed no effect of the 2012 Medicaid program on either secular trend during the post- vs. pre-program time periods (p-value=0.70) or immediate program effect (p-value=0.83). Results were similar in sensitivity analyses when adjusting for hospital characteristics, restricting to hospitals with consistent NHSN reporting, or incorporating a program implementation roll-in period. Knee replacement models also showed no program effect. Conclusions The 2012 Medicaid program to eliminate additional payments for mediastinitis following CABG had no impact on reported mediastinitis rates. PMID:29669607

Identifying and reducing disparities in successful addiction treatment completion: testing the role of Medicaid payment acceptance.

PubMed

Guerrero, Erick G; Garner, Bryan R; Cook, Benjamin; Kong, Yinfei; Vega, William A; Gelberg, Lillian

2017-05-25

Medicaid has become the largest payer of substance use disorder treatment and may enhance access to quality care and reduce disparities. We tested whether treatment programs' acceptance of Medicaid payments was associated with reduced disparities between Mexican Americans and non-Latino Whites. We analyzed client and program data from 122 publicly funded treatment programs in 2010 and 112 programs in 2013. These data were merged with information regarding 15,412 adult clients from both periods, of whom we selected only Mexican Americans (n = 7130, 46.3%) and non-Latino Whites (n = 8282, 53.7%). We used multilevel logistic regression and variance decomposition to examine associations and underlying factors associated with Mexican American and White differences in treatment completion. Variables of interest included client demographics; drug use severity and mental health issues; and program license, accreditation, and acceptance of Medicaid payments. Mexican Americans had lower odds of treatment completion (OR = 0.677; 95% CI = 0.534, 0.859) compared to non-Latino Whites. This disparity was explained in part by primary drug used, greater drug use severity, history of mental health disorders, and program acceptance of Medicaid payments. The interaction between Mexican Americans and acceptance of Medicaid was statistically significant (OR = 1.284; 95% CI = 1.008, 1.637). Findings highlighted key program and client drivers of this disparity and the promising role of program acceptance of Medicaid payment to eliminate disparities in treatment completion among Mexican Americans. Implications for health policy during the Trump Administration are discussed.

42 CFR 460.182 - Medicaid payment.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Medicaid payment. 460.182 Section 460.182 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

Medicaid Certified School Match Program: Nursing Services. Technical Assistance Paper.

ERIC Educational Resources Information Center

Florida State Dept. of Education, Tallahassee. Bureau of Instructional Support and Community Services.

This paper addresses issues related to Medicaid-reimbursable nursing services covered under the Florida Medicaid Certified School Match Program and the federal Medicare Catastrophic Coverage Act in coordination with the Individuals with Disabilities Education Act. Following a brief section providing background information, 23 questions and answers…

75 FR 23067 - Medicaid Program; State Flexibility for Medicaid Benefit Packages

Federal Register 2010, 2011, 2012, 2013, 2014

2010-04-30

... State governments. Within broad Federal guidelines, each State determines the design of its program... Health Benefits Coverage At proposed Sec. 440.335, we proposed to provide that if a State designs or... the same Medicaid benefits statewide, meaning States could design different benefit packages for rural...

Home-Care Use and Expenditures Among Medicaid Beneficiaries with AIDS

PubMed Central

Sambamoorthi, Usha; Collins, Sara R.; Crystal, Stephen; Walkup, James

1999-01-01

This article compares the use and cost of home-care services among traditional Medicaid recipients with acquired immunodeficiency syndrome (AIDS) and among participants in a statewide Human Immunodeficiency Virus (HIV)/AIDS-specific home and community-based Medicaid waiver program in New Jersey, using Medicaid claims and AIDS surveillance data. Waiver program participation appears to mitigate racial and risk group differences in the probability of home-care use. However, the program's successes are confined to its enrollees of which subgroups of the AIDS population are underrepresented. Our findings suggest the need to expand access to home-care programs to racial minorities and injection drug users (IDUs) with HIV/AIDS. PMID:11482120

76 FR 148 - Medicaid Program; Final FY 2009 and Preliminary FY 2011 Disproportionate Share Hospital...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-01-03

... Federal share) IMD and other mental health facility DSH expenditures applicable to the State's FY 1995 DSH... State's total computable DSH expenditures attributable to the FY 1995 DSH allotment for mental health... health DSH expenditures applicable to the State's FY 1995 DSH allotment by the total computable amount of...

42 CFR 457.616 - Application and tracking of payments against the fiscal year allotments.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 4 2013-10-01 2013-10-01 false Application and tracking of payments against the fiscal year allotments. 457.616 Section 457.616 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STATE CHILDREN'S HEALTH INSURANCE PROGRAMS (SCHIPs) ALLOTMENTS AND GRANTS TO STATES Payments to...

42 CFR 457.616 - Application and tracking of payments against the fiscal year allotments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Application and tracking of payments against the fiscal year allotments. 457.616 Section 457.616 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STATE CHILDREN'S HEALTH INSURANCE PROGRAMS (SCHIPs) ALLOTMENTS AND GRANTS TO STATES Payments to...

42 CFR 457.616 - Application and tracking of payments against the fiscal year allotments.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Application and tracking of payments against the fiscal year allotments. 457.616 Section 457.616 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STATE CHILDREN'S HEALTH INSURANCE PROGRAMS (SCHIPs) ALLOTMENTS AND GRANTS TO STATES Payments to...

42 CFR 457.616 - Application and tracking of payments against the fiscal year allotments.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Application and tracking of payments against the fiscal year allotments. 457.616 Section 457.616 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STATE CHILDREN'S HEALTH INSURANCE PROGRAMS (SCHIPs) ALLOTMENTS AND GRANTS TO STATES Payments to...

42 CFR 457.616 - Application and tracking of payments against the fiscal year allotments.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Application and tracking of payments against the fiscal year allotments. 457.616 Section 457.616 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STATE CHILDREN'S HEALTH INSURANCE PROGRAMS (SCHIPs) ALLOTMENTS AND GRANTS TO STATES Payments to...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-08

... information posted on our Center for Medicare and Medicaid Innovation (CMMI) Web site and in the Pioneer ACO Application. (For more information see http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care... postmarked on or before July 18, 2011.'' Authority: Section 1115A of the Social Security Act. Dated: June 2...

An overview of Medicaid managed care litigation.

PubMed

Rosenbaum, S; Teitelbaum, J; Kirby, C; Priebe, L; Klement, T

1998-11-01

Since the enactment of Medicaid in 1965, states have had the option of offering beneficiaries enrollment in managed care arrangements. With the advent of mandatory managed care reaching millions of beneficiaries (including a growing proportion of disabled recipients), the amount and scope of litigation involving Medicaid managed care plans can be expected to grow. A review of the current litigation regarding Medicaid managed care reveals two basic types of lawsuits: (1) those that challenge the practices of managed care companies under various federal and state laws that safeguard consumer rights, protect health care quality, and prohibit discrimination; and (2) suits that assert claims arising directly under the Medicaid statute and implementing regulations, as well as claims related to Constitutional safeguards that undergird the program. Lawsuits asserting claims arising under Medicaid tend to raise two basic questions: (1) the extent to which enrollment in a Medicaid managed care plan alters existing Medicaid beneficiary rights and state agency duties under federal or state Medicaid law; and (2) the extent to which managed care companies, as agents of the state, act under "color of law" (i.e., undertaking to perform official duties or acting with the imprimatur of state authority). Additionally, states might see an increase in litigation brought by prospective and current contractors who assert that they have been wrongfully denied contracts or improperly penalized for poor performance. These assertions may involve claims that are grounded in federal and state law, the Medicaid statute, and the Constitution. Moreover, in light of the consumer protection elements of the managed care reforms contained in the Balanced Budget Act, future managed care litigation may focus on the manner in which companies carry out states' obligations toward managed care enrollees. Resolution of Medicaid managed care cases involves the application of general principles of administrative and regulatory law. Thus, Medicaid managed care cases have implications for other public purchasers of managed care arrangements, including state mental health and alcohol and substance abuse agencies.

42 CFR 431.635 - Coordination of Medicaid with Special Supplemental Food Program for Women, Infants, and Children...

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Coordination of Medicaid with Special Supplemental Food Program for Women, Infants, and Children (WIC). 431.635 Section 431.635 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE...

42 CFR 431.635 - Coordination of Medicaid with Special Supplemental Food Program for Women, Infants, and Children...

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Coordination of Medicaid with Special Supplemental Food Program for Women, Infants, and Children (WIC). 431.635 Section 431.635 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE...

42 CFR 431.635 - Coordination of Medicaid with Special Supplemental Food Program for Women, Infants, and Children...

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Coordination of Medicaid with Special Supplemental Food Program for Women, Infants, and Children (WIC). 431.635 Section 431.635 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-12

... Medicare and Medicaid Services 42 CFR Part 488 [CMS-2435-P] Medicare and Medicaid Programs; Civil Money... regarding the imposition and collection of civil money penalties by CMS when nursing homes are not in... address facility noncompliance are civil money penalties. Authorized by sections 1819(h) and 1919(h) of...

Survey of Medicaid child dental services in Washington state: preparation for a marketing program.

PubMed

Milgrom, P; Riedy, C

1998-06-01

The authors surveyed Washington state dentists to gain an understanding of their participation in the Medicaid dental program, their willingness to learn more about the program and the degree of importance they attached to preventive care for preschool-aged children. They found that concerns about fees and administrative aspects predominated and concerns about client behaviors were expressed less often. Many dentists indicated a willingness to learn more about the program. These findings will be used to develop a plan to market the Medicaid program to Washington state dentists.

Florida's Medicaid AIDS Waiver: An Assessment of Dimensions of Quality

PubMed Central

Cowart, Marie E.; Mitchell, Jean M.

1995-01-01

Some State Medicaid agencies have implemented home and community-based waiver programs targeting acquired immunodeficiency syndrome (AIDS) patients. Under these initiatives, State Medicaid agencies can provide home and community-based services to persons with AIDS (PWA) as an alternative to more costly Medicaid-covered institutional care. This article evaluates quality of care under the Florida Medicaid waiver for PWA along two dimensions: program effectiveness and client satisfaction. Clients are generally satisfied with their case managers and the range and availability of services. Case managers appear to be well trained. Moreover, the probability of turnover is quite low, despite heavy caseloads and high mortality. The major difficulty faced by clients and case managers relates to the process of becoming Medicaid eligible. PMID:10151885

42 CFR 441.201 - Definition.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Definition. 441.201 Section 441.201 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Abortions § 441.201...

42 CFR 441.201 - Definition.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Definition. 441.201 Section 441.201 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Abortions § 441.201...

42 CFR 441.201 - Definition.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Definition. 441.201 Section 441.201 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Abortions § 441.201...

42 CFR 441.201 - Definition.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 4 2013-10-01 2013-10-01 false Definition. 441.201 Section 441.201 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Abortions § 441.201...

42 CFR 441.201 - Definition.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Definition. 441.201 Section 441.201 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Abortions § 441.201...

75 FR 43167 - Agency Information Collection Activities: Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-23

...: Health Insurance Benefit Agreement; Use: Applicants to the Medicare program are required to agree to... for initiating and expanding health insurance coverage for uninsured children. States are also... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [Document...

75 FR 63480 - Medicaid Program: Implementation of Section 614 of the Children's Health Insurance Program...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-10-15

... Children's Health Insurance Program Reauthorization Act of 2009 for Adjustments to the Federal Medical... section 614 of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Public Law... Medicaid program and required by Section 614 of the Children's Health Insurance Program Reauthorization Act...

Affordable Care Act Impact on Medicaid Coverage of Smoking-Cessation Treatments.

PubMed

McMenamin, Sara B; Yoeun, Sara W; Halpin, Helen A

2018-04-01

Four sections of the Affordable Care Act address the expansion of Medicaid coverage for recommended smoking-cessation treatments for: (1) pregnant women (Section 4107), (2) all enrollees through a financial incentive (1% Federal Medical Assistance Percentage increase) to offer comprehensive coverage (Section 4106), (3) all enrollees through Medicaid formulary requirements (Section 2502), and (4) Medicaid expansion enrollees (Section 2001). The purpose of this study is to document changes in Medicaid coverage for smoking-cessation treatments since the passage of the Affordable Care Act and to assess how implementation has differentially affected Medicaid coverage policies for: pregnant women, enrollees in traditional Medicaid, and Medicaid expansion enrollees. From January through June 2017, data were collected and analyzed from 51 Medicaid programs (50 states plus the District of Columbia) through a web-based survey and review of benefits documents to assess coverage policies for smoking-cessation treatments. Forty-seven Medicaid programs have increased coverage for smoking-cessation treatments post-implementation of the Affordable Care Act by adopting one or more of the four smoking-cessation treatment provisions. Coverage for pregnant women increased in 37 states, coverage for newly eligible expansion enrollees increased in 32 states, and 15 states added coverage and/or removed copayments in order to apply for a 1% increase in the Federal Medical Assistance Percentage. Coverage for all recommended pharmacotherapy and group and individual counseling increased from seven states in 2009 to 28 states in 2017. The Affordable Care Act was successful in improving and expanding state Medicaid coverage of effective smoking-cessation treatments. Many programs are not fully compliant with the law, and additional guidance and clarification from the Centers for Medicare and Medicaid Services may be needed. Copyright © 2018 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

Cost effectiveness of home and community-based care

PubMed Central

Vertrees, James C.; Manton, Kenneth G.; Adler, Gerald S.

1989-01-01

Medicaid section 2176 waivers allow States to provide home and community-based care to Medicaid eligibles who, but for these services, would enter Medicaid-funded nursing homes. One of the conditions required by Congress for granting these waivers is that this substitution results in no additional Medicaid spending (budget neutrality). The results of case studies of two of these waiver programs, one in California and one in Georgia, are presented in this article. The case studies contain a description of the operation of these programs in some detail. Next, the data and techniques needed to assess the ability of these programs to achieve budget neutrality are presented, and the performance of these programs along this dimension is evaluated. PMID:10313280

Medicaid-financed residential care for persons with mental retardation.

PubMed

Lakin, K C; Hall, M J

1990-12-01

Two sources of Medicaid support for persons with mental retardation and related conditions (MR/RC) are examined, the intermediate care facility for the mentally retarded (ICF/MR) program and the home and community-based services (HCBS) waiver. Results indicate that Medicaid support through the ICF/MR program has shown little recent growth in terms of number of persons served, although expenditures continue to increase. Medicaid's HCBS waiver is being used increasingly by States to support residential placement because of its greater flexibility and more individualized approach relative to ICF/MR care. Use of Medicaid to finance care for persons with MR/RC varies considerably across States.

Medicaid-financed residential care for persons with mental retardation

PubMed Central

Lakin, K. Charlie; Hall, Margaret Jean

1990-01-01

Two sources of Medicaid support for persons with mental retardation and related conditions (MRIRC) are examined, the intermediate care facility for the mentally retarded (ICF/MR) program and the home and community-based services (HCBS) waiver. Results indicate that Medicaid support through the ICF/MR program has shown little recent growth in terms of number of persons served, although expenditures continue to increase. Medicaid's HCBS waiver is being used increasingly by States to support residential placement because of its greater flexibility and more individualized approach relative to ICF/MR care. Use of Medicaid to finance care for persons with MR/RC varies considerably across States. PMID:10113489

Medicaid provider reimbursement policy for adult immunizations☆

PubMed Central

Stewart, Alexandra M.; Lindley, Megan C.; Cox, Marisa A.

2015-01-01

Background State Medicaid programs establish provider reimbursement policy for adult immunizations based on: costs, private insurance payments, and percentage of Medicare payments for equivalent services. Each program determines provider eligibility, payment amount, and permissible settings for administration. Total reimbursement consists of different combinations of Current Procedural Terminology codes: vaccine, vaccine administration, and visit. Objective Determine how Medicaid programs in the 50 states and the District of Columbia approach provider reimbursement for adult immunizations. Design Observational analysis using document review and a survey. Setting and participants Medicaid administrators in 50 states and the District of Columbia. Measurements Whether fee-for-service programs reimburse providers for: vaccines; their administration; and/or office visits when provided to adult enrollees. We assessed whether adult vaccination services are reimbursed when administered by a wide range of providers in a wide range of settings. Results Medicaid programs use one of 4 payment methods for adults: (1) a vaccine and an administration code; (2) a vaccine and visit code; (3) a vaccine code; and (4) a vaccine, visit, and administration code. Limitations Study results do not reflect any changes related to implementation of national health reform. Nine of fifty one programs did not respond to the survey or declined to participate, limiting the information available to researchers. Conclusions Medicaid reimbursement policy for adult vaccines impacts provider participation and enrollee access and uptake. While programs have generally increased reimbursement levels since 2003, each program could assess whether current policies reflect the most effective approach to encourage providers to increase vaccination services. PMID:26403369

Medicaid provider reimbursement policy for adult immunizations.

PubMed

Stewart, Alexandra M; Lindley, Megan C; Cox, Marisa A

2015-10-26

State Medicaid programs establish provider reimbursement policy for adult immunizations based on: costs, private insurance payments, and percentage of Medicare payments for equivalent services. Each program determines provider eligibility, payment amount, and permissible settings for administration. Total reimbursement consists of different combinations of Current Procedural Terminology codes: vaccine, vaccine administration, and visit. Determine how Medicaid programs in the 50 states and the District of Columbia approach provider reimbursement for adult immunizations. Observational analysis using document review and a survey. Medicaid administrators in 50 states and the District of Columbia. Whether fee-for-service programs reimburse providers for: vaccines; their administration; and/or office visits when provided to adult enrollees. We assessed whether adult vaccination services are reimbursed when administered by a wide range of providers in a wide range of settings. Medicaid programs use one of 4 payment methods for adults: (1) a vaccine and an administration code; (2) a vaccine and visit code; (3) a vaccine code; and (4) a vaccine, visit, and administration code. Study results do not reflect any changes related to implementation of national health reform. Nine of fifty one programs did not respond to the survey or declined to participate, limiting the information available to researchers. Medicaid reimbursement policy for adult vaccines impacts provider participation and enrollee access and uptake. While programs have generally increased reimbursement levels since 2003, each program could assess whether current policies reflect the most effective approach to encourage providers to increase vaccination services. Copyright © 2015 Elsevier Ltd. All rights reserved.

The Breast and Cervical Cancer Early Detection Program, Medicaid, and breast cancer outcomes among Ohio's underserved women.

PubMed

Koroukian, Siran M; Bakaki, Paul M; Htoo, Phyo Than; Han, Xiaozhen; Schluchter, Mark; Owusu, Cynthia; Cooper, Gregory S; Rose, Johnie; Flocke, Susan A

2017-08-15

As an organized screening program, the national Breast and Cervical Cancer Early Detection Program (BCCEDP) was launched in the early 1990s to improve breast cancer outcomes among underserved women. To analyze the impact of the BCCEDP on breast cancer outcomes in Ohio, this study compared cancer stages and mortality across BCCEDP participants, Medicaid beneficiaries, and "all others." This study linked data across the Ohio Cancer Incidence Surveillance System, Medicaid, the BCCEDP database, death certificates, and the US Census and identified 26,426 women aged 40 to 64 years who had been diagnosed with incident invasive breast cancer during the years 2002-2008 (deaths through 2010). The study groups were as follows: BCCEDP participants (1-time or repeat users), Medicaid beneficiaries (women enrolled in Medicaid before their cancer diagnosis [Medicaid/prediagnosis] or around the time of their cancer diagnosis [Medicaid/peridiagnosis]), and all others (women identified as neither BCCEDP participants nor Medicaid beneficiaries). The outcomes included advanced-stage cancer at diagnosis and mortality. A multivariable logistic and survival analysis was conducted to examine the independent association between the BCCEDP and Medicaid status and the outcomes. The percentage of women presenting with advanced-stage disease was highest among women in the Medicaid/peridiagnosis group (63.4%) and lowest among BCCEDP repeat users (38.6%). With adjustments for potential confounders and even in comparison with Medicaid/prediagnosis beneficiaries, those in the Medicaid/peridiagnosis group were twice as likely to be diagnosed with advanced-stage disease (adjusted odds ratio, 2.20; 95% confidence interval, 1.83-2.66). Medicaid/peridiagnosis women are at particularly high risk to be diagnosed with advanced-stage disease. Efforts to reduce breast cancer disparities must target this group of women before they present to Medicaid. Cancer 2017;123:3097-106. © 2017 American Cancer Society. © 2017 American Cancer Society.

42 CFR 480.137 - Disclosure to Federal and State enforcement agencies responsible for the investigation or...

Code of Federal Regulations, 2010 CFR

2010-10-01

... agencies responsible for the investigation or identification of fraud or abuse of the Medicare or Medicaid programs. 480.137 Section 480.137 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Medicare or Medicaid programs. (a) Required disclosure. Except as specified in §§ 480.139(a) and 480.140...

Psychotropic Medication Trends among Children and Adolescents with Autism Spectrum Disorder in the Medicaid Program

ERIC Educational Resources Information Center

Schubart, Jane R.; Camacho, Fabian; Leslie, Douglas

2014-01-01

This study characterized psychotropic medication use among Medicaid-enrolled children and adolescents with autism spectrum disorders by examining trends over time, including length of treatment and polypharmacy using 4 years of administrative claims data from 41 state Medicaid programs (2000-2003). The data set included nearly 3 million children…

45 CFR 155.345 - Coordination with Medicaid, CHIP, the Basic Health Program, and the Pre-existing Condition...

Code of Federal Regulations, 2012 CFR

2012-10-01

... 45 Public Welfare 1 2012-10-01 2012-10-01 false Coordination with Medicaid, CHIP, the Basic Health....345 Coordination with Medicaid, CHIP, the Basic Health Program, and the Pre-existing Condition..., CHIP, and the BHP as are necessary to fulfill the requirements of this subpart and provide copies of...

Does medicaid coverage matter?: A qualitative multi-state study of abortion affordability for low-income women.

PubMed

Dennis, Amanda; Manski, Ruth; Blanchard, Kelly

2014-11-01

Medicaid is designed to ensure low-income populations can afford health care. However, not all health services are covered by the program. Most state Medicaid programs restrict abortion coverage, though a small number of state programs offer such coverage. Little is known about how low-income women are affected by differing Medicaid coverage policies regarding abortion. We conducted in depth interviews with 98 low-income women who had abortions. We found that women's impressions about abortion costs and the availability of Medicaid coverage are generally accurate and that women rely predominantly on abortion facilities for confirmatory cost and coverage information. Additionally, when abortion is out of financial reach, women and the people in their lives experience numerous emotional and financial harms. Policies that aim to ensure abortion is affordable largely prevent these harms, though the availability of Medicaid coverage does not always guarantee access to affordable care. Findings can help advance evidence-based policies

The Supreme Court's surprising decision on the Medicaid expansion: how will the federal government and states proceed?

PubMed

Rosenbaum, Sara; Westmoreland, Timothy M

2012-08-01

In National Federation of Independent Business v. Sebelius, the US Supreme Court upheld the constitutionality of the requirement that all Americans have affordable health insurance coverage. But in an unprecedented move, seven justices first declared the mandatory Medicaid eligibility expansion unconstitutional. Then five justices, led by Chief Justice John Roberts, prevented the outright elimination of the expansion by fashioning a remedy that simply limited the federal government's enforcement powers over its provisions and allowed states not to proceed with expanding Medicaid without losing all of their federal Medicaid funding. The Court's approach raises two fundamental issues: First, does the Court's holding also affect the existing Medicaid program or numerous other Affordable Care Act Medicaid amendments establishing minimum Medicaid program requirements? And second, does the health and human services secretary have the flexibility to modify the pace or scope of the expansion as a negotiating strategy with the states? The answers to these questions are key because of the foundational role played by Medicaid in health reform.

A Cost Analysis of the Iowa Medicaid Primary Care Case Management Program

PubMed Central

Momany, Elizabeth T; Flach, Stephen D; Nelson, Forrest D; Damiano, Peter C

2006-01-01

Objective To determine the cost savings attributable to the implementation and expansion of a primary care case management (PCCM) program on Medicaid costs per member in Iowa from 1989 to 1997. Data Sources Medicaid administrative data from Iowa aggregated at the county level. Study Design Longitudinal analysis of costs per member per month, analyzed by category of medical expense using weighted least squares. We compared the actual costs with the expected costs (in the absence of the PCCM program) to estimate cost savings attributable to the PCCM program. Principal Findings We estimated that the PCCM program was associated with a savings of $66 million to the state of Iowa over the study period. Medicaid expenses were 3.8 percent less than what they would have been in the absence of the PCCM program. Effects of the PCCM program appeared to grow stronger over time. Use of the PCCM program was associated with increases in outpatient care and pharmaceutical expenses, but a decrease in hospital and physician expenses. Conclusions Use of a Medicaid PCCM program was associated with substantial aggregate cost savings over an 8-year period, and this effect became stronger over time. Cost reductions appear to have been mediated by substituting outpatient care for inpatient care. PMID:16899012

42 CFR 431.636 - Coordination of Medicaid with the Children's Health Insurance Program (CHIP).

Code of Federal Regulations, 2010 CFR

2010-10-01

... Insurance Program (CHIP). 431.636 Section 431.636 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES...'s Health Insurance Program (CHIP). (a) Statutory basis. This section implements— (1) Section 2102(b... coordination between a State child health program and other public health insurance programs. (b) Obligations...

42 CFR 442.14 - Effect of change of ownership.

Code of Federal Regulations, 2010 CFR

2010-10-01

....14 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STANDARDS FOR PAYMENT TO NURSING FACILITIES AND INTERMEDIATE CARE... agreement is subject to all applicable statutes and regulations and to the terms and conditions under which...

75 FR 51464 - Medicare and Medicaid Programs; Approval of the American Association for Accreditation of...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-20

... Surgery Facilities for Continued Deeming Authority for Ambulatory Surgical Centers AGENCY: Centers for... to approve without condition the American Association for Accreditation of Ambulatory Surgery... of Ambulatory Surgery Facilities on November 27, 2009. II. Deeming Applications Approval Process...

Comparing the Medicaid Retrospective Drug Utilization Review Program Cost-Savings Methods Used by State Agencies.

PubMed

Prada, Sergio I

2017-12-01

The Medicaid Drug Utilization Review (DUR) program is a 2-phase process conducted by Medicaid state agencies. The first phase is a prospective DUR and involves electronically monitoring prescription drug claims to identify prescription-related problems, such as therapeutic duplication, contraindications, incorrect dosage, or duration of treatment. The second phase is a retrospective DUR and involves ongoing and periodic examinations of claims data to identify patterns of fraud, abuse, underutilization, drug-drug interaction, or medically unnecessary care, implementing corrective actions when needed. The Centers for Medicare & Medicaid Services requires each state to measure prescription drug cost-savings generated from its DUR programs on an annual basis, but it provides no guidance or unified methodology for doing so. To describe and synthesize the methodologies used by states to measure cost-savings using their Medicaid retrospective DUR program in federal fiscal years 2014 and 2015. For each state, the cost-savings methodologies included in the Medicaid DUR 2014 and 2015 reports were downloaded from Medicaid's website. The reports were then reviewed and synthesized. Methods described by the states were classified according to research designs often described in evaluation textbooks. In 2014, the most often used prescription drugs cost-savings estimation methodology for the Medicaid retrospective DUR program was a simple pre-post intervention method, without a comparison group (ie, 12 states). In 2015, the most common methodology used was a pre-post intervention method, with a comparison group (ie, 14 states). Comparisons of savings attributed to the program among states are still unreliable, because of a lack of a common methodology available for measuring cost-savings. There is great variation among states in the methods used to measure prescription drug utilization cost-savings. This analysis suggests that there is still room for improvement in terms of methodology transparency, which is important, because lack of transparency hinders states from learning from each other. Ultimately, the federal government needs to evaluate and improve its DUR program.

Effects of enrollment in medicaid versus the state children's health insurance program on kindergarten children's untreated dental caries.

PubMed

Brickhouse, Tegwyn H; Rozier, R Gary; Slade, Gary D

2008-05-01

We compared levels of untreated dental caries in children enrolled in public insurance programs with those in nonenrolled children to determine the impact of public dental insurance and the type of plan (Medicaid vs State Children's Health Insurance Program [SCHIP]) on untreated dental caries in children. Dental health outcomes were obtained through a calibrated oral screening of kindergarten children (enrolled in the 2000-2001 school year). We obtained eligibility and claims data for children enrolled in Medicaid and SCHIP who were eligible for dental services during 1999 to 2000. We developed logistic regression models to compare children's likelihood and extent of untreated dental caries according to enrollment. Children enrolled in Medicaid or SCHIP were 1.7 times (95% confidence interval [CI] = 1.65, 1.77) more likely to have untreated dental caries than were nonenrolled children. SCHIP-enrolled children were significantly less likely to have untreated dental caries than were Medicaid-enrolled children (odds ratio [OR]=0.74; 95% CI=0.67, 0.82). According to a 2-part regression model, children enrolled in Medicaid or SCHIP have 17% more untreated dental caries than do nonenrolled children, whereas those in SCHIP had 16% fewer untreated dental caries than did those in Medicaid. Untreated tooth decay continues to be a significant problem for children with public insurance coverage. Children who participated in a separate SCHIP program had fewer untreated dental caries than did children enrolled in Medicaid.

Medicaid-based child restraint system disbursement and education and the vaccines for children program: comparative cost-effectiveness.

PubMed

Goldstein, Jesse A; Winston, Flaura K; Kallan, Michael J; Branas, Charles C; Schwartz, J Sanford

2008-01-01

Low-income children are disproportionately at risk for preventable motor-vehicle injury. Many of these children are covered by Medicaid programs placing substantial economic burden on states. Child restraint systems (CRSs) have demonstrated efficacy in preventing death and injury among children in crashes but remain underutilized because of poor access and education. The objective of this study was to evaluate the cost-effectiveness of Medicaid-based reimbursement for CRS disbursement and education for low-income children and compare it with vaccinations covered under the Vaccines For Children (VFC) program. A cost-effectiveness analysis was performed of Medicaid reimbursement for CRS disbursement/education for low-income children based on data from public and private databases. Primary outcomes measured include cost per life-year saved, death, serious injury, and minor injury averted, as well as medical, parental work loss, and future productivity loss costs averted. Cost-effectiveness calculations were compared with published cost-effectiveness data for vaccinations covered under the VFC program. The adoption of a CRS disbursement/education program could prevent up to 2 deaths, 12 serious injuries, and 51 minor injuries per 100,000 low-income children annually. When fully implemented, the program could save Medicaid over $1 million per 100,000 children in direct medical costs while costing $13 per child per year after all 8 years of benefit. From the perspective of Medicaid, the program would cost $17,000 per life-year saved, $60,000 per serious injury prevented, and $560,000 per death averted. The program would be cost saving from a societal perspective. These data are similar to published vaccination cost-effectiveness data. Implementation of a Medicaid-funded CRS disbursement/education program was comparable in cost-effectiveness with federal vaccination programs targeted toward similar populations and represents an important potential strategy for addressing injury disparities among low-income children.

The patient perspective: utilizing focus groups to inform care coordination for high-risk medicaid populations.

PubMed

Sheff, Alex; Park, Elyse R; Neagle, Mary; Oreskovic, Nicolas M

2017-07-25

Care coordination programs for high-risk, high-cost patients are a critical component of population health management. These programs aim to improve outcomes and reduce costs and have proliferated over the last decade. Some programs, originally designed for Medicare patients, are now transitioning to also serve Medicaid populations. However, there are still gaps in the understanding of what barriers to care Medicaid patients experience, and what supports will be most effective for providing them care coordination. We conducted two focus groups (n = 13) and thematic analyses to assess the outcomes drivers and programmatic preferences of Medicaid patients enrolled in a high-risk care coordination program at a major academic medical center in Boston, MA. Two focus groups identified areas where care coordination efforts were having a positive impact, as well as areas of unmet needs among the Medicaid population. Six themes emerged from the focus groups that clustered in three groupings: In the first group (1) enrollment in an existing medical care coordination programs, and (2) provider communication largely presented as positive accounts of assistance, and good relationships with providers, though participants also pointed to areas where these efforts fell short. In the second group (3) trauma histories, (4) mental health challenges, and (5) executive function difficulties all presented challenges faced by high-risk Medicaid patients that would likely require redress through additional programmatic supports. Finally, in the third group, (6) peer-to-peer support tendencies among patients suggested an untapped resource for care coordination programs. Programs aimed at high-risk Medicaid patients will want to consider programmatic adjustments to attend to patient needs in five areas: (1) provider connection/care coordination, (2) trauma, (3) mental health, (4) executive function/paperwork and coaching support, and (5) peer-to-peer support.

75 FR 11185 - Centers for Medicare & Medicaid Services; Delegation of Authority

Federal Register 2010, 2011, 2012, 2013, 2014

2010-03-10

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of the Secretary Centers for Medicare & Medicaid..., Centers for Medicare & Medicaid Services (CMS), or his or her successor, the authorities currently vested... or disasters that are related to Medicare, Medicaid, and the Children's Health Insurance Programs as...

42 CFR 460.182 - Medicaid payment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Medicaid payment. 460.182 Section 460.182 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED...) Payment § 460.182 Medicaid payment. (a) Under a PACE program agreement, the State administering agency...

A profile of Hawaiians in the Medicaid Fee-For-Service program.

PubMed

Loke, M; Kang-Kaulupali, K T; Honbo, L

2001-09-01

In Hawai'i, the Medicaid Fee-For-Service (FFS) program enrolled approximately 39,000 individuals in fiscal year (FY) 1999. This program specifically provides healthcare services to enrollees classified as aged, blind, disabled, in-state foster children, and children who live out-of-state in subsidized adoptions. The total expenditure associated with this program was over $300 million in FY 1999. Nearly 4,600 enrollees in the Medicaid FFS program were self-identified as Native Hawaiians or part-Hawaiians. Although the proportion of Hawaiians in the Medicaid program was a fair representation of Hawaiians in the state, the distribution by recipient category within the program was in sharp contrast. Aged Hawaiians appeared to be under-represented in the program while disabled Hawaiians were overrepresented. Foster children and children under subsidized adoption accounted for 1% of the total Hawaiian population. Excluding the foster children and children under subsidized adoption, recipients of Hawaiian ancestry in the Medicaid FFS program (aged, blind, and disabled) obtained health care services amounting to approximately $34 million in FY 1999. Females in this population received more services, with total Medicaid payments amounting to $18.7 million. A higher proportion of Hawaiian recipients were on the neighbor islands. In this FFS Hawaiian population, the top three disease-states by dollar volume in FY 1999, were Alzheimer's disease, acute cerebrovascular disease, and profound mental retardation. A total of $3 million in services were provided to recipients with these primary disease-states. The five leading disease-states facing Hawaiians were generally comparable to those confronting the overall FFS population.

New Jersey's Medicaid waiver for acquired immunodeficiency syndrome

PubMed Central

Merzel, Cheryl; Crystal, Stephen; Sambamoorthi, Usha; Karus, Daniel; Kurland, Carol

1992-01-01

This article contains data from a study of New Jersey's home and community-based Medicaid waiver program for persons with symptomatic human immunodeficiency virus illness. Major findings include lower hospital costs and utilization for waiver participants compared with general Medicaid acquired immunodeficiency syndrome admissions in New Jersey. Average program expenditures were $2,400 per person per month. Based on study findings, it is evident that the waiver program is an important means of providing financial benefits and access to services and that comprehensive case management is a critical factor in assuring program quality. PMID:10120180

Medicaid Long-Term Care Recipients Grew by 37%, Costs by 25% in 3 Years. Trends and Milestones.

ERIC Educational Resources Information Center

Anderson, Lynda; And Others

1997-01-01

This brief article presents data on trends in costs and numbers of recipients of Medicaid served by the Intermediate Care Facility/Mental Retardation program and the Medicaid Home and Community Based Services program. A table presents the data by state and a graph shows the increasing numbers of recipients and costs. (DB)

45 CFR 155.345 - Coordination with Medicaid, CHIP, the Basic Health Program, and the Pre-existing Condition...

Code of Federal Regulations, 2014 CFR

2014-10-01

... 45 Public Welfare 1 2014-10-01 2014-10-01 false Coordination with Medicaid, CHIP, the Basic Health....345 Coordination with Medicaid, CHIP, the Basic Health Program, and the Pre-existing Condition..., CHIP, and the BHP, if a BHP is operating in the service area of the Exchange, as are necessary to...

45 CFR 155.345 - Coordination with Medicaid, CHIP, the Basic Health Program, and the Pre-existing Condition...

Code of Federal Regulations, 2013 CFR

2013-10-01

... 45 Public Welfare 1 2013-10-01 2013-10-01 false Coordination with Medicaid, CHIP, the Basic Health....345 Coordination with Medicaid, CHIP, the Basic Health Program, and the Pre-existing Condition..., CHIP, and the BHP, if a BHP is operating in the service area of the Exchange, as are necessary to...

Medicaid Expansion And State Trends In Supplemental Security Income Program Participation.

PubMed

Soni, Aparna; Burns, Marguerite E; Dague, Laura; Simon, Kosali I

2017-08-01

The Affordable Care Act made low-income nonelderly adults eligible for Medicaid in 2014 without requiring them to obtain disabled status through the Supplemental Security Income (SSI) program. In states that participated in the Medicaid expansion, we found that SSI participation decreased by about 3 percent after 2014. Project HOPE—The People-to-People Health Foundation, Inc.

Medicaid.gov

MedlinePlus

... Monitoring Review Plans Program Integrity National Correct Coding Initiative Affordable Care Act Program Integrity Provisions Cost Sharing ... to Care Living Well Quality of Care Improvement Initiatives Medicaid Managed Care Performance Measurement Releases & Announcements Enrollment ...

Medicaid Benefits

MedlinePlus

... Monitoring Review Plans Program Integrity National Correct Coding Initiative Affordable Care Act Program Integrity Provisions Cost Sharing ... to Care Living Well Quality of Care Improvement Initiatives Medicaid Managed Care Performance Measurement Releases & Announcements Enrollment ...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-05-29

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services (CMS) [CMS-2382-N... Challenge AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice. SUMMARY: The Centers for Medicare & Medicaid Services (CMS), is announcing the launch of the ``CMS Provider Screening...

Medicaid program; mental retardation--definition of "persons with related conditions"--Health Care Financing Administration. Proposed rule.

PubMed

1983-02-23

We propose to amend the 1978 Medicaid regulations on intermediate care facility services for the mentally retarded and persons with related conditions to correct the definition of "persons with related conditions". This definition, because of an inadvertent error in 1978, is currently tied to the definition of developmental disability in the Developmental Disabilities Assistance and Bill of Rights Act (DDABRA) as amended in 1978. The DDABRA, as amended, covers the mentally ill. The 1978 regulations intended to make "no substantive change" to prior Medicaid regulations which did not cover the mentally ill. The cross-reference to the DDABRA produced the unintended result of incorporating into Medicaid regulations the revision to the definition of the developmentally disabled created by the 1978 amendments to the DDABRA and may tend to cause confusion about the kind of care that is covered by the Medicaid program. Therefore, a correction of this drafting error is necessary. To avoid results of this kind in the future this proposal would establish a Medicaid definition of conditions related to mental retardation that would meet specific needs of the Medicaid program and would be independent of the definition of developmental disability in the DDABRA.

Evaluating Florida's Medicaid Provider Services Network Demonstration

PubMed Central

Paul Duncan, R; Lemak, Christy H; Bruce Vogel, W; Johnson, Christopher E; Hall, Allyson G; Porter, Colleen K

2008-01-01

Research Objective To evaluate the design, development, and implementation of Florida's Medicaid provider service network (PSN) demonstration, and the implications of that demonstration for subsequent Medicaid Reform in Florida. Data Sources, Data Collection Organizational analyses were based on archival and enrollment data obtained from Florida's Medicaid program and the South Florida Community Care Network, as well as key informant interviews. Closely related fiscal analyses utilized Medicaid claims data from March 1999 through October 2001 extracted from the Florida Medicaid Management Information System. Study Design The organizational analyses reported here were based on a structured case study research design. Principal Findings Almost every aspect of the development of the new organizational form (PSN) took longer and was more difficult than anticipated. Prior organizational experience with insurance functions proved to be an asset. While fiscal analyses indicated that the program saved the state of Florida a significant amount of money, tracking the precise origin of the savings proved to be challenging. Conclusions By most standards, the PSN program was observed to meet its stated objectives. Based in part on this conclusion, the state chose to extend the use of PSNs within its 2006 Medicaid Reform initiative. PMID:18199192

42 CFR 495.344 - Approval of the State Medicaid HIT plan, the HIT PAPD and update, the HIT IAPD and update, and...

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false Approval of the State Medicaid HIT plan, the HIT... Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED... Requirements Specific to the Medicaid Program § 495.344 Approval of the State Medicaid HIT plan, the HIT PAPD...

42 CFR 436.1 - Purpose and applicability.

Code of Federal Regulations, 2010 CFR

2010-10-01

... (CONTINUED) MEDICAL ASSISTANCE PROGRAMS ELIGIBILITY IN GUAM, PUERTO RICO, AND THE VIRGIN ISLANDS General..., and the Virgin Islands— (a) The eligibility provisions that a State plan must contain; (b) The mandatory and optional groups of individuals to whom Medicaid is provided under a State plan; (c) The...

76 FR 46684 - Medicaid and Children's Health Insurance Programs; Disallowance of Claims for FFP and Technical...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-08-03

..., 433, 447, and 457 [CMS-2292-P] RIN 0938-AQ32 Medicaid and Children's Health Insurance Programs... Children's Health Insurance Program (CHIP) disallowance process to allow States the option to retain... [[Page 46685

42 CFR 455.200 - Basis and scope.

Code of Federal Regulations, 2011 CFR

2011-10-01

... scope. (a) Statutory basis. This subpart implements section 1936 of the Social Security Act that... contract under the Medicaid Integrity Program and to carry out the Medicaid integrity audit program...

42 CFR 455.200 - Basis and scope.

Code of Federal Regulations, 2010 CFR

2010-10-01

... scope. (a) Statutory basis. This subpart implements section 1936 of the Social Security Act that... contract under the Medicaid Integrity Program and to carry out the Medicaid integrity audit program...

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

...] Medicare, Medicaid, and Children's Health Insurance Programs; Renewal, Expansion, and Renaming of the...'s Health Insurance Program (CHIP) about options for selecting health care coverage under these and... needs are for experts in health disparities, State Health Insurance Assistance Programs (SHIPs), health...

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.

Racial disparities in orthodontic service use for Medicaid-enrolled children: An evaluation of the Washington Medicaid program.

PubMed

Merritt, Jantraveus M; Greenlee, Geoffrey; Bollen, Anne Marie; Scott, JoAnna M; Chi, Donald L

2016-04-01

We assessed the relationship between race and orthodontic service use for Medicaid-enrolled children. This cross-sectional study focused on 570,364 Medicaid-enrolled children in Washington state, ages 6 to 19 years. The main predictor variable was self-reported race (white vs nonwhite). The outcome variable was orthodontic service use, defined as children who were preauthorized for orthodontic treatment by Medicaid in 2012 and subsequently received orthodontic records and initiated treatment. Logistic regression models were used to test the hypothesis that nonwhites are less likely to use orthodontic care than are whites. A total of 8223 children were approved by Medicaid for orthodontic treatment, and 7313 received records and began treatment. Nonwhites were significantly more likely to use orthodontic care than were whites (odds ratio [OR] = 1.18; 95% confidence interval [CI] = 1.02, 1.36; P = 0.031). Hispanic nonwhite children were more likely to use orthodontic care than were non-Hispanic white children (OR = 1.42; 95% CI = 1.18, 1.70; P <0.001). In 2012, nonwhite children in the Washington Medicaid program were significantly more likely to use orthodontic care than were white children. The Washington Medicaid program demonstrates a potential model for addressing racial disparities in orthodontic service use. Future research should identify mechanisms underlying these findings and continue to monitor orthodontic service use for minority children in Medicaid. Copyright © 2016 American Association of Orthodontists. Published by Elsevier Inc. All rights reserved.

42 CFR 455.18 - Provider's statements on claims forms.

Code of Federal Regulations, 2011 CFR

2011-10-01

... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid Agency Fraud... in § 455.19, the agency must provide that all provider claims forms be imprinted in boldface type...

Progress Enrolling Children in Medicaid/CHIP: Who Is Left and What Are the Prospects for Covering More Children? Timely Analysis of Immediate Health Policy Issues

ERIC Educational Resources Information Center

Kenney, Genevieve; Cook, Allison; Dubay, Lisa

2009-01-01

The Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 gave states additional resources and tools aimed at improving participation in Medicaid and the Children's Health Insurance Program (CHIP). In 2007, five million uninsured children were eligible for Medicaid or CHIP, constituting 64 percent of all uninsured children.…

42 CFR 488.303 - State plan requirement.

Code of Federal Regulations, 2010 CFR

2010-10-01

... requirements apply to the Medicaid program. (b) A State may establish a program to reward, through public recognition, incentive payments, or both, nursing facilities that provide the highest quality care to Medicaid...

Development of a Medicaid Behavioral Health Case-Mix Model

ERIC Educational Resources Information Center

Robst, John

2009-01-01

Many Medicaid programs have either fully or partially carved out mental health services. The evaluation of carve-out plans requires a case-mix model that accounts for differing health status across Medicaid managed care plans. This article develops a diagnosis-based case-mix adjustment system specific to Medicaid behavioral health care. Several…

42 CFR 431.830 - Basic elements of the Medicaid quality control (MQC) claims processing assessment system.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Basic elements of the Medicaid quality control (MQC... & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STATE ORGANIZATION AND GENERAL ADMINISTRATION Quality Control Medicaid Quality Control (mqc) Claims Processing...

Florida's model of nursing home Medicaid reimbursement for disaster-related expenses.

PubMed

Thomas, Kali S; Hyer, Kathryn; Brown, Lisa M; Polivka-West, LuMarie; Branch, Laurence G

2010-04-01

This study describes Florida's model of Medicaid nursing home (NH) reimbursement to compensate NHs for disaster-related expenses incurred as a result of 8 hurricanes within a 2-year period. This Florida model can serve as a demonstration for a national model for disaster-related reimbursement. Florida reimburses NHs for approved disaster-related costs through hurricane interim rate requests (IRRs). The state developed its unique Medicaid per diem rate temporary add-on by adapting its standard rate-setting reimbursement methodology. To understand the payment mechanisms and the costs that facilities incurred as a result of natural disasters, we examined the IRRs and cost reports for facilities requesting and receiving reimbursement. Cost reports and IRR applications indicated that Florida Medicaid spent close to $16 million to pay for hurricane-related costs to NHs. Without Florida's Hurricane IRR program, many facilities would have not been reimbursed for their hurricane-related costs. Florida's model is one that Medicare and other states should consider adopting to ensure that NHs receive adequate reimbursement for disaster-related expenses, including tornadoes, earthquakes, floods, blizzards, and other catastrophic events.

Summary of 1990 Medicaid drug rebate legislation. ASHP Government Affairs Division.

PubMed

1991-01-01

Provisions of the federal Omnibus Budget Reconciliation Act of 1990 that are designed to control federal and state outlays for prescription drugs by requiring rebates from drug manufacturers to state Medicaid programs are described, and their potential effects on pharmacy practice in organized health-care settings are discussed. As of January 1, 1991, for a manufacturer's drug product line to be eligible for any coverage under Medicaid, the manufacturer must provide rebates to all state Medicaid programs. Health maintenance organizations are exempt from the law. Hospitals that dispense outpatient drugs to Medicaid patients under a formulary system and that bill Medicaid not more than purchase costs are exempt. The law requires no immediate action by hospitals and other organized care settings; action may be required when provisions of the law concerning drug-use review programs and patient counseling become effective. If a state enters a rebate agreement, its Medicaid plan must permit coverage of all of a manufacturer's prescription drug products, but the law does not affect formulary systems of individual health-care institutions. Formulary issues, the scope of hospital exemption, and pharmacist participation in DUR activities and patient counseling need to be clarified as state Medicaid plans are amended to comply with the law; pharmacists in organized health-care settings can best influence these changes through action at the state level.

Medicaid eligibility policy in the 1980s: medical utilitarianism and the "deserving" poor.

PubMed

Tanenbaum, S J

1995-01-01

Between 1981 and the early 1990s, the Medicaid program grew substantially, in part because, for the first time in the program's history, eligibility for medical assistance was severed from eligibility for income-maintenance payments. Program participation had always been reserved for the "deserving poor," and these were originally defined as persons excluded from market relationships through no fault of their own. The Medicaid expansion of the 1980s, however, created a new constituency of poor, and not-so-poor, persons whose actual or predictable medical problems promised a calculable return on program funds.

Reforming Access: Trends in Medicaid Enrollment for New Medicare Beneficiaries, 2008-2011.

PubMed

Keohane, Laura M; Rahman, Momotazur; Mor, Vincent

2016-04-01

To evaluate whether aligning the Part D low-income subsidy and Medicaid program enrollment pathways in 2010 increased Medicaid participation among new Medicare beneficiaries. Medicare enrollment records for years 2007-2011. We used a multinomial logistic model with state fixed effects to examine the annual change in limited and full Medicaid enrollment among new Medicare beneficiaries for 2 years before and after the reforms (2008-2011). We identified new Medicare beneficiaries in the years 2008-2011 and their participation in Medicaid based on Medicare enrollment records. The percentage of beneficiaries enrolling in limited Medicaid at the start of Medicare coverage increased in 2010 by 0.3 percentage points for individuals aging into Medicare and by 1.3 percentage points for those qualifying due to disability (p < .001). There was no significant difference in the size of enrollment increases between states with and without concurrent limited Medicaid eligibility expansions. Our findings suggest that streamlining financial assistance programs may improve Medicare beneficiaries' access to benefits. © Health Research and Educational Trust.

The Role of Medicaid and Other Government Programs in Providing Medical Care for Children and Pregnant Women.

ERIC Educational Resources Information Center

Hill, Ian T.

1992-01-01

Provides an overview of the major federal and state health care programs serving children and pregnant women, including (1) Medicaid; (2) the Maternal and Child Health Block Grant Program; (3) the Community and Migrant Health Center Program; and (4) the Special Supplemental Food Program for Women, Infants, and Children. (SLD)

42 CFR 495.328 - Request for reconsideration of adverse determination.

Code of Federal Regulations, 2010 CFR

2010-10-01

... RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.328 Request for... planning document or State Medicaid HIT Plan under this subpart, or determines that requirements are met...

42 CFR 457.1110 - Privacy protections.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 4 2013-10-01 2013-10-01 false Privacy protections. 457.1110 Section 457.1110 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STATE CHILDREN'S HEALTH INSURANCE PROGRAMS (SCHIPs) ALLOTMENTS AND GRANTS TO STATES State Plan Requirements: Applicant and Enrollee Protections §...

42 CFR 457.1110 - Privacy protections.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Privacy protections. 457.1110 Section 457.1110 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STATE CHILDREN'S HEALTH INSURANCE PROGRAMS (SCHIPs) ALLOTMENTS AND GRANTS TO STATES State Plan Requirements: Applicant and Enrollee Protections §...

42 CFR 457.1110 - Privacy protections.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Privacy protections. 457.1110 Section 457.1110 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STATE CHILDREN'S HEALTH INSURANCE PROGRAMS (SCHIPs) ALLOTMENTS AND GRANTS TO STATES State Plan Requirements: Applicant and Enrollee Protections §...

42 CFR 457.1110 - Privacy protections.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Privacy protections. 457.1110 Section 457.1110 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STATE CHILDREN'S HEALTH INSURANCE PROGRAMS (SCHIPs) ALLOTMENTS AND GRANTS TO STATES State Plan Requirements: Applicant and Enrollee Protections §...

42 CFR 457.1110 - Privacy protections.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Privacy protections. 457.1110 Section 457.1110 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STATE CHILDREN'S HEALTH INSURANCE PROGRAMS (SCHIPs) ALLOTMENTS AND GRANTS TO STATES State Plan Requirements: Applicant and Enrollee Protections §...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-05-25

... use in enforcement activities; monitoring procedures for provider entities found not in compliance... to activities relating to the survey and certification of facilities are at 42 CFR part 488. The... appropriately to complaints against accredited facilities. AOA/HFAP's processes and procedures for monitoring an...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-06-25

... activities; monitoring procedures for provider entities found not in compliance with the conditions or... concerning provider agreements are at 42 CFR part 489 and those pertaining to activities relating to the... appropriately to complaints against accredited facilities. ++ AOA/HFAP's processes and procedures for monitoring...

42 CFR 441.257 - Informed consent.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 4 2013-10-01 2013-10-01 false Informed consent. 441.257 Section 441.257 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Sterilizations § 441.257 Informed consent. (a) Informing...

42 CFR 441.257 - Informed consent.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Informed consent. 441.257 Section 441.257 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Sterilizations § 441.257 Informed consent. (a) Informing...

42 CFR 441.257 - Informed consent.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Informed consent. 441.257 Section 441.257 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Sterilizations § 441.257 Informed consent. (a) Informing...

42 CFR 441.510 - Eligibility.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Eligibility. 441.510 Section 441.510 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Home and Community-Based Attendant Services and Supports Stat...

42 CFR 441.510 - Eligibility.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Eligibility. 441.510 Section 441.510 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Home and Community-Based Attendant Services and Supports Stat...

42 CFR 441.510 - Eligibility.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 4 2013-10-01 2013-10-01 false Eligibility. 441.510 Section 441.510 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Home and Community-Based Attendant Services and Supports Stat...

76 FR 19365 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-04-07

... Fiscal Year 2011 Final Wage Indices Implementing the Medicare and Medicaid Extenders Act AGENCY: Centers... fiscal year (FY) 2011 wage indices and hospital reclassifications and other related tables which reflect... reclassifications and special exception wage indices through September 30, 2011. DATES: Applicability Date: The...

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

... Payments Under the Hospital Inpatient Prospective Payment System AGENCY: Centers for Medicare & Medicaid... and technologies under the hospital inpatient prospective payment system (IPPS). Interested parties are invited to this meeting to present their comments, recommendations, and data regarding whether the...

Effect of expansions in state Medicaid eligibility on access to care and the use of emergency department services for adult Medicaid enrollees.

PubMed

Ndumele, Chima D; Mor, Vincent; Allen, Susan; Burgess, James F; Trivedi, Amal N

2014-06-01

Medicaid enrollees typically report worse access to care than other insured populations. Expansions in Medicaid through less restrictive income eligibility requirements and the resulting influx of new enrollees may further erode access to care for those already enrolled in Medicaid. To assess the effect of previous Medicaid expansions on self-reported access to care and the use of emergency department services by Medicaid enrollees. Quasi-experimental difference-in-differences design among 1714 adult Medicaid enrollees in 10 states that expanded Medicaid between June 1, 2000, and October 1, 2009, and 5097 Medicaid enrollees in 14 bordering control states that did not expand Medicaid. Self-reported access to care and annualized emergency department use. Among states expanding their Medicaid program for adults, the mean income eligibility level increased from 82.6% to 144.2% of the federal poverty level. Income eligibility in matched control states remained constant at 77.1% of the federal poverty level. The proportion of adults reporting being enrolled in Medicaid increased from 7.2% to 8.8% in expansion states and from 6.1% to 6.4% in matched control states. In Medicaid program expansion states, the proportion of Medicaid enrollees reporting poor access to care declined from 8.5% before the expansion to 7.3% after the expansion. In matched control states, the proportion of Medicaid enrollees reporting poor access to care remained constant at 5.3%. The proportion of enrollees reporting any emergency department use decreased from 41.2% to 40.1% in expansion states and from 37.3% to 36.1% in matched control states. In the period following expansions, newly eligible enrollees reported poorer access to care than previously enrolled beneficiaries, although the overall difference between groups did not reach statistical significance. We found no evidence that expanding the number of individuals eligible for Medicaid coverage eroded perceived access to care or increased the use of emergency services among adult Medicaid enrollees.

Medicaid and the politics of groups: recipients, providers, and policy making.

PubMed

Kronebusch, K

1997-06-01

There is a substantial heterogeneity of interests within the Medicaid program. Its major beneficiary groups include the elderly, people with disabilities, children in low-income families, and adults receiving Aid to Families with Dependent Children. Providers who deliver medical services to these recipients represent another set of potential claimants. These groups are likely to be treated differently by the politics that affect the design and management of the Medicaid program. The Medicaid recipient groups vary in several important dimensions: First, the groups differ politically, a dimension that includes their political participation, their relationships to parties and electoral coalitions, the images they present to other political actors, and the legacy of public policies that affect them. Second, the groups have different medical and social needs. Third, the groups differ with respect to economic constraints, including the political economy of labor markets and of government spending programs, and they have differing relationships to the various types of medical providers. The medical providers are themselves political actors with a variety of characteristics that create political advantages relative to recipients, although there is also diversity among providers. The politics of the Medicaid program involves more than simply technical decisions about eligibility, coverage of medical services, reimbursement, and the implementation of managed care initiatives. Instead the differences between the program's multiple claimants are an important element of current Medicaid politics and the likely path of future reforms.

The quality of Medicaid and Medicare data obtained from CMS and its contractors: implications for pharmacoepidemiology.

PubMed

Leonard, Charles E; Brensinger, Colleen M; Nam, Young Hee; Bilker, Warren B; Barosso, Geralyn M; Mangaali, Margaret J; Hennessy, Sean

2017-04-26

Administrative claims of United States Centers for Medicare and Medicaid Services (CMS) beneficiaries have long been used in non-experimental research. While CMS performs in-house checks of these claims, little is known of their quality for conducting pharmacoepidemiologic research. We performed exploratory analyses of the quality of Medicaid and Medicare data obtained from CMS and its contractors. Our study population consisted of Medicaid beneficiaries (with and without dual coverage by Medicare) from California, Florida, New York, Ohio, and Pennsylvania. We obtained and compiled 1999-2011 data from these state Medicaid programs (constituting about 38% of nationwide Medicaid enrollment), together with corresponding national Medicare data for dually-enrolled beneficiaries. This descriptive study examined longitudinal patterns in: dispensed prescriptions by state, by quarter; and inpatient hospitalizations by federal benefit, state, and age group. We further examined discrepancies between demographic characteristics and disease states, in particular frequencies of pregnancy complications among men and women beyond childbearing age, and prostate cancers among women. Dispensed prescriptions generally increased steadily and consistently over time, suggesting that these claims may be complete. A commercially-available National Drug Code lookup database was able to identify the dispensed drug for 95.2-99.4% of these claims. Because of co-coverage by Medicare, Medicaid data appeared to miss a substantial number of hospitalizations among beneficiaries ≥ 45 years of age. Pregnancy complication diagnoses were rare in males and in females ≥ 60 years of age, and prostate cancer diagnoses were rare in females. CMS claims from five large states obtained directly from CMS and its contractors appeared to be of high quality. Researchers using Medicaid data to study hospital outcomes should obtain supplemental Medicare data on dual enrollees, even for non-elders. Not applicable.

Effectiveness of preventive dental treatments by physicians for young Medicaid enrollees.

PubMed

Pahel, Bhavna T; Rozier, R Gary; Stearns, Sally C; Quiñonez, Rocio B

2011-03-01

To estimate the effectiveness of a medical office-based preventive dental program (Into the Mouths of Babes [IMB]), which included fluoride varnish application, in reducing treatments related to dental caries. We used longitudinal claims and enrollment data for all children aged 72 months or younger enrolled in North Carolina Medicaid from 2000 through 2006. Regression analyses compared subgroups of children who received up to 6 IMB visits at ages 6 to 35 months with children who received no IMB visits. Analyses were adjusted for child and area characteristics. Children enrolled in North Carolina Medicaid with ≥ 4 IMB visits experienced, on average, a 17% reduction in dental-caries-related treatments up to 6 years of age compared with children with no IMB visits. When we simulated data for initial IMB visits at 12 and 15 months of age, there was a cumulative 49% reduction in caries-related treatments at 17 months of age. The cumulative effectiveness declined because of an increase in treatments from 24 to 36 months, an increase in referrals for dental caries occurred with increasing time since fluoride application, and emergence of teeth not initially treated with fluoride. North Carolina's IMB program was effective in reducing caries-related treatments for children with ≥ 4 IMB visits. Multiple applications of fluoride at the time of primary tooth emergence seem to be most beneficial. Referrals to dentists for treatment of existing disease detected by physicians during IMB implementation limited the cumulative reductions in caries-related treatments, but also contributed to improved oral health.

42 CFR 455.17 - Reporting requirements.

Code of Federal Regulations, 2011 CFR

2011-10-01

... (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid Agency Fraud Detection and Investigation Program § 455.17 Reporting requirements. The agency must report the following fraud or abuse... complaints of fraud and abuse made to the agency that warrant preliminary investigation. (b) For each case of...

Medicaid expenditures for the disabled under a work incentive program

PubMed Central

Andrews, Roxanne M.; Ruther, Martin; Baugh, David K.; Pine, Penelope L.; Rymer, Marilyn P.

1988-01-01

Congress enacted Section 1619 of the Social Security Act to enable the disabled receiving Supplemental Security Income (SSI) to obtain jobs and still retain Medicaid health benefits. Congress intended this work incentive to remove the fear of the severely disabled that by obtaining employment they would lose Medicaid benefits. Based on data from 11 States, our analysis found that Medicaid expenditures for Section 1619 enrollees were relatively small and only one-half the average Medicaid expenditure for the disabled. Retaining Medicaid appears to provide a significant work incentive because Medicaid expenditures represent 13 percent of Section 1619 enrollees' earnings. PMID:10318077

75 FR 44971 - Medicaid Program; Request for Comments on Legislative Changes To Provide Quality of Care to Children

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-30

... Health Insurance Program, including recommendations for quality reporting by the States. The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) requires the Secretary of Health and Human... provided to children under Medicaid and the Children's Health Insurance Program. DATES: Comment Date: To be...

Health Care Financing Administration--Medicaid program; Medicaid management information systems. Final rule.

PubMed

1980-03-05

These regulations set forth a new procedure to improve Medicaid management by explicitly authorizing HCFA to expand or revise State Medicaid Management Information Systems (MMIS) as necessary to meet program needs. Under this procedure, HCFA will publish major new requirements for comment before deciding to adopt them, and will provide increased Federal matching and reasonable phase-in time for their implementation. HCFA will also periodically review ongoing systems to determine whether all system requirements and performance standards are being met and may reduce the level of Federal matching for those MMIS systems which do not meet prescribed standards.

Medicaid Eligibility

MedlinePlus

... recover for other Medicaid benefits, except for Medicare cost-sharing benefits paid on behalf of Medicare Savings Program beneficiaries. Third Party Liability: Third Party Liability (TPL) refers to third ... or all of the cost of medical services provided to a Medicaid beneficiary. ...

Medicaid Contradictions: Adding, Subtracting, and Redeterminations in Illinois.

PubMed

Koetting, Michael

2016-04-01

States are required to conduct annual Medicaid redeterminations. How these redeterminations are undertaken is crucial to determining the nature of Medicaid coverage. There can be wide variations in the proportion of clients disenrolled, with potentially large numbers of people disenrolled each year. This case study of Illinois Medicaid shows how, as the Affordable Care Act added people, redeterminations were taking people off the rolls-about 25 percent of all Medicaid clients were disenrolled in one year. Many of these people were no longer eligible, but it appears that a larger number were in fact eligible but simply failed to comply with administrative requirements in a timely way. Balancing between the two imperatives of program integrity and continuity of care is a difficult act for Medicaid programs. The Illinois experience also illustrates impacts on information technology and outsourcing of eligibility functions, not to mention budget considerations. Copyright © 2016 by Duke University Press.

The Long-Term Impacts of Medicaid Exposure in Early Childhood: Evidence from the Program's Origin*

PubMed Central

Boudreaux, Michel H.; Golberstein, Ezra; McAlpine, Donna D.

2016-01-01

This paper examines the long-term impact of exposure to Medicaid in early childhood on adult health and economic status. The staggered timing of Medicaid's adoption across the states created meaningful variation in cumulative exposure to Medicaid for birth cohorts that are now in adulthood. Analyses of the Panel Study of Income Dynamics suggest exposure to Medicaid in early childhood (age 0-5) is associated with statistically significant and meaningful improvements in adult health (age 25-54), and this effect is only seen in subgroups targeted by the program. Results for economic outcomes are imprecise and we are unable to come to definitive conclusions. Using separate data we find evidence of two mechanisms that could plausibly link Medicaid's introduction to long-term outcomes: contemporaneous increases in health services utilization for children and reductions in family medical debt. PMID:26763123

Comparing the Medicaid Retrospective Drug Utilization Review Program Cost-Savings Methods Used by State Agencies

PubMed Central

Prada, Sergio I.

2017-01-01

Background The Medicaid Drug Utilization Review (DUR) program is a 2-phase process conducted by Medicaid state agencies. The first phase is a prospective DUR and involves electronically monitoring prescription drug claims to identify prescription-related problems, such as therapeutic duplication, contraindications, incorrect dosage, or duration of treatment. The second phase is a retrospective DUR and involves ongoing and periodic examinations of claims data to identify patterns of fraud, abuse, underutilization, drug–drug interaction, or medically unnecessary care, implementing corrective actions when needed. The Centers for Medicare & Medicaid Services requires each state to measure prescription drug cost-savings generated from its DUR programs on an annual basis, but it provides no guidance or unified methodology for doing so. Objectives To describe and synthesize the methodologies used by states to measure cost-savings using their Medicaid retrospective DUR program in federal fiscal years 2014 and 2015. Method For each state, the cost-savings methodologies included in the Medicaid DUR 2014 and 2015 reports were downloaded from Medicaid's website. The reports were then reviewed and synthesized. Methods described by the states were classified according to research designs often described in evaluation textbooks. Discussion In 2014, the most often used prescription drugs cost-savings estimation methodology for the Medicaid retrospective DUR program was a simple pre-post intervention method, without a comparison group (ie, 12 states). In 2015, the most common methodology used was a pre-post intervention method, with a comparison group (ie, 14 states). Comparisons of savings attributed to the program among states are still unreliable, because of a lack of a common methodology available for measuring cost-savings. Conclusion There is great variation among states in the methods used to measure prescription drug utilization cost-savings. This analysis suggests that there is still room for improvement in terms of methodology transparency, which is important, because lack of transparency hinders states from learning from each other. Ultimately, the federal government needs to evaluate and improve its DUR program. PMID:29403573

Health Care Expenditures for Children with Autism Spectrum Disorders in Medicaid

ERIC Educational Resources Information Center

Wang, Li; Leslie, Douglas L.

2010-01-01

Objective: To study trends in health care expenditures associated with autism spectrum disorders (ASDs) in state Medicaid programs. Method: Using Medicaid data from 42 states from 2000 to 2003, patients aged 17 years and under who were continuously enrolled in fee-for-service Medicaid were studied. Patients with claims related to autistic disorder…

Understanding dual enrollees' use of Medicare home health services: the effects of differences in Medicaid home care programs.

PubMed

Kenney, G; Rajan, S

2000-01-01

Both the Medicare and Medicaid programs have experienced considerable growth in spending on home care in recent years. As policymakers adopt measures (such as those legislated in the Balanced Budget Act of 1997) to curb the rate of spending growth on home care services, it is important to understand interactions between the Medicare and Medicaid home care programs in serving the dually enrolled population. This study examines the potential effects of the Medicaid home care program on Medicare home health utilization using multivariate models. The study relied on data from the Health Care Financing Administration's Medicare Current Beneficiary Survey (MCBS), a longitudinal survey of Medicare enrollees. The primary MCBS file used was from Round 1 of the survey, which was fielded between September and December 1991. The unit of analysis was individuals. The authors used descriptive and multivariate methods to explore the relationship between Medicare coverage and state home care program characteristics. Included were variables that have been found to be significant determinants of Medicare home health utilization in other studies as well as variables to indicate the availability and generosity of Medicaid home care services in each state represented in the survey. The findings were consistent with those of previous studies, in that dual enrollees were disproportionate users of Medicare home health services, accounting for only 16% of enrollees but receiving 40% of all visits. In addition, lower levels of Medicare home health use were observed in states with relatively higher Medicaid spending on home health and personal care services, but this relationship appeared to be heavily dominated by the inclusion of enrollees living in New York State. When individuals from New York were excluded from the analysis, we found a negative but statistically significant relationship between Medicaid outlays on home health and personal care services and Medicare home health utilization. Because the Medicare and Medicaid programs are interconnected through the sizable dual enrollee population, changes in one program are likely to have ramifications for the other. This study presents another step in exploring how the two programs interact and emphasizes the fact that costs can be shifted between the two programs as policy changes are made to control the rate of home care spending growth.

Medicaid's Complex Goals: Challenges for Managed Care and Behavioral Health

PubMed Central

Gold, Marsha; Mittler, Jessica

2000-01-01

The Medicaid program has become increasingly complex as policymakers use it to address various policy objectives, leading to structural tensions that surface with Medicaid managed care. In this article, we illustrate this complexity by focusing on the experience of three States with behavioral health carveouts—Maryland, Oregon, and Tennessee. Converting to Medicaid managed care forces policymakers to confront Medicaid's competing policy objectives, multiplicity of stakeholders, and diverse patients, many with complex needs. Emerging Medicaid managed care systems typically represent compromises in which existing inequities and fragmentation are reconfigured rather than eliminated. PMID:12500322

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

... Vol. 76 Monday, No. 243 December 19, 2011 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Parts 402 and 403 Medicare, Medicaid, Children's Health...; [[Page 78742

Using prescription monitoring program data to characterize out-of-pocket payments for opioid prescriptions in a state Medicaid program.

PubMed

Hartung, Daniel M; Ahmed, Sharia M; Middleton, Luke; Van Otterloo, Joshua; Zhang, Kun; Keast, Shellie; Kim, Hyunjee; Johnston, Kirbee; Deyo, Richard A

2017-09-01

Out-of-pocket payment for prescription opioids is believed to be an indicator of abuse or diversion, but few studies describe its epidemiology. Prescription drug monitoring programs (PDMPs) collect controlled substance prescription fill data regardless of payment source and thus can be used to study this phenomenon. To estimate the frequency and characteristics of prescription fills for opioids that are likely paid out-of-pocket by individuals in the Oregon Medicaid program. Cross-sectional analysis using Oregon Medicaid administrative claims and PDMP data (2012 to 2013). Continuously enrolled nondually eligible Medicaid beneficiaries who could be linked to the PDMP with two opioid fills covered by Oregon Medicaid. Patient characteristics and fill characteristics for opioid fills that lacked a Medicaid pharmacy claim. Fill characteristics included opioid name, type, and association with indicators of high-risk opioid use. A total of 33 592 Medicaid beneficiaries filled a total of 555 103 opioid prescriptions. Of these opioid fills, 74 953 (13.5%) could not be matched to a Medicaid claim. Hydromorphone (30%), fentanyl (18%), and methadone (15%) were the most likely to lack a matching claim. The 3 largest predictors for missing claims were opioid fills that overlapped with other opioids (adjusted odds ratio [aOR] 1.37; 95% confidence interval [CI], 1.34-1.4), long-acting opioids (aOR 1.52; 95% CI, 1.47-1.57), and fills at multiple pharmacies (aOR 1.45; 95% CI, 1.39-1.52). Prescription opioid fills that were likely paid out-of-pocket were common and associated with several known indicators of high-risk opioid use. Copyright © 2017 John Wiley & Sons, Ltd.

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 Medicare...

42 CFR 432.1 - Basis and purpose.

Code of Federal Regulations, 2010 CFR

2010-10-01

... system of State personnel administration and training and use of subprofessional staff and volunteers in State Medicaid programs, and section 1903(a), rates of FFP for Medicaid staffing and training costs. It... State training programs for all staff. ...

The effect of Medicaid wage pass-through programs on the wages of direct care workers.

PubMed

Baughman, Reagan A; Smith, Kristin

2010-05-01

Despite growing demand for nursing and home health care as the US population ages, compensation levels in the low-skill nursing labor market that provides the bulk of long-term care remain quite low. The challenge facing providers of long-term care is that Medicaid reimbursement rates for nursing home and home health care severely restrict the wage growth that is necessary to attract workers, resulting in high turnover and labor shortages. Almost half of US states have responded by enacting "pass-through" provisions in their Medicaid programs, channeling additional long-term care funding directly to compensation of lower-skill nursing workers. We test the effect of Medicaid wage pass-through programs on hourly wages for direct care workers. We estimate several specifications of wage models using employment data from the 1996 and 2001 panels of the Survey of Income and Program Participation for nursing, home health, and personal care aides. The effect of pass-through programs is identified by an indicator variable for states with programs; 20 states adopted pass-throughs during the sample period. Workers in states with pass-through programs earn as much as 12% more per hour than workers in other states after those programs are implemented. Medicaid wage pass-through programs appear to be a viable policy option for raising compensation levels of direct care workers, with an eye toward improving recruitment and retention in long-term care settings.

Addressing women's health needs and improving birth outcomes: results from a peer-to-peer state Medicaid learning project.

PubMed

Johnson, Kay

2012-08-01

High rates of maternal mortality, infant mortality, and preterm births, as well as continuing disparities in pregnancy outcomes, have prompted a number of state Medicaid agencies to focus on improving the quality and continuity of care delivered to women of childbearing age. As part of a peer-to-peer learning project, seven Medicaid agencies worked to develop the programs, policies, and infrastructures needed to identify and reduce women's health risks either prior to or between pregnancies. The states also identified public health strategies. These strategies led to a policy checklist to help leaders in other states identify improvement opportunities that fit within their programs' eligibility requirements, quality improvement objectives, and health system resources. Many of the identified programs and policies may help states use the upcoming expansion of the Medicaid program to improve women's health and thereby reduce adverse birth outcomes.

Medicaid prior-authorization programs and the use of cyclooxygenase-2 inhibitors.

PubMed

Fischer, Michael A; Schneeweiss, Sebastian; Avorn, Jerry; Solomon, Daniel H

2004-11-18

Over the past five years, selective cyclooxygenase-2 inhibitors (coxibs) have accounted for a growing proportion of prescriptions for nonsteroidal antiinflammatory drugs (NSAIDs). To control these expenses, many state Medicaid programs have implemented prior-authorization requirements before coxibs can be prescribed. We evaluated the effect of such programs on the use of coxibs by Medicaid beneficiaries. We surveyed state Medicaid agencies to determine whether prescription of coxibs required prior authorization and, if so, the criteria for authorization. For each program, we compared these criteria with evidence-based recommendations for prescribing of coxibs. Using data for all filled prescriptions in 50 state Medicaid programs from 1999 through the end of 2003, we calculated the proportion of defined daily doses of NSAIDs accounted for by coxibs. Time-series analyses were used to measure the changes in prescription patterns after the implementation of each prior-authorization program. By 2001, coxibs accounted for half of all NSAID doses covered by Medicaid. This proportion varied widely according to the state in 2003, from a low of 11 percent to a high of 70 percent of all NSAID doses. Twenty-two states implemented prior-authorization programs for coxibs during the study period. Overall, the implementation of such programs reduced the proportion of NSAID doses made up by coxibs by 15.0 percent (95 percent confidence interval, 10.9 to 19.2 percent), corresponding to a decrease of 10.28 dollars (95 percent confidence interval, 7.56 dollars to 13.00 dollars) in spending per NSAID prescription. The effect of such programs was not influenced by the degree to which a prior-authorization program incorporated evidence-based prescribing recommendations. The use of coxibs and spending on NSAIDs varies widely by state and declined substantially after the implementation of prior-authorization programs. Determining whether these reductions are clinically appropriate will have important implications for the development of rational drug-reimbursement policies. Copyright 2004 Massachusetts Medical Society.

42 CFR 455.23 - Suspension of payments in cases of fraud.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Suspension of payments in cases of fraud. 455.23... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PROGRAM INTEGRITY: MEDICAID Medicaid Agency Fraud Detection and Investigation Program § 455.23 Suspension of payments in cases of fraud. (a) Basis for...

77 FR 70783 - Medicare and Medicaid Programs; Approval of the Accreditation Association for Ambulatory Health...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-11-27

...] Medicare and Medicaid Programs; Approval of the Accreditation Association for Ambulatory Health Care (AAAHC... announces our decision to approve the Accreditation Association for Ambulatory Health Care (AAAHC) for... Ambulatory Health Care's (AAAHC) current term of approval for their ASC accreditation program expires on...

Barriers to Medicaid Participation among Florida Dentists

PubMed Central

Logan, Henrietta L.; Catalanotto, Frank; Guo, Yi; Marks, John; Dharamsi, Shafik

2015-01-01

Background Finding dentists who treat Medicaid-enrolled children is a struggle for many parents. The purpose of this study was to identify non-reimbursement factors that influence the decision by dentists about whether or not to participate in the Medicaid program in Florida. Methods Data from a mailed survey was analyzed using a logistic regression model to test the association of Medicaid participation with the Perceived Barriers and Social Responsibility variables. Results General and pediatric dentists (n=882) who identified themselves as either Medicaid (14%) or Non-Medicaid (86%) participants responded. Five items emerged as significant predictors of Medicaid participation, with a final concordance index of 0.905. Two previously unreported barriers to participation in Medicaid emerged: 1) dentists’ perception of social stigma from other dentists for participating in Medicaid, and 2) the lack of specialists to whom Medicaid patients can be referred. Conclusions This study provides new information about non-reimbursement barriers to Medicaid participation. PMID:25702734

MEDICAID and SCHIP: Recent HHS Approvals of Demonstration Waiver Projects Raise Concerns

DTIC Science & Technology

2002-07-01

Medicaid beneficiaries. However, because the demonstration defines adults as age 19 and older , HHS granted Utah a waiver of the EPSDT requirement...SCHIP children, at or below 200% FPL Adults age 19 and older below 150% FPL, including childless adults from state-only program, and parents... Seniors age 65 and older , at or below 200% FPL, not otherwise eligible for Medicaid; many from state-only pharmacy benefit program Number of

The structure and content of telephonic scripts found useful in a Medicaid Chronic Disease Management Program.

PubMed

Roth, Alexis M; Ackermann, Ronald T; Downs, Stephen M; Downs, Anne M; Zillich, Alan J; Holmes, Ann M; Katz, Barry P; Murray, Michael D; Inui, Thomas S

2010-06-01

In 2003, the Indiana Office of Medicaid Policy and Planning launched the Indiana Chronic Disease Management Program (ICDMP), a programme intended to improve the health and healthcare utilization of 15,000 Aged, Blind and Disabled Medicaid members living with diabetes and/or congestive heart failure in Indiana. Within ICDMP, programme components derived from the Chronic Care Model and education based on an integrated theoretical framework were utilized to create a telephonic care management intervention that was delivered by trained, non-clinical Care Managers (CMs) working under the supervision of a Registered Nurse. CMs utilized computer-assisted health education scripts to address clinically important topics, including medication adherence, diet, exercise and prevention of disease-specific complications. Employing reflective listening techniques, barriers to optimal self-management were assessed and members were encouraged to engage in health-improving actions. ICDMP evaluation results suggest that this low-intensity telephonic intervention shifted utilization and lowered costs. We discuss this patient-centred method for motivating behaviour change, the theoretical constructs underlying the scripts and the branched-logic format that makes them suitable to use as a computer-based application. Our aim is to share these public-domain materials with other programmes.

Acceptance of New Medicaid Patients by Primary Care Physicians and Experiences with Physician Availability among Children on Medicaid or the Children's Health Insurance Program

PubMed Central

Decker, Sandra L

2015-01-01

Objective To estimate the relationship between physicians' acceptance of new Medicaid patients and access to health care. Data Sources The National Ambulatory Medical Care Survey (NAMCS) Electronic Health Records Survey and the National Health Interview Survey (NHIS) 2011/2012. Study Design Linear probability models estimated the relationship between measures of experiences with physician availability among children on Medicaid or the Children's Health Insurance Program (CHIP) from the NHIS and state-level estimates of the percent of primary care physicians accepting new Medicaid patients from the NAMCS, controlling for other factors. Principal Findings Nearly 16 percent of children with a significant health condition or development delay had a doctor's office or clinic indicate that the child's health insurance was not accepted in states with less than 60 percent of physicians accepting new Medicaid patients, compared to less than 4 percent in states with at least 75 percent of physicians accepting new Medicaid patients. Adjusted estimates and estimates for other measures of access to care were similar. Conclusions Measures of experiences with physician availability for children on Medicaid/CHIP were generally good, though better in states where more primary care physicians accepted new Medicaid patients. PMID:25683869

Reforming the Medicaid Disproportionate Share Hospital Program

PubMed Central

Coughlin, Teresa A.; Ku, Leighton; Kim, Johnny

2000-01-01

Since 1991, three Federal laws have sought to reform the Medicaid disproportionate share hospital (DSH) program, which is designed to help safety net hospitals. This article provides findings from a 40-State survey about Medicaid DSH and supplemental payment programs in 1997. Results indicate that the overall size of the DSH program did not grow from 1993 to 1997, but the composition of DSH revenues and expenditures changed substantially: A much higher share of the DSH funds were being paid to local hospitals and relatively less was being retained by the States. The study also revealed that large differences in States' use of DSH still persist. PMID:12500325

Aid to people with disabilities: Medicaid's growing role.

PubMed

Carbaugh, Alicia L; Elias, Risa; Rowland, Diane

2006-01-01

Medicaid is the nation's largest health care program providing assistance with health and long-term care services for millions of low-income Americans, including people with chronic illness and severe disabilities. This article traces the evolution of Medicaid's now-substantial role for people with disabilities; assesses Medicaid's contributions over the last four decades to improving health insurance coverage, access to care, and the delivery of care; and examines the program's future challenges as a source of assistance to children and adults with disabilities. Medicaid has shown that it is an important source of health insurance coverage for this population, people for whom private coverage is often unavailable or unaffordable, substantially expanding coverage and helping to reduce the disparities in access to care between the low-income population and the privately insured.

Implementation of Medicaid Managed Long-Term Services and Supports for Adults with Intellectual And/Or Developmental Disabilities in Kansas

ERIC Educational Resources Information Center

Williamson, Heather J.; Perkins, Elizabeth A.; Levin, Bruce L.; Baldwin, Julie A.; Lulinski, Amie; Armstrong, Mary I.; Massey, Oliver T.

2017-01-01

Many adults with intellectual and/or developmental disabilities (IDD) can access health and long-term services and supports (LTSS) through Medicaid. States are reforming their Medicaid LTSS programs from a fee-for-service model to a Medicaid managed LTSS (MLTSS) approach, anticipating improved quality of care and reduced costs, although there is…

The Relative Benefits and Cost of Medicaid Home- and Community-Based Services in Florida

ERIC Educational Resources Information Center

Mitchell, Glenn, II; Salmon, Jennifer R.; Polivka, Larry; Soberon-Ferrer, Horacio

2006-01-01

Purpose: We compared inpatient days, nursing home days, and total Medicaid claims for five Medicaid-funded home- and community-based services (HCBS) programs for in-home and assisted living services in Florida. Design and Methods: We studied a single cohort of Medicaid enrollees in Florida aged 60 and older, who were enrolled for the first time in…

42 CFR 435.225 - Individuals under age 19 who would be eligible for Medicaid if they were in a medical institution.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Medicaid if they were in a medical institution. 435.225 Section 435.225 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS... age 19 who would be eligible for Medicaid if they were in a medical institution. (a) The agency may...

Medicaid program; Medicaid Management Information Systems; performance standards--HCFA. General notice.

PubMed

1983-05-31

The purpose of this notice is to respond to the comments we received on the Medicaid Management Information Systems Performance Standards that we published in a notice with comment period on June 30, 1981 (46 FR 33653).

76 FR 28791 - Agency Information Collection Activities: Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-18

... participation for expenditures under their Medicaid Electronic Health Record Incentive Program related to health... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [Document... currently approved collection; Title of Information Collection: State Medicaid Health Information Technology...

Single women and the dynamics of Medicaid.

PubMed

Short, P F; Freedman, V A

1998-12-01

To investigate transitions in and out of Medicaid for a cohort of single adult women of childbearing age in order to address questions that arise as policymakers try to encourage transitions from welfare to work. Longitudinal data from Waves 2 through 8 of the 1990 panel of the Survey of Income and Program Participation, a nationally representative survey of American adults covering May 1990-1992. We estimate a series of discrete-time logit models with duration dependence to obtain transition probabilities among Medicaid, privately insured, and uninsured spells. Explanatory variables in the models include prior insurance history, income limits on Medicaid by state, and important socioeconomic and demographic characteristics. We use these models to characterize insurance spells for a cohort of single women. Most Medicaid spells are relatively short. Over half end in a year or less; only one spell out of seven lasts longer than five years. Two-thirds of Medicaid disenrollees become uninsured. Former welfare recipients are prone to frequent changes in insurance status. In states with more generous income limits for AFDC, women stay on Medicaid longer, but they do not move into the program at a faster rate. Imposing time limits on Medicaid eligibility would affect only a small proportion of Medicaid spells but would eliminate a significant proportion of the caseload at a point in time. In considering changes in Medicaid that would encourage transitions from welfare to work and would alter the dynamics of Medicaid, policymakers need to consider how transitions both in and out of private insurance and Medicaid would be affected.

Length of Stay and Inpatient Costs Under Medicaid Managed Care in Florida

PubMed Central

Park, Jungwon

2015-01-01

This study examines the patterns of length of stay (LOS) and inpatient costs for both Medicaid managed care and nonmanaged care patients using data from Medicaid patients aged 18 to 64 years who were discharged from hospitals in Florida between 2006 and 2012. This study used pooled cross-sectional multilevel modeling. The results show that the type of Medicaid program in which patients were enrolled was significantly related to the hospital LOS and inpatient costs. Medicaid managed care patients had 7% shorter LOSs and a 1.9% lower inpatient cost than did Medicaid fee-for-service (FFS) patients. Medicaid managed care patients had shorter LOSs in the Medicaid managed care market with high competition. High managed care penetration generates a cost-decreasing spillover to Medicaid FFS patients. PMID:26472718

42 CFR 433.111 - Definitions.

Code of Federal Regulations, 2014 CFR

2014-10-01

... ASSISTANCE PROGRAMS STATE FISCAL ADMINISTRATION Mechanized Claims Processing and Information Retrieval... information retrieval system” or “system” means the system of software and hardware used to process Medicaid... management information required by the Medicaid single State agency and Federal Government for program...

42 CFR 433.111 - Definitions.

Code of Federal Regulations, 2013 CFR

2013-10-01

... ASSISTANCE PROGRAMS STATE FISCAL ADMINISTRATION Mechanized Claims Processing and Information Retrieval... information retrieval system” or “system” means the system of software and hardware used to process Medicaid... management information required by the Medicaid single State agency and Federal Government for program...

42 CFR 433.111 - Definitions.

Code of Federal Regulations, 2012 CFR

2012-10-01

... ASSISTANCE PROGRAMS STATE FISCAL ADMINISTRATION Mechanized Claims Processing and Information Retrieval... information retrieval system” or “system” means the system of software and hardware used to process Medicaid... management information required by the Medicaid single State agency and Federal Government for program...

42 CFR 433.111 - Definitions.

Code of Federal Regulations, 2011 CFR

2011-10-01

... ASSISTANCE PROGRAMS STATE FISCAL ADMINISTRATION Mechanized Claims Processing and Information Retrieval... information retrieval system” or “system” means the system of software and hardware used to process Medicaid... management information required by the Medicaid single State agency and Federal Government for program...

42 CFR 433.111 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... management information required by the Medicaid single State agency and Federal Government for program... ASSISTANCE PROGRAMS STATE FISCAL ADMINISTRATION Mechanized Claims Processing and Information Retrieval... information retrieval system” or “system” means the system of software and hardware used to process Medicaid...

Impacts on Emergency Department Visits from Personal Responsibility Provisions: Evidence from West Virginia's Medicaid Redesign.

PubMed

Gurley-Calvez, Tami; Kenney, Genevieve M; Simon, Kosali I; Wissoker, Douglas

2016-08-01

To examine the impact of a 2007 redesign of West Virginia's Medicaid program, which included an incentive and "nudging" scheme intended to encourage better health care behaviors and reduce Emergency Department (ED) visits. West Virginia Medicaid enrollment and claims data from 2005 to 2010. We utilized a "differences in differences" technique with individual and time fixed effects to assess the impact of redesign on ED visits. Starting in 2007, categorically eligible Medicaid beneficiaries were moved from traditional Medicaid to the new Mountain Health Choices (MHC) Program on a rolling basis, approximating a natural experiment. Members chose between a Basic plan, which was less generous than traditional Medicaid, or an Enhanced plan, which was more generous but required additional enrollment steps. Data were obtained from the West Virginia Bureau for Medical Services. We found that contrary to intentions, the MHC program increased ED visits. Those who selected or defaulted into the Basic plan experienced increased overall and preventable ED visits, while those who selected the Enhanced plan experienced a slight reduction in preventable ED visits; the net effect was an increase in ED visits, as most individuals enrolled in the Basic plan. © Health Research and Educational Trust.

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

... conducting required surveys; capacity to furnish information for use in enforcement activities; monitoring... are at 42 CFR part 489 and those pertaining to activities relating to the survey and certification of... facilities. ++ The Joint Commission's processes and procedures for monitoring an HHA found out of compliance...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-22

... pertaining to activities relating to the survey and certification of facilities are at 42 CFR part 488. The...; resources for conducting required surveys; capacity to furnish information for use in enforcement activities; monitoring procedures for provider entities found not in compliance with the conditions or requirements; and...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-22

... information for use in enforcement activities; monitoring procedures for provider entities found not in... pertaining to activities relating to the survey and certification of facilities are located at 42 CFR part...'s processes and procedures for monitoring a hospital that is out of compliance with AOA/HFAP's...

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

... information for use in enforcement activities; monitoring procedures for provider entities found not in... those pertaining to activities relating to the survey and certification of facilities are at 42 CFR part... Commission's processes and procedures for monitoring psychiatric hospitals found out of compliance with the...

78 FR 12325 - Medicare and Medicaid Programs; Application From the Center for Improvement in Healthcare Quality...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-02-22

... use in enforcement activities; monitoring procedures for provider entities found not in compliance... located at 42 CFR part 489 and those pertaining to activities relating to the survey and certification of... accredited facilities. ++ CIHQ's processes and procedures for monitoring a hospital that is out of compliance...

42 CFR Appendix to Subpart F of... - Required Consent Form

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Required Consent Form Appendix to Subpart F of Part 441 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Sterilizations Pt. 441, Subpt. F, App....

42 CFR Appendix to Subpart F of... - Required Consent Form

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Required Consent Form Appendix to Subpart F of Part 441 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Sterilizations Pt. 441, Subpt. F, App....

42 CFR Appendix to Subpart F of... - Required Consent Form

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Required Consent Form Appendix to Subpart F of Part 441 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Sterilizations Pt. 441, Subpt. F, App....

42 CFR Appendix to Subpart F of... - Required Consent Form

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Required Consent Form Appendix to Subpart F of Part 441 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Sterilizations Pt. 441, Subpt. F, App....

42 CFR Appendix to Subpart F of... - Required Consent Form

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 4 2013-10-01 2013-10-01 false Required Consent Form Appendix to Subpart F of Part 441 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES Sterilizations Pt. 441, Subpt. F, App....

42 CFR 431.210 - Content of notice.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Content of notice. 431.210 Section 431.210 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STATE ORGANIZATION AND GENERAL ADMINISTRATION Fair Hearings for Applicants and Beneficiaries Notice § 431.210 Content of...

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

... continued recognition as a national accrediting organization for hospitals that wish to participate in the... effective September 26, 2012, through September 26, 2018. DATES: This final notice is effective September 26... accreditation by an approved national accrediting organization (AO) that all applicable Medicare conditions are...

42 CFR 440.220 - Required services for the medically needy.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Required services for the medically needy. 440.220 Section 440.220 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: GENERAL PROVISIONS Requirements and Limits Applicable to All Services § 440.220 Require...

42 CFR 441.11 - Continuation of FFP for institutional services.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Continuation of FFP for institutional services. 441.11 Section 441.11 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES General Provisions § 441.11...

42 CFR 440.220 - Required services for the medically needy.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Required services for the medically needy. 440.220 Section 440.220 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: GENERAL PROVISIONS Requirements and Limits Applicable to All Services § 440.220 Require...

42 CFR 441.11 - Continuation of FFP for institutional services.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Continuation of FFP for institutional services. 441.11 Section 441.11 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES General Provisions § 441.11...

42 CFR 441.11 - Continuation of FFP for institutional services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Continuation of FFP for institutional services. 441.11 Section 441.11 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES General Provisions § 441.11...

42 CFR 440.220 - Required services for the medically needy.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Required services for the medically needy. 440.220 Section 440.220 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: GENERAL PROVISIONS Requirements and Limits Applicable to All Services § 440.220 Require...

42 CFR 440.220 - Required services for the medically needy.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Required services for the medically needy. 440.220 Section 440.220 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: GENERAL PROVISIONS Requirements and Limits Applicable to All Services § 440.220 Require...

42 CFR 440.220 - Required services for the medically needy.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 4 2013-10-01 2013-10-01 false Required services for the medically needy. 440.220 Section 440.220 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS SERVICES: GENERAL PROVISIONS Requirements and Limits Applicable to All Services § 440.220 Require...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-28

...) survey review and decision-making process for accreditation. The comparison of AOA/HFAP's accreditation... September 25, 2013. II. Application Approval Process Section 1865(a)(3)(A) of the Act provides a statutory... survey process to: ++ Determine the composition of the survey team, surveyor qualifications, and AOA/HFAP...

42 CFR 457.350 - Eligibility screening and enrollment in other insurance affordability programs.

Code of Federal Regulations, 2013 CFR

2013-10-01

... CHIP coverage under the plan; and (2) Enrollment is facilitated for applicants and enrollees found to... information to determine CHIP eligibility, or whose eligibility is being renewed under a change in... CHIP, but who is potentially eligible for: (1) Medicaid on the basis of having household income at or...

42 CFR 457.350 - Eligibility screening and enrollment in other insurance affordability programs.

Code of Federal Regulations, 2014 CFR

2014-10-01

... CHIP coverage under the plan; and (2) Enrollment is facilitated for applicants and enrollees found to... information to determine CHIP eligibility, or whose eligibility is being renewed under a change in... CHIP, but who is potentially eligible for: (1) Medicaid on the basis of having household income at or...

42 CFR 406.7 - Forms to apply for entitlement under Medicare Part A.

Code of Federal Regulations, 2010 CFR

2010-10-01

... supplementary medical insurance program.) CMS-43—Application for Health Insurance Benefits under Medicare for... 42 Public Health 2 2010-10-01 2010-10-01 false Forms to apply for entitlement under Medicare Part A. 406.7 Section 406.7 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH...

76 FR 56712 - CLIA Program and HIPAA Privacy Rule; Patients' Access to Test Reports

Federal Register 2010, 2011, 2012, 2013, 2014

2011-09-14

...; Patients' Access to Test Reports AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS; Centers for...) regulations to specify that, upon a patient's request, the laboratory may provide access to completed test... provide for release of test reports to authorized persons and, if applicable, the individuals (or their...

Designing and Operating Cost-Effective Medicaid Non-Emergency Transportation Programs; A Guidebook for State Medicaid Agencies

DOT National Transportation Integrated Search

1998-08-01

Millions of Americans depend on Medicaid-funded transportation to reach medical appointments. In rural areas where medical providers are often in short supply, communities are far from primary care physicians or specialists, and public transportation...

45 CFR 155.545 - Appeal decisions.

Code of Federal Regulations, 2014 CFR

2014-10-01

..., and if the Medicaid or CHIP agencies delegate authority to conduct the Medicaid fair hearing or CHIP... the Exchange or the Medicaid or CHIP agency, as applicable. (c) Implementation of appeal decisions...

45 CFR 155.545 - Appeal decisions.

Code of Federal Regulations, 2013 CFR

2013-10-01

..., and if the Medicaid or CHIP agencies delegate authority to conduct the Medicaid fair hearing or CHIP... the Exchange or the Medicaid or CHIP agency, as applicable. (c) Implementation of appeal decisions...

Medicaid Home Care Services and Survival in New York City

ERIC Educational Resources Information Center

Albert, Steven M.; Simone, Bridget; Brassard, Andrea; Stern, Yaakov; Mayeux, Richard

2005-01-01

Purpose: New York City's Medicaid Home Care Services Program provides an integrated program of housekeeping and personal assistance care along with regular nursing assessments. We sought to determine if this program of supportive care offers a survival benefit to older adults. Design and Methods: Administrative data from New York City's Medicaid…

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

... SOCIAL SECURITY ADMINISTRATION [Docket No. SSA 2012-0015] Privacy Act of 1974, as Amended; Computer Matching Program (SSA/ Centers for Medicare and Medicaid Services (CMS))--Match Number 1094 AGENCY: Social Security Administration (SSA). ACTION: Notice of a new computer matching program that will expire...

75 FR 48815 - Medicaid Program and Children's Health Insurance Program (CHIP); Revisions to the Medicaid...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-11

... size may be reduced by the finite population correction factor. The finite population correction is a statistical formula utilized to determine sample size where the population is considered finite rather than... program may notify us and the annual sample size will be reduced by the finite population correction...

42 CFR 420.204 - Principals convicted of a program-related crime.

Code of Federal Regulations, 2010 CFR

2010-10-01

... the identity of any person who: (1) Has an ownership or control interest in the provider or part B... to involvement in the Medicare, Medicaid, title V or title XX social services program, since the... Medicare, Medicaid, title V or title XX social services programs. In making this decision, CMS considers...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-12-27

... information on this effort can be found at: http://www.bt.cdc.gov/cri/ . An evaluative report of this program...' emergency plans are designed primarily to shelter in place. The GAO also found that administrators...

42 CFR 430.88 - Evidence.

Code of Federal Regulations, 2010 CFR

2010-10-01

... CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS Hearings on Conformity of State Medicaid Plans and Practice to Federal Requirements § 430.88 Evidence. (a) Evidentiary purpose. The hearing is...

Length of Stay and Inpatient Costs Under Medicaid Managed Care in Florida.

PubMed

Park, Jungwon

2015-01-01

This study examines the patterns of length of stay (LOS) and inpatient costs for both Medicaid managed care and nonmanaged care patients using data from Medicaid patients aged 18 to 64 years who were discharged from hospitals in Florida between 2006 and 2012. This study used pooled cross-sectional multilevel modeling. The results show that the type of Medicaid program in which patients were enrolled was significantly related to the hospital LOS and inpatient costs. Medicaid managed care patients had 7% shorter LOSs and a 1.9% lower inpatient cost than did Medicaid fee-for-service (FFS) patients. Medicaid managed care patients had shorter LOSs in the Medicaid managed care market with high competition. High managed care penetration generates a cost-decreasing spillover to Medicaid FFS patients. © The Author(s) 2015.

42 CFR 495.304 - Medicaid provider scope and eligibility.

Code of Federal Regulations, 2012 CFR

2012-10-01

... SERVICES (CONTINUED) STANDARDS AND CERTIFICATION STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY... incentives program: (1) Medicaid EPs. (2) Acute care hospitals. (3) Children's hospitals. (b) Medicaid EP... patient volume for each year for which the hospital seeks an EHR incentive payment. (2) A children's...

42 CFR 495.304 - Medicaid provider scope and eligibility.

Code of Federal Regulations, 2013 CFR

2013-10-01

... SERVICES (CONTINUED) STANDARDS AND CERTIFICATION STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY... incentives program: (1) Medicaid EPs. (2) Acute care hospitals. (3) Children's hospitals. (b) Medicaid EP... patient volume for each year for which the hospital seeks an EHR incentive payment. (2) A children's...

42 CFR 495.304 - Medicaid provider scope and eligibility.

Code of Federal Regulations, 2014 CFR

2014-10-01

... SERVICES (CONTINUED) STANDARDS AND CERTIFICATION STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY... incentives program: (1) Medicaid EPs. (2) Acute care hospitals. (3) Children's hospitals. (b) Medicaid EP... patient volume for each year for which the hospital seeks an EHR incentive payment. (2) A children's...

42 CFR 495.304 - Medicaid provider scope and eligibility.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES (CONTINUED) STANDARDS AND CERTIFICATION STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY... incentives program: (1) Medicaid EPs. (2) Acute care hospitals. (3) Children's hospitals. (b) Medicaid EP... each year for which the hospital seeks an EHR incentive payment. (2) A children's hospital is exempt...

42 CFR 495.304 - Medicaid provider scope and eligibility.

Code of Federal Regulations, 2011 CFR

2011-10-01

... SERVICES (CONTINUED) STANDARDS AND CERTIFICATION STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY... incentives program: (1) Medicaid EPs. (2) Acute care hospitals. (3) Children's hospitals. (b) Medicaid EP... each year for which the hospital seeks an EHR incentive payment. (2) A children's hospital is exempt...

Medicaid program; elimination of reimbursement under Medicaid for school administration expenditures and costs related to transportation of school-age children between home and school. Final rule.

PubMed

2007-12-28

Under the Medicaid program, Federal payment is available for the costs of administrative activities "as found necessary by the Secretary for the proper and efficient administration of the State plan." This final rule eliminates Federal Medicaid payment for the costs of certain school-based administrative and transportation activities because the Secretary has found that these activities are not necessary for the proper and efficient administration of the Medicaid State plan and are not within the definition of the optional transportation benefit. Based on these determinations, under this final rule, Federal Medicaid payments will no longer be available for administrative activities performed by school employees or contractors, or anyone under the control of a public or private educational institution, and for transportation from home to school. In addition, this final rule responds to public comments received on the September 7, 2007 proposed rule.

Consumer-directed models of personal care: lessons from Medicaid.

PubMed

Doty, P; Kasper, J; Litvak, S

1996-01-01

"Consumer-directed" models of financing and services delivery are compared with models that emphasize professional control and accountability within the context of Medicaid-financed personal care services (PCS). The Medicaid PCS benefit finances aide or attendant services for low-income persons with functional disabilities to assist them with daily living tasks. Consumer-directed modes of service provision permit service recipients themselves to have greater choice and control over all aspects of service provision. Client surveys in three states found that clients were most satisfied with the program elements of Medicaid PCS services that gave them more choice and control. Case studies of how Medicaid PCS programs in particular states are administered indicate that the use of aides who are independent providers, unattached to a home health or home care agency, is a critical aspect of consumer direction. By itself, however, this factor does not guarantee consumer direction because other Medicaid PCS rules and regulations may restrict client choice and control.

A canary in the coal mine: documenting citizenship and identity in the State of Massachusetts.

PubMed

Kwong, Richard M; Miller, Edward Alan

2010-06-01

The U.S. federal government requires original documentation of citizenship and identity for applicants to qualify for coverage under Medicaid. The purpose of this investigation is to identify what challenges one state Medicaid agency has faced when implementing this requirement; and to identify what strategies this agency and other interested parties (e.g., providers, community advocates) adopted to help overcome them. The setting for this study is MassHealth, the Medicaid agency for the State of Massachusetts. Data derive from archival documents, direct observation, and in-depth interviews with key stakeholders, including state officials, provider agencies, community health centers, and beneficiary advocates. While MassHealth has met several of the implementation benchmarks put forth in federal regulations and guidance letters, the agency has fallen short in several respects. This includes assisting applicants seeking to enroll in MassHealth and maintaining a seamless documentation submission process. The result has been an increase in application processing time and misinterpretations in the MassHealth community; for example, that legal immigrants should not apply for coverage even though the new requirement does not affect them. Assuming a prominent role in informing and assisting MassHealth applicants has been providers and community-based organizations. Consumer advocacy groups have also worked to streamline the process for demonstrating citizenship and identity. Synergies have been formed between MassHealth and these other organizations as well. Findings suggest a number of lessons for state Medicaid agencies wishing to address the challenges posed by federal requirements to demonstrate citizenship and identity. These include working to ensure the readability, comprehension and non-English translation of materials provided to program applicants. It also includes strengthening the document handling process and forming partnerships with providers, beneficiary advocates, and other community organizations. Copyright (c) 2009 Elsevier Ireland Ltd. All rights reserved.

The effect of Medicaid adult vision coverage on the likelihood of appropriate correction of distance vision: Evidence from the National Health and Nutrition Examination Survey.

PubMed

Lipton, Brandy J; Decker, Sandra L

2016-02-01

Medicaid is the main public health insurance program for individuals with low income in the United States. Some state Medicaid programs cover preventive eye care services and vision correction, while others cover emergency eye care only. Similar to other optional benefits, states may add and drop adult vision benefits over time. This article examines whether providing adult vision benefits is associated with an increase in the percentage of low-income individuals with appropriately corrected distance vision as measured during an eye exam. We estimate the effect of Medicaid vision coverage on the likelihood of having appropriately corrected distance vision using examination data from the 2001-2008 National Health and Nutrition Examination Survey. We compare vision outcomes for Medicaid beneficiaries (n = 712) and other low income adults not enrolled in Medicaid (n = 4786) before and after changes to state vision coverage policies. Between 29 and 33 states provided Medicaid adult vision benefits during 2001-2008, depending on the year. Our findings imply that Medicaid adult vision coverage is associated with a significant increase in the percentage of Medicaid beneficiaries with appropriately corrected distance vision of up to 10 percentage points. Providing vision coverage to adults on Medicaid significantly increases the likelihood of appropriate correction of distance vision. Further research on the impact of vision coverage on related functional outcomes and the effects of Medicaid coverage of other services may be appropriate. Copyright © 2015 Elsevier Ltd. All rights reserved.

76 FR 18766 - Early Retiree Reinsurance Program

Federal Register 2010, 2011, 2012, 2013, 2014

2011-04-05

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-9996-N] Early Retiree Reinsurance Program AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice announces that CMS is exercising its authority under section 1102(f) of the...

Single women and the dynamics of Medicaid.

PubMed Central

Short, P F; Freedman, V A

1998-01-01

OBJECTIVE: To investigate transitions in and out of Medicaid for a cohort of single adult women of childbearing age in order to address questions that arise as policymakers try to encourage transitions from welfare to work. DATA SOURCES: Longitudinal data from Waves 2 through 8 of the 1990 panel of the Survey of Income and Program Participation, a nationally representative survey of American adults covering May 1990-1992. STUDY DESIGN: We estimate a series of discrete-time logit models with duration dependence to obtain transition probabilities among Medicaid, privately insured, and uninsured spells. Explanatory variables in the models include prior insurance history, income limits on Medicaid by state, and important socioeconomic and demographic characteristics. We use these models to characterize insurance spells for a cohort of single women. PRINCIPAL FINDINGS: Most Medicaid spells are relatively short. Over half end in a year or less; only one spell out of seven lasts longer than five years. Two-thirds of Medicaid disenrollees become uninsured. Former welfare recipients are prone to frequent changes in insurance status. In states with more generous income limits for AFDC, women stay on Medicaid longer, but they do not move into the program at a faster rate. CONCLUSIONS: Imposing time limits on Medicaid eligibility would affect only a small proportion of Medicaid spells but would eliminate a significant proportion of the caseload at a point in time. In considering changes in Medicaid that would encourage transitions from welfare to work and would alter the dynamics of Medicaid, policymakers need to consider how transitions both in and out of private insurance and Medicaid would be affected. Images Figure 2 Figure 3 Figure 4 PMID:9865222

Racial Disparities in Orthodontic Service Utilization for Medicaid-Enrolled Children: An Evaluation of the Washington Medicaid Program

PubMed Central

Merritt, Jantraveus M.; Greenlee, Geoffrey; Bollen, Anne Marie; Scott, JoAnna M.; Chi, Donald L.

2016-01-01

Introduction We assess the relationship between race and orthodontic service utilization for Medicaid-enrolled children. Methods This cross-sectional study focused on 570,364 Washington Medicaid-enrolled children ages 6-19 years. The main predictor variable was self-reported race (White versus non-White). The outcome variable was orthodontic service utilization, defined as children who were pre-authorized for orthodontic treatment by Medicaid in 2012 and subsequently received orthodontic records and initiated treatment. Logistic regression models were used to test the hypothesis that non-Whites would be less likely to utilize orthodontic care than Whites. Results A total of 8,223 children were approved by Medicaid for orthodontic treatment and 7,313 received records and initiated treatment. Non-Whites were significantly more likely to utilize orthodontic care than Whites (Odds Ratio [OR]=1.18; 95% confidence interval [CI]=1.02, 1.36; p=.031). Hispanic non-White children were more likely to utilize orthodontic care than non-Hispanic White children (OR=1.42; 95% CI=1.18, 1.70; p<.001). Conclusion In 2012, non-White children in Washington Medicaid were significantly more likely to utilize orthodontic care than White children. The Washington Medicaid program demonstrates a potential model for addressing racial disparities in orthodontic service utilization. Future research should identify mechanisms underlying these findings and continue to monitor orthodontic service utilization for minority children in Medicaid. PMID:27021456

76 FR 28196 - Medicare and Medicaid Programs; Opportunities for Alignment Under Medicaid and Medicare

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-16

... nation's health care expenditures in 2006.\\7\\ Furthermore, dual eligibles account for a..., Federal Coordinated Health Care Office, at (410) 786-8911 or [email protected] . SUPPLEMENTARY... Coordinated Health Care Office (``Medicare-Medicaid Coordination Office'') and charged the new office with...

42 CFR 456.22 - Sample basis evaluation of services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 456.22 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: All Medicaid Services § 456... available services and facilities the Medicaid agency must have procedures for the on-going evaluation, on a...

A Guide to Screening for the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) Under Medicaid.

ERIC Educational Resources Information Center

Frankenburg, William K.; North, A. Frederick, Jr.

The manual was designed to help public officials, physicians, nurses, and others to plan and implement an Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program under Medicaid. Procedures for carrying out components of an EPSDT program are recommended. Part 1 discusses organization and administration of screening, diagnosis, and…

75 FR 30046 - Medicaid and CHIP Programs; Meeting of the CHIP Working Group-June 14, 2010

Federal Register 2010, 2011, 2012, 2013, 2014

2010-05-28

... specified under section 311(b)(1)(C) of the Children's Health Insurance Program Reauthorization Act of 2009... Secretary of Labor are required under section 311(b)(1)(C) of the Children's Health Insurance Program... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-2316-N...

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

... Savings Program and the Innovation Center AGENCY: Centers for Medicare & Medicaid Services (CMS) and...) of the Social Security Act (of the Act), as added by the Affordable Care Act (ACA) authorizes the... payment and service delivery models by the Center for Medicare and Medicaid Innovation. This notice with...

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

... to qualify to participate as a skilled nursing facility (SNF) in the Medicare program, or as a nursing facility (NF) in the Medicaid program. We are proposing these requirements to ensure that long... According to CMS data, at any point in time, approximately 1.4 million elderly and disabled nursing home...

Medicaid Program; Mechanized Claims Processing and Information Retrieval Systems (90/10). Final rule.

PubMed

2015-12-04

This final rule will extend enhanced funding for Medicaid eligibility systems as part of a state's mechanized claims processing system, and will update conditions and standards for such systems, including adding to and updating current Medicaid Management Information Systems (MMIS) conditions and standards. These changes will allow states to improve customer service and support the dynamic nature of Medicaid eligibility, enrollment, and delivery systems.

Unforeseen consequences: Medicaid and the funding of nonprofit service organizations.

PubMed

Allard, Scott W; Smith, Steven Rathgeb

2014-12-01

Medicaid reimbursements have become a key source of funding for nonprofit social service organizations operating outside the medical care sector, as well as an important tool for states seeking resources to fund social service programs within a devolving safety net. Drawing on unique survey data of more than one thousand nonprofit social service agencies in seven urban and rural communities, this article examines Medicaid funding of nonprofit social service organizations that target programs at working-age, nondisabled adults. We find that about one-quarter of nonprofit service organizations--mostly providers offering substance abuse and mental health treatment in conjunction with other services--report receiving Medicaid reimbursements, although very few are overly reliant on these funds. We also find Medicaid-funded social service nonprofits to be less accessible to residents of high-poverty neighborhoods or areas with concentrations of black or Hispanic residents than to residents of more affluent and white communities. We should expect that the role of Medicaid within the nonprofit social service sector will shift in the next few years, however, as states grapple with persistent budgetary pressures, rising Medicaid costs, and decisions to participate in the Medicaid expansion provisions contained within the 2010 Patient Protection and Affordable Care Act. Copyright © 2014 by Duke University Press.

The impact of citizenship documentation requirements on access to Medicaid for pregnant women in Oregon

PubMed Central

Bauer, Joanna; Angus, Lisa; Fischler, Nurit; Rosenberg, Kenneth D.; Gipson, Teresa F.; DeVoe, Jennifer E.

2012-01-01

Objectives The federal Deficit Reduction Act of 2005 mandated citizenship documentation from all Medicaid applicants as a condition of eligibility and was implemented in Oregon on September 1, 2006. We assessed whether new citizenship documentation requirements were associated with delays in Medicaid authorization for newly pregnant eligible applicants during the first nine months of DRA implementation in Oregon. Methods We conducted a pre-post analysis of administrative records to compare the length of time between Medicaid application and authorization for all newly pregnant, Medicaid-eligible applicants in Oregon (n= 29,284), nine months before and after September 1, 2006. We compared mean days from application to authorization (McNemar’s), and proportion of eligible applicants who waited over 7, 30 and 45 days to be authorized (Peason’s coefficient). Results The mean number of days women waited for authorization increased from 18 days in the nine months before DRA implementation to 22.6 days in the post-implementation nine month period (p=<0.001). The proportion of eligible applicants who waited 7, 30 and 45 days increased significantly following DRA implementation (p=<0.001). The proportion of eligible applicants who were not authorized within the standard 45-day period increased from 6.9% to 12.5% following the DRA. Conclusions Implementation of new citizenship documentation requirements was associated with significant delays in Medicaid authorization for eligible pregnant women in Oregon. Such delays in gaining insurance coverage can detrimentally affect access to early prenatal care initiation among a vulnerable population known to be at higher risk for certain preventable pregnancy-related complications. PMID:20602160

42 CFR 460.68 - Program integrity.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Program integrity. 460.68 Section 460.68 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED... of criminal offenses related to their involvement in Medicaid, Medicare, other health insurance or...

42 CFR 460.68 - Program integrity.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Program integrity. 460.68 Section 460.68 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED... of criminal offenses related to their involvement in Medicaid, Medicare, other health insurance or...

42 CFR 460.68 - Program integrity.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Program integrity. 460.68 Section 460.68 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED... of criminal offenses related to their involvement in Medicaid, Medicare, other health insurance or...

42 CFR 460.68 - Program integrity.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 4 2013-10-01 2013-10-01 false Program integrity. 460.68 Section 460.68 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED... of criminal offenses related to their involvement in Medicaid, Medicare, other health insurance or...

42 CFR 460.68 - Program integrity.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Program integrity. 460.68 Section 460.68 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED... of criminal offenses related to their involvement in Medicaid, Medicare, other health insurance or...

Examining the potential of information technology to improve public insurance application processes: enrollee assessments from a concurrent mixed method analysis.

PubMed

Mishra, Abhay Nath; Ketsche, Patricia; Marton, James; Snyder, Angela; McLaren, Susan

2014-01-01

To assess the perceived readiness of Medicaid and Children's Health Insurance Program (CHIP) enrollees to use information technologies (IT) in order to facilitate improvements in the application processes for these public insurance programs. We conducted a concurrent mixed method study of Medicaid and CHIP enrollees in a southern state. We conducted focus groups to identify enrollee concerns regarding the current application process and their IT proficiency. Additionally, we surveyed beneficiaries via telephone about their access to and use of the Internet, and willingness to adopt IT-enabled processes. 2013 households completed the survey. We used χ(2) analysis for comparisons across different groups of respondents. A majority of enrollees will embrace IT-enabled enrollment, but a small yet significant group continues to lack access to facilitating technologies. Moreover, a segment of beneficiaries in the two programs continues to place a high value on personal interactions with program caseworkers. IT holds the promise of improving efficiency and reducing barriers for enrollees, but state and federal agencies managing public insurance programs need to ensure access to traditional processes and make caseworkers available to those who require and value such assistance, even after implementing IT-enabled processes. The use of IT-enabled processes is essential for effectively managing eligibility and enrollment determinations for public programs and private plans offered through state or federally operated exchanges. However, state and federal officials should be cognizant of the technological readiness of recipients and provide offline help to ensure broad participation in the insurance market. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

The effect of Medicaid premiums on enrollment: a regression discontinuity approach.

PubMed

Dague, Laura

2014-09-01

This paper estimates the effect that premiums in Medicaid have on the length of enrollment of program beneficiaries. Whether and how low income-families will participate in the exchanges and in states' Medicaid programs depends crucially on the structure and amounts of the premiums they will face. I take advantage of discontinuities in the structure of Wisconsin's Medicaid program to identify the effects of premiums on enrollment for low-income families. I use a 3-year administrative panel of enrollment data to estimate these effects. I find an increase in the premium from 0 to 10 dollars per month results in 1.4 fewer months enrolled and reduces the probability of remaining enrolled for a full year by 12 percentage points, but other discrete changes in premium amounts do not affect enrollment or have a much smaller effect. I find no evidence of program enrollees intentionally decreasing labor supply in order to avoid the premiums. Copyright © 2014 Elsevier B.V. All rights reserved.

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

PubMed

Howard, Larry L

2014-09-01

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

Poor program's progress: the unanticipated politics of Medicaid policy.

PubMed

Brown, Lawrence D; Sparer, Michael S

2003-01-01

Advocates of U.S. national health insurance tend to share an image that highlights universal standards of coverage, social insurance financing, and national administration--in short, the basic features of Medicare. Such an approach is said to be good (equitable and efficient) policy and equally good politics. Medicaid, by contrast, is often taken to exemplify poor policy and poorer politics: means-tested eligibility, general revenue financing, and federal/state administration, which encourage inequities and disparities of care. This stark juxtaposition fails, however, to address important counterintuitive elements in the political evolution of these programs. Medicare's benefits and beneficiaries have stayed disturbingly stable, but Medicaid's relatively broad benefits have held firm, and its categories of beneficiaries have expanded. Repeated alarms about "bankruptcy" have undermined confidence in Medicare's trust funding, while Medicaid's claims on the taxpayer's dollar have worn well. Medicare's national administration has avoided disparities, but at the price of sacrificing state and local flexibility that can ease such "reforms" as the introduction of managed care. That Medicaid has fared better than a "poor people's program" supposedly could has provocative implications for health reform debates.

A "Cap" on Medicaid: How Block Grants, Per Capita Caps, and Capped Allotments Might Fundamentally Change the Safety Net.

PubMed

Mager-Mardeusz, Haleigh; Lenz, Cosima; Kominski, Gerald F

2017-04-01

Changing the Medicaid program is a top priority for the Republican party. Common themes from GOP proposals include converting Medicaid from a jointly financed entitlement benefit to a form of capped federal financing. While proponents of this reform argue that it would provide greater flexibility and a more predictable budget for state governments, serious consequences would likely result for Medicaid enrollees and state governments. Under all three scenarios promoted by Republicans--block grants, capped allotments, and per capita caps—most states would face increased costs. For all three scenarios, the capped nature of the funding guarantees that the real value of funds would decrease in future years relative to what would be expected from growth under the current program. Although the federal government would undoubtedly realize savings from all three scenarios, the impact might lead states to reduce benefits and services, create waiting lists, impose cost-sharing on a traditionally low-income enrollee population, or impose other obstacles to coverage. Nationally, as many as 20.5 million Americans stand to lose coverage under the proposed Medicaid changes. In California, up to 6 million people could lose coverage if changes to the Medicaid program were coupled with the repeal of coverage for the expansion population.

Medicaid: taking stock.

PubMed

Davidson, S M

1993-01-01

In the last few years, Medicaid has attracted more than casual attention, one reflection of which is the fact that JHPPL has published five papers on the program in its last few issues. This paper, a sixth, takes a broader view of the program than is typically the case. After a critique of the five recent articles, I discuss several questions raised by them and reach the following conclusions: First, the states do not invest enough in producing program data suitable for policy analysis and research. One lesson: Better data and analysis can help the states to avoid expensive mistakes. Second, those policy analyses that have been offered fail to give sufficient attention to the political dimension of policy. That is one reason why policy choices produce unexpected effects. Third, since Medicaid is a relatively small player in the vast medical care market, incentives adopted by Medicaid officials throughout the country rarely have the desired effects. Finally, as long as Medicaid remains the principal mechanism to provide access to health care for the poor, it must be made as efficient and effective as possible. Yet, for both political and economic reasons, Medicaid can never be what its original planners had hoped, the vehicle for providing the poor with reliable access to mainstream medical care.

42 CFR 456.171 - Medicaid agency review of need for admission.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Medicaid agency review of need for admission. 456.171 Section 456.171 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Mental...

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

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 482... Critical Access Hospital Conditions of Participation To Ensure Visitation Rights for All Patients AGENCY...) to ensure the visitation rights of all patients. Medicare- and Medicaid- participating hospitals and...

42 CFR 1000.30 - Definitions specific to Medicaid.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 5 2014-10-01 2014-10-01 false Definitions specific to Medicaid. 1000.30 Section 1000.30 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES... Government's share of a State's expenditures under the Medicaid program. FMAP stands for the Federal medical...

42 CFR 400.203 - Definitions specific to Medicaid.

Code of Federal Regulations, 2011 CFR

2011-10-01

... program, any individual or entity that is engaged in the delivery of health care services and is legally... 42 Public Health 2 2011-10-01 2011-10-01 false Definitions specific to Medicaid. 400.203 Section 400.203 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN...

42 CFR 400.203 - Definitions specific to Medicaid.

Code of Federal Regulations, 2012 CFR

2012-10-01

... program, any individual or entity that is engaged in the delivery of health care services and is legally... 42 Public Health 2 2012-10-01 2012-10-01 false Definitions specific to Medicaid. 400.203 Section 400.203 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN...

42 CFR 400.203 - Definitions specific to Medicaid.

Code of Federal Regulations, 2010 CFR

2010-10-01

... program, any individual or entity that is engaged in the delivery of health care services and is legally... 42 Public Health 2 2010-10-01 2010-10-01 false Definitions specific to Medicaid. 400.203 Section 400.203 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN...

42 CFR 1000.30 - Definitions specific to Medicaid.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 5 2013-10-01 2013-10-01 false Definitions specific to Medicaid. 1000.30 Section 1000.30 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES... Government's share of a State's expenditures under the Medicaid program. FMAP stands for the Federal medical...

42 CFR 400.203 - Definitions specific to Medicaid.

Code of Federal Regulations, 2014 CFR

2014-10-01

... program, any individual or entity that is engaged in the delivery of health care services and is legally... 42 Public Health 2 2014-10-01 2014-10-01 false Definitions specific to Medicaid. 400.203 Section 400.203 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN...

42 CFR 1000.30 - Definitions specific to Medicaid.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 5 2012-10-01 2012-10-01 false Definitions specific to Medicaid. 1000.30 Section 1000.30 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES... Government's share of a State's expenditures under the Medicaid program. FMAP stands for the Federal medical...

42 CFR 1000.30 - Definitions specific to Medicaid.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false Definitions specific to Medicaid. 1000.30 Section 1000.30 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES... Government's share of a State's expenditures under the Medicaid program. FMAP stands for the Federal medical...

42 CFR 400.203 - Definitions specific to Medicaid.

Code of Federal Regulations, 2013 CFR

2013-10-01

... program, any individual or entity that is engaged in the delivery of health care services and is legally... 42 Public Health 2 2013-10-01 2013-10-01 false Definitions specific to Medicaid. 400.203 Section 400.203 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN...

42 CFR 1000.30 - Definitions specific to Medicaid.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 5 2011-10-01 2011-10-01 false Definitions specific to Medicaid. 1000.30 Section 1000.30 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES... Government's share of a State's expenditures under the Medicaid program. FMAP stands for the Federal medical...

42 CFR 405.377 - Withholding Medicare payments to recover Medicaid overpayments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Withholding Medicare payments to recover Medicaid overpayments. 405.377 Section 405.377 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED Suspension...

42 CFR 405.377 - Withholding Medicare payments to recover Medicaid overpayments.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 2 2011-10-01 2011-10-01 false Withholding Medicare payments to recover Medicaid overpayments. 405.377 Section 405.377 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED Suspension...

42 CFR 431.974 - Basic elements of Medicaid and CHIP eligibility reviews.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Basic elements of Medicaid and CHIP eligibility reviews. 431.974 Section 431.974 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STATE ORGANIZATION AND GENERAL...

42 CFR 431.974 - Basic elements of Medicaid and CHIP eligibility reviews.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Basic elements of Medicaid and CHIP eligibility reviews. 431.974 Section 431.974 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STATE ORGANIZATION AND GENERAL...

School-Based Mental Health Services under Medicaid Managed Care: Policy Report.

ERIC Educational Resources Information Center

Robinson, Gail K.; Barrett, Marihelen; Tunkelrott, Traci; Kim, John

This document reviews how schools and providers of school-based mental health programs have implemented managed care contracts with Medicaid managed care organizations. Observations were made at three sites (Albuquerque, NM; Baltimore, MD; New London, CT) where school-based mental health services were provided by Medicaid organizations. Following…

42 CFR 498.3 - Scope and applicability.

Code of Federal Regulations, 2014 CFR

2014-10-01

... PROGRAM AND FOR DETERMINATIONS THAT AFFECT THE PARTICIPATION OF ICFs/IID AND CERTAIN NFs IN THE MEDICAID..., subpart D—for nursing facilities (NFs). (ii) Part 488, subpart E (§ 488.330(e))—for SNFs and NFs. (iii) Part 488, subpart E (§ 488.330(e)) and subpart F (§ 488.446)—for SNFs and NFs and their administrators...

42 CFR 498.3 - Scope and applicability.

Code of Federal Regulations, 2012 CFR

2012-10-01

... PROGRAM AND FOR DETERMINATIONS THAT AFFECT THE PARTICIPATION OF ICFs/IID AND CERTAIN NFs IN THE MEDICAID..., subpart D—for nursing facilities (NFs). (ii) Part 488, subpart E (§ 488.330(e))—for SNFs and NFs. (ii) Part 488, subpart E (§ 488.330(e)) and subpart F (§ 488.446)—for SNFs and NFs and their administrators...

42 CFR 498.3 - Scope and applicability.

Code of Federal Regulations, 2013 CFR

2013-10-01

... PROGRAM AND FOR DETERMINATIONS THAT AFFECT THE PARTICIPATION OF ICFs/IID AND CERTAIN NFs IN THE MEDICAID..., subpart D—for nursing facilities (NFs). (ii) Part 488, subpart E (§ 488.330(e))—for SNFs and NFs. (iii) Part 488, subpart E (§ 488.330(e)) and subpart F (§ 488.446)—for SNFs and NFs and their administrators...

42 CFR 498.3 - Scope and applicability.

Code of Federal Regulations, 2011 CFR

2011-10-01

... PROGRAM AND FOR DETERMINATIONS THAT AFFECT THE PARTICIPATION OF ICFs/MR AND CERTAIN NFs IN THE MEDICAID..., subpart D—for nursing facilities (NFs). (ii) Part 488, subpart E (§ 488.330(e))—for SNFs and NFs. (ii) Part 488, subpart E (§ 488.330(e)) and subpart F (§ 488.446)—for SNFs and NFs and their administrators...

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

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare and Medicaid Services [CMS-2332-PN... Secretary of the Department of Health and Human Services publish a notice that identifies the national accrediting body making the request, describes the nature of the request, and provides at least a 30-day...

Medicare and Medicaid programs; rural hospitals: provision of long-term care services (swing-bed provision); flexibility in application of standards--Health Care Financing Administration. Interim final rule with comment period.

PubMed

1982-07-20

These regulations implement sections 904 and 949 of Pub. L. 96-499, the Omnibus Reconciliation Act of 1980. Under section 904 (the swing-bed provision), certain small, rural hospitals may use their inpatient facilities to furnish skilled nursing facility (SNF) services to Medicare and Medicaid beneficiaries, and intermediate care facility (ICF) services to Medicaid beneficiaries. These hospitals will be reimbursed at rates appropriate for those services, which are generally lower than hospital rates. This statutory provision is intended to encourage the most efficient and effective use of inpatient hospital beds for delivery of either hospital or SNF and ICF services. Under section 949, rural hospitals of 50 or fewer beds may be exempted from certain personnel standards in the conditions of participation for hospitals. This exemption applies only to the extent that it does not jeopardize or adversely affect the health and safety of patients.

How Will Repealing the ACA Affect Medicaid? Impact on Health Care Coverage, Delivery, and Payment.

PubMed

Rosenbaum, Sara; Rothenberg, Sara; Schmucker, Sara; Gunsalus, Rachel; Beckerman, J. Zoë

2017-03-01

ISSUE: The Affordable Care Act enhanced Medicaid's role as a health care purchaser by expanding eligibility and broadening the range of tools and strategies available to states. All states have embraced delivery and payment reform as basic elements of their programs. GOAL: To examine the effects of reducing the size and scope of Medicaid under legislation to repeal the ACA. FINDINGS AND CONCLUSIONS: Were the ACA's Medicaid expansion to be eliminated and were federal Medicaid funding to experience major reductions through block grants or per capita caps, the effects on system transformation would be significant. Over 70 percent of Medicaid spending is driven by enrollment in a program that covers 74 million people; on a per capita basis Medicaid costs less than Medicare or commercial insurance. States would need to absorb major financial losses by reducing the number of people served, reducing the scope of services covered, introducing higher cost-sharing, or further reducing already low payments. Far from improving quality and efficiency, these changes would cause the number of uninsured to rise while depriving health care providers and health plans of the resources needed to care for patients and invest in the tools that are essential to system transformation

Expanding Medicaid Access without Expanding Medicaid: Why Did Some Nonexpansion States Continue the Primary Care Fee Bump?

PubMed

Wilk, Adam S; Evans, Leigh C; Jones, David K

2018-02-01

Six states that have rejected the Patient Protection and Affordable Care Act's (ACA) Medicaid expansion nonetheless extended the primary care "fee bump," by which the federal government increased Medicaid fees for primary care services up to 100 percent of Medicare fees during 2013-14. We conducted semistructured interviews with leaders in five of these states, as well as in three comparison states, to examine why they would continue a provision of the ACA that moderately expands access at significant state expense while rejecting the expansion and its large federal match, focusing on relevant economic, political, and procedural factors. We found that fee bump extension proposals were more successful where they were dissociated from major national policy debates, actionable with the input of relatively few stakeholder entities, and well aligned with preexisting policy-making structures and decision trends. Republican proposals to cap or reduce federal funding for Medicaid, if enacted, would compel states to contain program costs. In this context, states' established decision-making processes for updating Medicaid fee schedules, which we elucidate in this study, may shape the future of the Medicaid program. Copyright © 2018 by Duke University Press 2018.

Medicaid program; state plan home and community-based services, 5-year period for waivers, provider payment reassignment, and home and community-based setting requirements for Community First Choice and home and community-based services (HCBS) waivers. Final rule.

PubMed

2014-01-16

This final rule amends the Medicaid regulations to define and describe state plan section 1915(i) home and community-based services (HCBS) under the Social Security Act (the Act) amended by the Affordable Care Act. This rule offers states new flexibilities in providing necessary and appropriate services to elderly and disabled populations. This rule describes Medicaid coverage of the optional state plan benefit to furnish home and community based-services and draw federal matching funds. This rule also provides for a 5-year duration for certain demonstration projects or waivers at the discretion of the Secretary, when they provide medical assistance for individuals dually eligible for Medicaid and Medicare benefits, includes payment reassignment provisions because state Medicaid programs often operate as the primary or only payer for the class of practitioners that includes HCBS providers, and amends Medicaid regulations to provide home and community-based setting requirements related to the Affordable Care Act for Community First Choice State plan option. This final rule also makes several important changes to the regulations implementing Medicaid 1915(c) HCBS waivers.

Medicaid Waivers Targeting Children With Autism Spectrum Disorder Reduce The Need For Parents To Stop Working.

PubMed

Leslie, Douglas L; Iskandarani, Khaled; Velott, Diana L; Stein, Bradley D; Mandell, David S; Agbese, Edeanya; Dick, Andrew W

2017-02-01

Several states have passed Medicaid home and community-based services waivers that expand eligibility criteria and available services for children with autism spectrum disorder. Although previous research has shown considerable variation in these waivers, little is known about the programs' impact on parents' workforce participation. We used nationally representative survey data combined with detailed information on state Medicaid waiver programs to determine the effects of waivers on whether parents of children with autism spectrum disorder had to stop working because of the child's condition. Increases in the Medicaid home and community-based services waiver cost limit and enrollment limit significantly reduced the likelihood that a parent had to stop working, although the results varied considerably by household income level. These findings suggest that the Medicaid waivers are effective policies to address the care-related needs of children with autism spectrum disorder. Project HOPE—The People-to-People Health Foundation, Inc.

Determinants of change in Medicaid pharmaceutical cost sharing: does evidence affect policy?

PubMed

Soumerai, S B; Ross-Degnan, D; Fortess, E E; Walser, B L

1997-01-01

Since 1980, many Medicaid programs have instituted, adjusted, or abolished pharmaceutical copayments or limitations on the number of prescriptions per patient (caps). Studies indicate that prescription caps can harm patients and increase Medicaid costs. However, because there is little information on how state policy makers select and evaluate such policies, in-depth telephone interviews were conducted with key informants in Medicaid programs that had recently made changes in cost-sharing policies. Among the barriers to evidence-based policy making were lack of political power, skills, and infrastructure; crisis-oriented decisions; compartmentalized budgeting; lack of advocates for disadvantaged patients; and the absence of timely research. Research was applied successfully when the interests of patient advocates and the drug industry were aligned and when Medicaid analysis were able to identify and communicate relevant research to policy makers at the time, or "teachable moment," that policy was being changed.

Efforts to reform medicaid in a time of fiscal stress: are we merely shuffling chairs on the deck of the titanic?

PubMed

McEldowney, Rene; Jenkins, Carol L

2005-01-01

With states facing their worst financial crisis since World War II, Medicaid programs across the nation are facing a period of significant stress. Medicaid expenditures are a major part of most states' budgets, which make them an important target when policy makers and legislators are faced with budget deficits. This study compares programs across states and identifies major reform trends being used by state officials as they try to balance the needs of their Medicaid recipients with the realities of budget shortfalls. Our research illustrates that the short-term view prevails: many states have relied heavily on one time funding sources, such as tobacco settlement monies in conjunction with traditional cost controlling mechanisms (e.g., freezing provider reimbursement rates, reducing program eligibility levels, requiring prior authorization for services) as their means of addressing the current crisis.

45 CFR 155.525 - Eligibility pending appeal.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Exchange or the Medicaid or CHIP agency, as applicable, must continue to consider the appellant eligible... as determined by the Medicaid or CHIP agency consistent with 42 CFR parts 435 and 457, as applicable...

45 CFR 155.525 - Eligibility pending appeal.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Exchange or the Medicaid or CHIP agency, as applicable, must continue to consider the appellant eligible... as determined by the Medicaid or CHIP agency consistent with 42 CFR parts 435 and 457, as applicable...

75 FR 46948 - Medicare Program; Listening Session Regarding Confidential Feedback Reports and the...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-04

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-1578-N] Medicare Program; Listening Session Regarding Confidential Feedback Reports and the Implementation of a Value-Based Payment Modifier for Physicians, September 24, 2010 AGENCY: Centers for Medicare & Medicaid...

75 FR 69082 - Federal Financial Participation in State Assistance Expenditures; Federal Matching Shares for...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-10

... Expenditures; Federal Matching Shares for Medicaid, the Children's Health Insurance Program, and Aid to Needy... assistance (Medicaid) and Children's Health Insurance Program (CHIP) expenditures, Temporary Assistance for... expenditures for most medical assistance and child health assistance, and assistance payments for certain...

Medicaid program; health care-related taxes. Final rule.

PubMed

2009-06-30

This rule finalizes our proposal to delay enforcement of certain clarifications regarding standards for determining hold harmless arrangements in the final rule entitled, "Medicaid Program; Health Care-Related Taxes" from the expiration of a Congressional moratorium on enforcement from July 1, 2009 to June 30, 2010.

42 CFR 430.12 - Submittal of State plans and plan amendments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... periodic reports on the Medicaid program, excluding periodic statistical, budget and fiscal reports. (iii... the Medicaid program. For changes related to advance directive requirements, amendments must be... concerning advance directives. (2) Prompt submittal of amendments is necessary— (i) So that CMS can determine...

ACE Inhibitor and ARB utilization and expenditures in the Medicaid fee-for-service program from 1991 to 2008.

PubMed

Bian, Boyang; Kelton, Christina M L; Guo, Jeff J; Wigle, Patricia R

2010-01-01

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are widely prescribed for the treatment of hypertension and heart failure, as well as for kidney disease prevention in patients with diabetes mellitus and the management of patients after myocardial infarction. To (a) describe ACE inhibitor and ARB utilization and spending in the Medicaid fee-for-service program from 1991 through 2008, and (b) estimate the potential cost savings for the collective Medicaid programs from a higher ratio of generic ACE inhibitor utilization. A retrospective, descriptive analysis was performed using the National Summary Files from the Medicaid State Drug Utilization Data, which are composed of pharmacy claims that are subject to federally mandated rebates from pharmaceutical manufacturers. For the years 1991-2008, quarterly claim counts and expenditures were calculated by summing data for individual ACE inhibitors and ARBs. Quarterly per-claim expenditure as a proxy for drug price was computed for all brand and generic drugs. Market shares were calculated based on the number of pharmacy claims and Medicaid expenditures. In the Medicaid fee-for-service program, ACE inhibitors accounted for 100% of the claims in the combined market for ACE inhibitors and ARBs in 1991, 80.6% in 2000, and 64.7% in 2008. The Medicaid expenditure per ACE inhibitor claim dropped from $37.24 in 1991 to $24.03 in 2008 when generics accounted for 92.5% of ACE inhibitor claims; after adjusting for inflation for the period from 1991 to 2008, the real price drop was 59.2%. Brand ACE inhibitors accounted for only 7.5% of the claims in 2008 for all ACE inhibitors but 32.1% of spending; excluding the effects of manufacturer rebates, Medicaid spending would have been reduced by $28.7 million (9%) in 2008 if all ACE inhibitor claims were generic. The average price per ACE inhibitor claim in 2008 was $24.03 ($17.64 per generic claim vs. $103.45 per brand claim) versus $81.98 per ARB claim. If the ACE inhibitor ratio had been 75% in 2008 rather than 64.7%, the Medicaid program would have saved approximately 13% or about $41.8 million, again excluding the effects of manufacturer rebates. If the ACE inhibitor ratio had been 90% in 2008, the cost savings for the combined Medicaid fee-forservice programs would have been about 33% or about $102.3 million. The total cost savings opportunity with 100% generic ACE inhibitor utilization in 2008 and an ACE inhibitor ratio of 75% was $75.1 million (24%) or $142.3M (46%) with a 90% ACE inhibitor ratio. Factors that affect Medicaid spending by contributing to increased utilization of ACE inhibitors and ARBs, such as the rising prevalence of hypertension, heart disease, and diabetes, can be offset by reduction in the average price attained through a higher proportion of ACE inhibitors and a higher percentage of generic versus brand ACE inhibitors.

The poverty-reducing effect of Medicaid.

PubMed

Sommers, Benjamin D; Oellerich, Donald

2013-09-01

Medicaid provides health insurance for 54 million Americans. Using the Census Bureau's Supplemental Poverty Measure (which subtracts out-of-pocket medical expenses from family resources), we estimated the impact of eliminating Medicaid. In our counterfactual, Medicaid beneficiaries would become uninsured or gain other insurance. Counterfactual medical expenditures were drawn stochastically from propensity-score-matched individuals without Medicaid. While this method captures the importance of risk protection, it likely underestimates Medicaid's impact due to unobserved differences between Medicaid and non-Medicaid individuals. Nonetheless, we find that Medicaid reduces out-of-pocket medical spending from $871 to $376 per beneficiary, and decreases poverty rates by 1.0% among children, 2.2% among disabled adults, and 0.7% among elderly individuals. When factoring in institutionalized populations, an additional 500,000 people were kept out of poverty. Overall, Medicaid kept at least 2.6 million-and as many as 3.4 million-out of poverty in 2010, making it the U.S.'s third largest anti-poverty program. Published by Elsevier B.V.

How Well Does Medicaid Work in Improving Access to Care?

PubMed Central

Long, Sharon K; Coughlin, Teresa; King, Jennifer

2005-01-01

Objective To provide an assessment of how well the Medicaid program is working at improving access to and use of health care for low-income mothers. Data Source/Study Setting The 1997 and 1999 National Survey of America's Families, with state and county information drawn from the Area Resource File and other sources. Study Design Estimate the effects of Medicaid on access and use relative to private coverage and being uninsured, using instrumental variables methods to control for selection into insurance status. Data Collection/Extraction Method This study combines data from 1997 and 1999 for mothers in families with incomes below 200 percent of the federal poverty level. Principal Findings We find that Medicaid beneficiaries' access and use are significantly better than those obtained by the uninsured. Analysis that controls for insurance selection shows that the benefits of having Medicaid coverage versus being uninsured are substantially larger than what is estimated when selection is not accounted for. Our results also indicate that Medicaid beneficiaries' access and use are comparable to that of the low-income privately insured. Once insurance selection is controlled for, access and use under Medicaid is not significantly different from access and use under private insurance. Without controls for insurance selection, access and use for Medicaid beneficiaries is found to be significantly worse than for the low-income privately insured. Conclusions Our results show that the Medicaid program improved access to care relative to uninsurance for low-income mothers, achieving access and use levels comparable to those of the privately insured. Our results also indicate that prior research, which generally has not controlled for selection into insurance coverage, has likely understated the gains of Medicaid relative to uninsurance and overstated the gains of private coverage relative to Medicaid. PMID:15663701

Managed care purchasing under SCHIP: a nationwide analysis of freestanding SCHIP contracts.

PubMed

Rosenbaum, S; Shaw, K; Sonosky, C

2001-12-01

This Policy Brief is the third in a series that examines the State Children's Health Insurance Program (SCHIP), in particular, those state programs that operate directly under the authority of Title XXI of the Social Security Act rather than as an expansion of Medicaid (or a Medicaid demonstration initiative). This series is designed to examine how states structure and administer insurance programs for low-income children when they elect to administer separate SCHIP plans that exist outside of the requirements and constraints of Medicaid. Understanding how states use their flexibility under "separate SCHIP programs" (as they are termed) has become an increasingly important policy question, in the face of heightened interest on the part of Governors, the Bush Administration, and others in comprehensive Medicaid reform. The first two policy briefs in this series analyzed the entitlement status of separately administered SCHIP programs, as well as issues related to coverage design and the definition of medical necessity. This Policy Brief provides the first nationwide overview of how separate SCHIP programs structure "freestanding" SCHIP managed care contracts, i.e., contracts that exist independently of a state's Medicaid managed care agreements. Fifteen such "freestanding" contracts existed as of Calendar Year 2000, and we report here on their general terms of coverage, access, and care coordination. A forthcoming related study will examine behavioral health care in freestanding SCHIP agreements. Following a brief background and discussion of research methods, we present our principal findings and discuss their implications.

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-02-18

... nursing facility (SNF) in the Medicare program, or a nursing facility (NF) in the Medicaid program. These..., as of April 2010, there are 15,713 long-term care (LTC) facilities (commonly referred to as nursing homes) in the U.S. LTC facilities are also referred to as skilled nursing facilities (SNFs) in the...

Iowa's Medicaid Expansion Promoted Healthy Behaviors But Was Challenging To Implement And Attracted Few Participants.

PubMed

Askelson, Natoshia M; Wright, Brad; Bentler, Suzanne; Momany, Elizabeth T; Damiano, Peter

2017-05-01

As part of Iowa's Medicaid expansion, the Healthy Behaviors Program was designed to provide members with incentives to complete specified healthy activities in return for waiving monthly premiums. We used claims data and interviews to document the first year (2014) of the program's implementation. Healthy activities completion rates did not exceed 17 percent. Interviews with members and clinic managers revealed low levels of awareness of the program's existence, deficits in knowledge about how the program works, and a variety of barriers to activity completion. Our findings suggest that the lack of knowledge hindered the state's ability to incentivize activities and that it subjected beneficiaries to premium expenses and potential disenrollment. These results should guide federal and state policy makers in devising more effective ways of educating Medicaid beneficiaries and providers about programs that incentivize responsibility for healthy behaviors. The results suggest that efforts by federal and state governments to reform Medicaid by shifting responsibility onto program members for healthy behaviors are unlikely to succeed, especially without careful thought and design of premiums, penalties, and incentives for participants. Project HOPE—The People-to-People Health Foundation, Inc.

Economic impact of a Medicaid population health management program.

PubMed

Rust, George; Strothers, Harry; Miller, William Johnson; McLaren, Susan; Moore, Barbara; Sambamoorthi, Usha

2011-10-01

A population health management program was implemented to assess growth in health care expenditures for the disabled segment of Georgia's Medicaid population before and during the first year of a population health outcomes management program, and to compare those expenditures with projected costs based on various cost inflation trend assumptions. A retrospective, nonexperimental approach was used to analyze claims data from Georgia Medicaid claims files for all program-eligible persons for each relevant time period (intent-to-treat basis). These included all non-Medicare, noninstitutionalized Medicaid aged-blind-disabled adults older than 18 years of age. Comparisons of health care expenditures and utilization were made between base year (2003-2004) and performance year one (2006-2007), and of the difference between actual expenditures incurred in the performance year vs. projected expenditures based on various cost inflation assumptions. Demographic characteristics and clinical complexity of the population (as measured by the Chronic Illness and Disability Payment System risk score) actually increased from baseline to implementation. Actual expenditures were less than projected expenditures using any relevant medical inflation assumption. Actual expenditures were less than projected expenditures by $9.82 million when using a conservative US general medical inflation rate, by $43.6 million using national Medicaid cost trends, and by $106 million using Georgia Medicaid's own cost projections for the non-dually eligible disabled segment of Medicaid enrollees. Quadratic growth curve modeling also demonstrated a lower rate of increase in total expenditures. The rate of increase in expenditures was lower over the first year of program implementation compared with baseline. Weighted utilization rates were also lower in high-cost categories, such as inpatient days, despite increases in the risk profile of the population. Varying levels of cost avoidance could be inferred from differences between actual and projected expenditures using each of the health-related inflation assumptions.

Economic Impact of a Medicaid Population Health Management Program

PubMed Central

Strothers, Harry; Miller, William Johnson; McLaren, Susan; Moore, Barbara; Sambamoorthi, Usha

2011-01-01

Abstract A population health management program was implemented to assess growth in health care expenditures for the disabled segment of Georgia's Medicaid population before and during the first year of a population health outcomes management program, and to compare those expenditures with projected costs based on various cost inflation trend assumptions. A retrospective, nonexperimental approach was used to analyze claims data from Georgia Medicaid claims files for all program-eligible persons for each relevant time period (intent-to-treat basis). These included all non-Medicare, noninstitutionalized Medicaid aged-blind-disabled adults older than 18 years of age. Comparisons of health care expenditures and utilization were made between base year (2003–2004) and performance year one (2006–2007), and of the difference between actual expenditures incurred in the performance year vs. projected expenditures based on various cost inflation assumptions. Demographic characteristics and clinical complexity of the population (as measured by the Chronic Illness and Disability Payment System risk score) actually increased from baseline to implementation. Actual expenditures were less than projected expenditures using any relevant medical inflation assumption. Actual expenditures were less than projected expenditures by $9.82 million when using a conservative US general medical inflation rate, by $43.6 million using national Medicaid cost trends, and by $106 million using Georgia Medicaid's own cost projections for the non-dually eligible disabled segment of Medicaid enrollees. Quadratic growth curve modeling also demonstrated a lower rate of increase in total expenditures. The rate of increase in expenditures was lower over the first year of program implementation compared with baseline. Weighted utilization rates were also lower in high-cost categories, such as inpatient days, despite increases in the risk profile of the population. Varying levels of cost avoidance could be inferred from differences between actual and projected expenditures using each of the health-related inflation assumptions. (Population Health Management 2011;14:215–222) PMID:21506728

State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Accessing Treatments - United States, 2015-2017.

PubMed

DiGiulio, Anne; Jump, Zach; Yu, Annie; Babb, Stephen; Schecter, Anna; Williams, Kisha-Ann S; Yembra, Debbie; Armour, Brian S

2018-04-06

Cigarette smoking prevalence among Medicaid enrollees (25.3%) is approximately twice that of privately insured Americans (11.8%), placing Medicaid enrollees at increased risk for smoking-related disease and death (1). Medicaid spends approximately $39 billion annually on treating smoking-related diseases (2). Individual, group, and telephone counseling and seven Food and Drug Administration (FDA)-approved medications* are effective in helping tobacco users quit (3). Although state Medicaid coverage of tobacco cessation treatments improved during 2014-2015, coverage was still limited in most states (4). To monitor recent changes in state Medicaid cessation coverage for traditional (i.e., nonexpansion) Medicaid enrollees, the American Lung Association collected data on coverage of a total of nine cessation treatments: individual counseling, group counseling, and seven FDA-approved cessation medications † in state Medicaid programs during July 1, 2015-June 30, 2017. The American Lung Association also collected data on seven barriers to accessing covered treatments, such as copayments and prior authorization. As of June 30, 2017, 10 states covered all nine of these treatments for all enrollees, up from nine states as of June 30, 2015; of these 10 states, Missouri was the only state to have removed all seven barriers to accessing these cessation treatments. State Medicaid programs that cover all evidence-based cessation treatments, remove barriers to accessing these treatments, and promote covered treatments to Medicaid enrollees and health care providers would be expected to reduce smoking, smoking-related disease, and smoking-attributable federal and state health care expenditures (5-7).

Medical Expenditures Associated With Diabetes Among Youth With Medicaid Coverage.

PubMed

Shrestha, Sundar S; Zhang, Ping; Thompson, Theodore J; Gregg, Edward W; Albright, Ann; Imperatore, Giuseppina

2017-07-01

Information on diabetes-related excess medical expenditures for youth is important to understand the magnitude of financial burden and to plan the health care resources needed for managing diabetes. However, diabetes-related excess medical expenditures for youth covered by Medicaid program have not been investigated recently. To estimate excess diabetes-related medical expenditures among youth aged below 20 years enrolled in Medicaid programs in the United States. We analyzed data from 2008 to 2012 MarketScan multistate Medicaid database for 6502 youths with diagnosed diabetes and 6502 propensity score matched youths without diabetes, enrolled in fee-for-service payment plans. We stratified analysis by Medicaid eligibility criteria (poverty or disability). We used 2-part regression models to estimate diabetes-related excess medical expenditures, adjusted for age, sex, race/ethnicity, year of claims, depression status, asthma status, and interaction terms. For poverty-based Medicaid enrollees, estimated annual diabetes-related total medical expenditure was $9046 per person [$3681 (no diabetes) vs. $12,727 (diabetes); P<0001], of which 41.7%, 34.0%, and 24.3% were accounted for by prescription drugs, outpatient, and inpatient care, respectively. For disability-based Medicaid enrollees, the estimated annual diabetes-related total medical expenditure was $9944 per person ($14,149 vs. $24,093; P<0001), of which 41.5% was accounted for by prescription drugs, 31.3% by inpatient, and 27.3% by outpatient care. The per capita annual diabetes-related medical expenditures in youth covered by publicly financed Medicaid programs are substantial, which is larger among those with disabilities than without disabilities. Identifying cost-effective ways of managing diabetes in this vulnerable segment of the youth population is needed.

42 CFR 495.354 - Rules for charging equipment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false Rules for charging equipment. 495.354 Section 495.354 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES... PROGRAM Requirements Specific to the Medicaid Program § 495.354 Rules for charging equipment. Equipment...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-26

... achieving better health for populations, better health care for individuals, and lower growth in expenditures through continuous improvement for Medicare, Medicaid, and Children's Health Insurance Program... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-5505-N3...

42 CFR 495.360 - Software and ownership rights.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false Software and ownership rights. 495.360 Section 495.360 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES... PROGRAM Requirements Specific to the Medicaid Program § 495.360 Software and ownership rights. (a) General...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-12-07

... Centers for Medicare & Medicaid Services 42 CFR Part 401 Medicare Program; Availability of Medicare Data...; Availability of Medicare Data for Performance Measurement AGENCY: Centers for Medicare & Medicaid Services (CMS... regarding the release and use of standardized extracts of Medicare claims data for qualified entities to...

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

... SOCIAL SECURITY ADMINISTRATION [Docket No. SSA 2013-0059] Privacy Act of 1974, as Amended; Computer Matching Program (SSA/ Centers for Medicare & Medicaid Services (CMS))--Match Number 1076 AGENCY: Social Security Administration (SSA). ACTION: Notice of a renewal of an existing computer matching...

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

... SOCIAL SECURITY ADMINISTRATION [Docket No. SSA 2011-0022] Privacy Act of 1974, as Amended; Computer Matching Program (SSA/ Centers for Medicare & Medicaid Services (CMS))--Match Number 1076 AGENCY: Social Security Administration (SSA). ACTION: Notice of a renewal of an existing computer matching...

76 FR 9283 - Medicaid Program; Payment Adjustment for Provider-Preventable Conditions Including Health Care...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-02-17

... under section 1903 of the Social Security Act for any amounts expended for providing medical assistance... (the Act) authorizes Federal grants to the States for Medicaid programs to provide medical assistance... all Federal requirements. The Federal government pays its share of medical assistance expenditures to...

The Indiana Chronic Disease Management Program's impact on medicaid claims: a longitudinal, statewide evaluation.

PubMed

Katz, Barry P; Holmes, Ann M; Stump, Timothy E; Downs, Steven M; Zillich, Alan J; Ackermann, Ronald T; Inui, Thomas S

2009-02-01

: Disease management programs have grown in popularity over the past decade as a strategy to curb escalating healthcare costs for persons with chronic diseases. : To evaluate the effect of the Indiana Chronic Disease Management Program (ICDMP) on the longitudinal changes in Medicaid claims statewide. : Phased implementation of a chronic disease management program in 3 regions of the state. Fourteen repeated cohorts of Medicaid members were drawn over a period of 3.5 years and the trends in claims were evaluated using a repeated measures model. : A total of 44,218 Medicaid members with diabetes and/or congestive heart failure in 3 geographic regions in Indiana. : Across all 3 regions and both disease classes, we found a flattening of cost trends between the pre- and post-ICDMP-initiation periods. This change in the slopes was significant for all of the models except for congestive heart failure in southern Indiana. Thus, the average per member claims paid was increasing at a faster rate before ICDMP but slowed once the program was initiated. To distinguish shorter and longer-term effects related to ICDMP, we estimated annual slopes within the pre- and post-ICDMP- time periods. A similar pattern was found in all regions: claims were increasing before ICDMP, flattened in the years around program initiation, and remained flat in the final year of follow-up. : This analysis shows that the trend in average total claims changed significantly after the implementation of ICDMP, with a decline in the rate of increase in claims paid observed for targeted Medicaid program populations across the state of Indiana.

Comparison of Project Management Software Tool Use in Healthcare and Other Industries

ERIC Educational Resources Information Center

Tait, Isabelle E.

2013-01-01

Hospitals, clinics, and physicians' offices are being mandated to implement health information technology to support electronic health records or receive reduced government reimbursements for the treatment of Medicare and Medicaid patients. The EHR Medicare and Medicaid Incentive Program, managed by the Centers for Medicare and Medicaid Services,…

42 CFR 431.958 - Definitions and use of terms.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Estimating Improper Payments in Medicaid and CHIP § 431.958 Definitions and use of terms. Active case means a case containing information on a beneficiary who is enrolled in the Medicaid or CHIP program in the... purposes of the PERM eligibility reviews under this part, the entity that performs the Medicaid and CHIP...

42 CFR 431.958 - Definitions and use of terms.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Estimating Improper Payments in Medicaid and CHIP § 431.958 Definitions and use of terms. Active case means a case containing information on a beneficiary who is enrolled in the Medicaid or CHIP program in the... purposes of the PERM eligibility reviews under this part, the entity that performs the Medicaid and CHIP...

42 CFR 431.958 - Definitions and use of terms.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Estimating Improper Payments in Medicaid and CHIP § 431.958 Definitions and use of terms. Active case means a case containing information on a beneficiary who is enrolled in the Medicaid or CHIP program in the... purposes of the PERM eligibility reviews under this part, the entity that performs the Medicaid and CHIP...

42 CFR 431.958 - Definitions and use of terms.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Estimating Improper Payments in Medicaid and CHIP § 431.958 Definitions and use of terms. Active case means a case containing information on a beneficiary who is enrolled in the Medicaid or CHIP program in the... purposes of the PERM eligibility reviews under this part, the entity that performs the Medicaid and CHIP...

42 CFR 431.958 - Definitions and use of terms.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Estimating Improper Payments in Medicaid and CHIP § 431.958 Definitions and use of terms. Active case means a case containing information on a beneficiary who is enrolled in the Medicaid or CHIP program in the... purposes of the PERM eligibility reviews under this part, the entity that performs the Medicaid and CHIP...

Doula care, birth outcomes, and costs among Medicaid beneficiaries.

PubMed

Kozhimannil, Katy Backes; Hardeman, Rachel R; Attanasio, Laura B; Blauer-Peterson, Cori; O'Brien, Michelle

2013-04-01

We compared childbirth-related outcomes for Medicaid recipients who received prenatal education and childbirth support from trained doulas with outcomes from a national sample of similar women and estimated potential cost savings. We calculated descriptive statistics for Medicaid-funded births nationally (from the 2009 Nationwide Inpatient Sample; n = 279,008) and births supported by doula care (n = 1079) in Minneapolis, Minnesota, in 2010 to 2012; used multivariate regression to estimate impacts of doula care; and modeled potential cost savings associated with reductions in cesarean delivery for doula-supported births. The cesarean rate was 22.3% among doula-supported births and 31.5% among Medicaid beneficiaries nationally. The corresponding preterm birth rates were 6.1% and 7.3%, respectively. After control for clinical and sociodemographic factors, odds of cesarean delivery were 40.9% lower for doula-supported births (adjusted odds ratio = 0.59; P < .001). Potential cost savings to Medicaid programs associated with such cesarean rate reductions are substantial but depend on states' reimbursement rates, birth volume, and current cesarean rates. State Medicaid programs should consider offering coverage for birth doulas to realize potential cost savings associated with reduced cesarean rates.

Findings from the Medicaid Competition Demonstrations: A guide for States

PubMed Central

Heinen, LuAnn; Fox, Peter D.; Anderson, Maren D.

1990-01-01

The Medicaid Competition Demonstrations were initiated in 1983-84 in six States (California, Florida, Minnesota, Missouri, New Jersey, and New York). State experiences in implementing the demonstrations are presented in this article. Although problems of enrolling Medicaid recipients in prepaid plans or with primary care case managers under these demonstrations proved challenging to States, lessons were learned in three key areas: program design and administration, health plan and provider relations, and beneficiary acceptance. Therefore, States considering similar programs in the future could benefit from these findings. PMID:10113403

CMS Innovation Center Health Care Innovation Awards

PubMed Central

Berry, Sandra H.; Concannon, Thomas W.; Morganti, Kristy Gonzalez; Auerbach, David I.; Beckett, Megan K.; Chen, Peggy G.; Farley, Donna O.; Han, Bing; Harris, Katherine M.; Jones, Spencer S.; Liu, Hangsheng; Lovejoy, Susan L.; Marsh, Terry; Martsolf, Grant R.; Nelson, Christopher; Okeke, Edward N.; Pearson, Marjorie L.; Pillemer, Francesca; Sorbero, Melony E.; Towe, Vivian; Weinick, Robin M.

2013-01-01

Abstract The Center for Medicare and Medicaid Innovation within the Centers for Medicare & Medicaid Services (CMS) has funded 108 Health Care Innovation Awards, funded through the Affordable Care Act, for applicants who proposed compelling new models of service delivery or payment improvements that promise to deliver better health, better health care, and lower costs through improved quality of care for Medicare, Medicaid, and Children's Health Insurance Program enrollees. CMS is also interested in learning how new models would affect subpopulations of beneficiaries (e.g., those eligible for Medicare and Medicaid and complex patients) who have unique characteristics or health care needs that could be related to poor outcomes. In addition, the initiative seeks to identify new models of workforce development and deployment, as well as models that can be rapidly deployed and have the promise of sustainability. This article describes a strategy for evaluating the results. The goal for the evaluation design process is to create standardized approaches for answering key questions that can be customized to similar groups of awardees and that allow for rapid and comparable assessment across awardees. The evaluation plan envisions that data collection and analysis will be carried out on three levels: at the level of the individual awardee, at the level of the awardee grouping, and as a summary evaluation that includes all awardees. Key dimensions for the evaluation framework include implementation effectiveness, program effectiveness, workforce issues, impact on priority populations, and context. The ultimate goal is to identify strategies that can be employed widely to lower cost while improving care. PMID:28083297

Health and federal budgetary effects of increasing access to antiretroviral medications for HIV by expanding Medicaid.

PubMed

Kahn, J G; Haile, B; Kates, J; Chang, S

2001-09-01

OBJECTIVES. This study modeled the health and federal fiscal effects of expanding Medicaid for HIV-infected people to improve access to highly active antiretroviral therapy. A disease state model of the US HIV epidemic, with and without Medicaid expansion, was used. Eligibility required a CD4 cell count less than 500/mm3 or viral load greater than 10,000, absent or inadequate medication insurance, and annual income less than $10,000. Two benefits were modeled, "full" and "limited" (medications, outpatient care). Federal spending for Medicaid, Medicare, AIDS Drug Assistance Program, Supplemental Security Income, and Social Security Disability Insurance were assessed. An estimated 38,000 individuals would enroll in a Medicaid HIV expansion. Over 5 years, expansion would prevent an estimated 13,000 AIDS diagnoses and 2600 deaths and add 5,816 years of life. Net federal costs for all programs are $739 million (full benefits) and $480 million (limited benefits); for Medicaid alone, the costs are $1.43 and $1.17 billion, respectively. Results were sensitive to awareness of serostatus, highly active antiretroviral therapy cost, and participation rate. Strategies for federal cost neutrality include Medicaid HIV drug price reductions as low as 9% and private insurance buy-ins. Expansion of the Medicaid eligibility to increase access to antiretroviral therapy would have substantial health benefits at affordable costs.

Society of Behavioral Medicine (SBM) position statement: SBM urges Congress to preserve and extend funding for Medicaid services.

PubMed

Behrman, Pamela; Demirci, Jill; Yanez, Betina; Beharie, Nisha; Laroche, Helena

2018-05-08

In May 2017, the Trump administration proposed steep cuts to Medicaid funding. This proposal was met with bipartisan criticism, as this program provides vital healthcare coverage for vulnerable children, adults, and families, including those living below the federal poverty line. In addition to the proposed funding cuts, federally authorized state restrictions to Medicaid access (e.g., work requirements) have been proposed, putting the Medicaid coverage of scores of enrollees at risk. Overwhelming health costs from inadequate or absent insurance are found to contribute to financial problems, including bankruptcy. Financial strain, in turn, is related to serious and life-threatening health problems in both children and adults. Given these impacts, the Society of Behavioral Medicine (SBM) urges Congress to protect and extend Medicaid funding. To maintain subscriber access, SBM recommends that Congress continue to use percentage rather than block funding determinants and eliminate states' authority to enforce program qualification requirements, including work provisions and stipulations for locking out subscribers who do not pay their premiums on time. It is also recommended that Congress increase and improve the scope and quality of reporting Medicaid's evidence base. This could be achieved through regular evaluations, focusing on Medicaid's impact on the health and economic well-being of its participants. SBM further recommends efforts to increase the public's awareness of and participation in Medicaid for eligible individuals, children, and families.

The Medicaid personal care services program: implications for social work practice.

PubMed

Oktay, J S; Palley, H A

1991-05-01

Results of a survey of Medicaid personal care programs in 15 states and the District of Columbia in 1987 show that these programs suffer from many problems. Low wages and slow payment make recruitment and retention of qualified workers difficult. Other problems include lack of coordination among agencies, lack of adequate standards for training or supervision of workers, unequal access to programs, and inequities among states. Implications for social workers are discussed.

Overview of Medicaid capitation and case-management initiatives

PubMed Central

Freund, Deborah A.; Neuschler, Edward

1986-01-01

Case-management programs have grown in number and in acceptance in the Medicaid program since 1981. In this article, we review their structure and incentives as well as what is known about their impact on cost and use. These programs also have been difficult to implement, posing myriad management challenges for prepaid program managers and State administrators. We highlight the problems in the following areas: eligibility, enrollment, rate setting, and management information systems. PMID:10311923

Medicaid Disproportionate Share and Other Special Financing Programs

PubMed Central

Ku, Leighton; Coughlin, Teresa A.

1995-01-01

Medicaid disproportionate share hospital (DSH) and related programs, such as provider-specific taxes or intergovernmental transfers (IGTs), help support uncompensated care and effectively reduce State Medicaid expenditures by increasing Federal matching funds. We analyze the uses of these funds, based on a survey completed by 39 States and case studies of 6 States. We find that only a small share of these funds were available to cover the costs of uncompensated care. One method to ensure that funds are used for health care would be to reprogram funds into health insurance subsidies. An alternative to improve equity of funding across the Nation would be to create a substitute Federal grant program to directly support uncompensated care. PMID:10142580

Equity in the Medicaid Program: Changes in the Latter 1980s

PubMed Central

Adams, E. Kathleen

1995-01-01

The possibility of health care reform has helped focus attention on equity in the receipt of health care. This is a particular issue for the Medicaid program, as State variations in eligibility and payment policies have historically created inequity. This study examines equity for Medicaid beneficiaries and State taxpayers during the latter 1980s. Findings indicate that federally mandated expansions significantly increased equity in the coverage of the poor, but inequality in real resources per enrollee remained significant. Although equity improved from 1984 through 1991, the increased use of provider-specific tax and voluntary donation (T&D) programs by traditionally high-spending States played an important role in the 1992 figures. PMID:10142581

States With Medically Needy Pathways: Differences in Long-Term and Temporary Medicaid Entry for Low-Income Medicare Beneficiaries.

PubMed

Keohane, Laura M; Trivedi, Amal; Mor, Vincent

2017-10-01

Medically needy pathways may provide temporary catastrophic coverage for low-income Medicare beneficiaries who do not otherwise qualify for full Medicaid benefits. Between January 2009 and June 2010, states with medically needy pathways had a higher percentage of low-income beneficiaries join Medicaid than states without such programs (7.5% vs. 4.1%, p < .01). However, among new full Medicaid participants, living in a state with a medically needy pathway was associated with a 3.8 percentage point (adjusted 95% confidence interval [1.8, 5.8]) increase in the probability of switching to partial Medicaid and a 4.5 percentage point (adjusted 95% confidence interval [2.9, 6.2]) increase in the probability of exiting Medicaid within 12 months. The predicted risk of leaving Medicaid was greatest when new Medicaid participants used only hospital services, rather than nursing home services, in their first month of Medicaid benefits. Alternative strategies for protecting low-income Medicare beneficiaries' access to care could provide more stable coverage.

Texas dentists' attitudes toward the Dental Medicaid program.

PubMed

Blackwelder, Aaron; Shulman, Jay D

2007-01-01

The purpose of this study was to report the attitudes of Texas dentists toward the Dental Medicaid program. A self-administered survey was mailed to all pediatric dentists and a random sample of general dentists. Surveys from 347 (69%) of 500 dentists (171 of 295 general dentists [58%] and 169 of 205 pediatric dentists [82%]) were returned. 57% of pediatric dentists and 29% of general dentists (P<.0001) treated at least 1 Medicaid patient in the past year. The major areas of dissatisfaction were: (1) broken appointments; (2) low reimbursement levels; and (3) patient noncompliance. This mirrors results from studies in Iowa, Louisiana, Ohio, Washington, and California. Both pediatric and general practitioners identified the following barriers to core for the Medicaid population: (1) low dental IQ; (2) few providers; and (3) no transportation. The major areas of dissatisfaction included both programmatic and patient-related factors. Attributes of the system (eg, lower reimbursement levels) are more modifiable than attributes of the patient population (eg, patient noncompliance and low dental IQ). Underfunding of dental Medicaid is endemic to all states studied in the literature. Providers, legislators, and government programs should target the programmatic problems with future efforts and funding.

Comparison of Orthodontic Medicaid Funding in the United States 2006 to 2015.

PubMed

Minick, Gerald; Tilliss, Terri; Shellhart, W Craig; Newman, Sheldon M; Carey, Clifton M; Horne, Andrew; Whitt, Susan; Oesterle, Larry J

2017-01-01

Orthodontic treatment is reimbursed by Medicaid based on orthodontic and financial need with qualifiers determined by individual states. Changes in Medicaid-funded orthodontic treatment following the "Great Recession" in 2007 and the enactment of the Affordable Care Act in 2010 were compared for the 50 United States and the District of Columbia to better understand disparities in access to care. The results from this 2015 survey were compared to data gathered in 2006 (1). Medicaid officials were contacted by email, telephone, or postal mail regarding the age limit for treatment, practitioner type who can determine eligibility and provide treatment, records required for case review, and rate and frequency of reimbursement. When not attained by direct contact, the information was gleaned from online websites, provider manuals, and state orthodontists. Information gathered from 50 states and the District of Columbia documents that Medicaid program characteristics and expenditures continue to vary by state. Expenditures and reimbursement rates have decreased since 2006 and vary widely by geographic region. Some states have tightened restrictions on qualifiers and increased submission requirements by providers. The variation and lack of uniformity that still exists among Medicaid orthodontic programs in different states creates disparities in orthodontic care for US citizens. Barriers to care for Medicaid-funded orthodontic treatment have increased since 2006.

How Medicaid and Other Public Policies Affect Use of Tobacco Cessation Therapy, United States, 2010–2014

PubMed Central

Brantley, Erin; Bysshe, Tyler; Steinmetz, Erika; Bruen, Brian K.

2016-01-01

Introduction State Medicaid programs can cover tobacco cessation therapies for millions of low-income smokers in the United States, but use of this benefit is low and varies widely by state. This article assesses the effects of changes in Medicaid benefit policies, general tobacco policies, smoking norms, and public health programs on the use of cessation therapy among Medicaid smokers. Methods We used longitudinal panel analysis, using 2-way fixed effects models, to examine the effects of changes in state policies and characteristics on state-level use of Medicaid tobacco cessation medications from 2010 through 2014. Results Medicaid policies that require patients to obtain counseling to get medications reduced the use of cessation medications by approximately one-quarter to one-third; states that cover all types of cessation medications increased usage by approximately one-quarter to one-third. Non-Medicaid policies did not have significant effects on use levels. Conclusions States could increase efforts to quit by developing more comprehensive coverage and reducing barriers to coverage. Reductions in barriers could bolster smoking cessation rates, and the costs would be small compared with the costs of treating smoking-related diseases. Innovative initiatives to help smokers quit could improve health and reduce health care costs. PMID:27788063

What Would Block Grants or Limits on Per Capita Spending Mean for Medicaid?

PubMed

Rosenbaum, Sara; Schmucker, Sara; Rothenberg, Sara; Gunsalus, Rachel

2016-11-01

Issue: President-elect Trump and some in Congress have called for establishing absolute limits on the federal government’s spending on Medicaid, not only for the population covered through the Affordable Care Act’s eligibility expansion but for the program overall. Such a change would effectively reverse a 50-year trend of expanding Medicaid in order to protect the most vulnerable Americans. Goal: To explore the two most common proposals for reengineering federal funding of Medicaid: block grants that set limits on total annual spending regardless of enrollment, and caps that limit average spending per enrollee. Methods: Review of existing policy proposals and other documents. Key findings and conclusions: Current proposals for dramatically reducing federal spending on Medicaid would achieve this goal by creating fixed-funding formulas divorced from the actual costs of providing care. As such, they would create funding gaps for states to either absorb or, more likely, offset through new limits placed on their programs. As a result, block-granting Medicaid or instituting "per capita caps" would most likely reduce the number of Americans eligible for Medicaid and narrow coverage for remaining enrollees. The latter approach would, however, allow for population growth, though its desirability to the new president and Congress is unclear. The full extent of funding and benefit reductions is as yet unknown.

Home and Community-Based Services Waivers

PubMed Central

Duckett, Mary Jean; Guy, Mary R.

2000-01-01

The history and current status of the Medicaid Home and Community-Based Services Waiver Program are presented. The article discusses the States' role in developing and implementing creative alternatives to institutional care for individuals who are Medicaid eligible. Also described are services that may be provided under the waiver program and populations served. PMID:25372343

Evaluation of chronic disease management on outcomes and cost of care for Medicaid beneficiaries.

PubMed

Zhang, Ning Jackie; Wan, Thomas T H; Rossiter, Louis F; Murawski, Matthew M; Patel, Urvashi B

2008-05-01

To evaluate the impacts of the chronic disease management program on the outcomes and cost of care for Virginia Medicaid beneficiaries. A total of 35,628 patients and their physicians and pharmacists received interventions for five chronic diseases and comorbidities from 1999 to 2001. Comparisons of medical utilization and clinical outcomes between experimental groups and control group were conducted using ANOVA and ANCOVA analyses. Findings indicate that the disease state management (DSM) program statistically significantly improved patient's drug compliance and quality of life while reducing (ER), hospital, and physician office visits and adverse events. The average cost per hospitalization would have been $42 higher without the interventions. A coordinated disease management program designed for Medicaid patients experiencing significant chronic diseases can substantially improve clinical outcomes and reduce unnecessary medical utilization, while lowering costs, although these results were not observed across all disease groups. The DSM model may be potentially useful for Medicaid programs in states or other countries. If the adoption of the DSM model is to be promoted, evidence of its effectiveness should be tested in broader settings and best practice standards are expected.

Medicaid Matters: Children's Health and Medicaid Eligibility Expansions

ERIC Educational Resources Information Center

Lykens, Kristine A.; Jargowsky, Paul A.

2002-01-01

In the late 1980s, a series of federal laws were enacted which expanded Medicaid eligibility to more of the nation's children. States had a great amount of discretion in how fast and how far these expansions were implemented. As a result, there was great variation among the states in defining who was eligible for the program. This variation…

Fiscal Year 2001 Medicaid Home and Community-Based Services Expenditures Exceed Those of ICFs/MR.

ERIC Educational Resources Information Center

Lakin, K. Charlie; Prouty, Robert; Smith, Jerra; Polister, Barb; Smith, Gary

2002-01-01

This article reports that in 2001, for the first time since its creation 20 years earlier, Medicaid Home and Community-Based Services (HCBS) Waiver programs for persons with intellectual and developmental disabilities had Federal and state expenditures that exceeded those for Medicaid Intermediate Care Facilities for Persons with Mental…

Nursing Home Patient Outcomes: The Results of an Incentive Reimbursement Experiment. Long-Term Care Studies Program Research Report.

ERIC Educational Resources Information Center

Thorburn, Phyllis; Meiners, Mark R.

A major demonstration and evaluation project was undertaken to study the consequences of using incentive payments to change admission, discharge, and outcome patterns for Medicaid patients in nursing homes. Thirty-six proprietary, Medicaid-certified, skilled nursing homes in San Diego County with a combined Medicaid inpatient census of…

77 FR 75633 - Agency Information Collection Activities: Submission for OMB Review; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2012-12-21

... state agencies to (among other things): (1) Submit and amend Medicaid state plans, CHIP state plans, and..., demonstration, and benchmark and grant programs. It will be used by CMS to (among other things): (1) Provide for.... The webinar can be accessed on the Internet at: http://www.medicaid.gov/State-Resource-Center/Medicaid...

State medicaid coverage for tobacco cessation treatments and barriers to coverage - United States, 2008-2014.

PubMed

Singleterry, Jennifer; Jump, Zach; Lancet, Elizabeth; Babb, Stephen; MacNeil, Allison; Zhang, Lei

2014-03-28

Medicaid enrollees have a higher smoking prevalence than the general population (30.1% of adult Medicaid enrollees aged <65 years smoke, compared with 18.1% of U.S. adults of all ages), and smoking-related disease is a major contributor to increasing Medicaid costs. Evidence-based cessation treatments exist, including individual, group, and telephone counseling and seven Food and Drug Administration (FDA)-approved medications. A Healthy People 2020 objective (TU-8) calls for all state Medicaid programs to adopt comprehensive coverage of these treatments. However, most states do not provide such coverage. To monitor trends in state Medicaid cessation coverage, the American Lung Association collected data on coverage of all evidence-based cessation treatments except telephone counseling by state Medicaid programs (for a total of nine treatments), as well as data on barriers to accessing these treatments (such as charging copayments or limiting the number of covered quit attempts) from December 31, 2008, to January 31, 2014. As of 2014, all 50 states and the District of Columbia cover some cessation treatments for at least some Medicaid enrollees, but only seven states cover all nine treatments for all enrollees. Common barriers in 2014 include duration limits (40 states for at least some populations or plans), annual limits (37 states), prior authorization requirements (36 states), and copayments (35 states). Comparing 2008 with 2014, 33 states added treatments to coverage, and 22 states removed treatments from coverage; 26 states removed barriers to accessing treatments, and 29 states added new barriers. The evidence from previous analyses suggests that states could reduce smoking-related morbidity and health-care costs among Medicaid enrollees by providing Medicaid coverage for all evidence-based cessation treatments, removing all barriers to accessing these treatments, promoting the coverage, and monitoring its use.

Effects of Early Dual-Eligible Special Needs Plans on Health Expenditure.

PubMed

Zhang, Yongkang; Diana, Mark L

2017-10-18

To examine the effects of the penetration of dual-eligible special needs plans (D-SNPs) on health care spending. Secondary state-level panel data from Medicare-Medicaid Linked Enrollee Analytic Data Source (MMLEADS) public use file and Special Needs Plan Comprehensive Reports, Area Health Resource Files, and Medicaid Managed Care Enrollment Report between 2007 and 2011. A difference-in-difference strategy that adjusts for dual-eligibles' demographic and socioeconomic characteristics, state health resources, beneficiaries' health risk factors, Medicare/Medicaid enrollment, and state- and year-fixed effects. Data from MMLEADS were summarized from Centers for Medicare and Medicaid Services (CMS)'s Chronic Conditions Data Warehouse, which contains 100 percent of Medicare enrollment data, claims for beneficiaries who are enrolled in the fee-for-service (FFS) program, and Medicaid Analytic Extract files. The MMLEADS public use file also includes payment information for managed care. Data in Special Needs Plan Comprehensive Reports were from CMS's Health Plan Management System. Results indicate that D-SNPs penetration was associated with reduced Medicare spending per dual-eligible beneficiary. Specifically, a 1 percent increase in D-SNPs penetration was associated with 0.2 percent reduction in Medicare spending per beneficiary. We found no association between D-SNPs penetration and Medicaid or total spending. Involving Medicaid services in D-SNPs may be crucial to improve coordination between Medicare and Medicaid programs and control Medicaid spending among dual-eligible beneficiaries. Starting from 2013, D-SNPs were mandated to have contracts with state Medicaid agencies. This change may introduce new effects of D-SNPs on health care spending. More research is needed to examine the impact of D-SNPs on dual-eligible spending. © Health Research and Educational Trust.

The Relationship of Community-based Nurse Care Coordination to Costs in the Medicare and Medicaid Programs

PubMed Central

Marek, Karen Dorman; Adams, Scott J.; Stetzer, Frank; Popejoy, Lori; Rantz, Marilyn

2011-01-01

The purpose of this evaluation was to study the relationship of nurse care coordination (NCC) to the costs of Medicare and Medicaid in a community-based care program called Missouri Care Options (MCO). A retrospective cohort design was used comparing 57 MCO clients with NCC to 80 MCO clients without NCC. Total cost was measured using Medicare and Medicaid claims databases. Fixed effects analysis was used to estimate the relationship of the NCC intervention to costs. Controlling for high resource use on admission, monthly Medicare costs were lower ($686) in the 12 months of NCC intervention (p =.04) while Medicaid costs were higher ($203; p=.03) for the NCC group when compared to the costs of MCO group. PMID:20499393

Stakeholder assessment of comparative effectiveness research needs for Medicaid populations.

PubMed

Fischer, Michael A; Allen-Coleman, Cora; Farrell, Stephen F; Schneeweiss, Sebastian

2015-09-01

Patients, providers and policy-makers rely heavily on comparative effectiveness research (CER) when making complex, real-world medical decisions. In particular, Medicaid providers and policy-makers face unique challenges in decision-making because their program cares for traditionally underserved populations, especially children, pregnant women and people with mental illness. Because these patient populations have generally been underrepresented in research discussions, CER questions for these groups may be understudied. To address this problem, the Agency for Healthcare Research and Quality commissioned our team to work with Medicaid Medical Directors and other stakeholders to identify relevant CER questions. Through an iterative process of topic identification and refinement, we developed relevant, feasible and actionable questions based on issues affecting Medicaid programs nationwide. We describe challenges and limitations and provide recommendations for future stakeholder engagement.

Stakeholder assessment of comparative effectiveness research needs for Medicaid populations

PubMed Central

Fischer, Michael A; Allen-Coleman, Cora; Farrell, Stephen F; Schneeweiss, Sebastian

2015-01-01

Patients, providers and policy-makers rely heavily on comparative effectiveness research (CER) when making complex, real-world medical decisions. In particular, Medicaid providers and policy-makers face unique challenges in decision-making because their program cares for traditionally underserved populations, especially children, pregnant women and people with mental illness. Because these patient populations have generally been underrepresented in research discussions, CER questions for these groups may be understudied. To address this problem, the Agency for Healthcare Research and Quality commissioned our team to work with Medicaid Medical Directors and other stakeholders to identify relevant CER questions. Through an iterative process of topic identification and refinement, we developed relevant, feasible and actionable questions based on issues affecting Medicaid programs nationwide. We describe challenges and limitations and provide recommendations for future stakeholder engagement. PMID:26388438

Predicting dentists' decisions: a choice-based conjoint analysis of Medicaid participation.

PubMed

Kateeb, Elham T; McKernan, Susan C; Gaeth, Gary J; Kuthy, Raymond A; Adrianse, Nancy B; Damiano, Peter C

2016-06-01

Private practice dentists are the major source of care for the dental safety net; however, the proportion of dentists who participate in state Medicaid programs is low, often due to poor perceptions of the program's administration and patient population. Using a discrete choice experiment and a series of hypothetical scenarios, this study evaluated trade-offs dentists make when deciding to accept Medicaid patients. An online choice-based conjoint survey was sent to 272 general dentists in Iowa. Hypothetical scenarios presented factors at systematically varied levels. The primary determination was whether dentists would accept a new Medicaid patient in each scenario. Using an ecological model of behavior, determining factors were selected from the categories of policy, administration, community, and patient population to estimate dentists' relative preferences. 62 percent of general dentists responded to the survey. The probability of accepting a new Medicaid patient was highest (81 percent) when reimbursement rates were 85 percent of the dentist's fees, patients never missed appointments, claims were approved on first submission, and no other practices in the area accepted Medicaid. Although dentists preferred higher reimbursement rates, 56 percent would still accept a new Medicaid patient when reimbursement decreased to 55 percent if they were told that the patient would never miss appointments and claims would be approved on initial submission. This study revealed trade-offs that dentists make when deciding to participate in Medicaid. Findings indicate that states can potentially improve Medicaid participation without changing reimbursement rates by making improvements in claims processing and care coordination to reduce missed appointments. © 2015 American Association of Public Health Dentistry.

The politics of Medicaid: 1980-1989.

PubMed

Cohen, S S

1990-01-01

Grim statistics on infant mortality and women's health alone are not enough to keep Medicaid funded. What is also needed is a strong, vociferous lobby dedicated to protecting these important programs.

The Effects of a Disease Management Program on Self-Reported Health Behaviors and Health Outcomes: Evidence from the "Florida--A Healthy State (FAHS)" Medicaid Program

ERIC Educational Resources Information Center

Morisky, Donald E.; Kominski, Gerald F.; Afifi, Abdelmonem A.; Kotlerman, Jenny B.

2009-01-01

Premature morbidity and mortality from chronic diseases account for a major proportion of expenditures for health care cost in the United States. The purpose of this study was to measure the effects of a disease management program on physiological and behavioral health indicators for Medicaid patients in Florida. A two-year prospective study of…

45 CFR 155.302 - Options for conducting eligibility determinations.

Code of Federal Regulations, 2012 CFR

2012-10-01

... this section. (b) Medicaid and CHIP. Notwithstanding the requirements of this subpart, the Exchange may conduct an assessment of eligibility for Medicaid and CHIP, rather than an eligibility determination for Medicaid and CHIP, provided that— (1) The Exchange makes such an assessment based on the applicable...

Financial performance of health plans in Medicaid managed care.

PubMed

McCue, Mike

2012-01-01

This study assesses the financial performance of health plans that enroll Medicaid members across the key plan traits, specifically Medicaid dominant, publicly traded, and provider-sponsored. National Association of Insurance Commissioners (NAIC) financial data, coupled with selected state financial data, were analyzed for 170 Medicaid health plans for 2009. A mean test compared the mean values for medical loss, administrative cost, and operating margin ratios across these plan traits. Medicaid dominant plans are plans with 75 percent of their total enrollment in the Medicaid line of business. Plans that are Medicaid dominant and publicly traded incurred a lower medical loss ratio and higher administrative cost ratio than multi-product and non-publicly traded plans. Medicaid dominant plans also earned a higher operating profit margin. Plans offering commercial and Medicare products are operating at a loss for their Medicaid line of business. Health plans that do not specialize in Medicaid are losing money. Higher medical cost rather than administrative cost is the underlying reason for this financial loss. Since Medicaid enrollees do not account for their primary book of business, these plans may not have invested in the medical management programs to reduce inappropriate emergency room use and avoid costly hospitalization.

Patterns of use of a free nicotine patch program for Medicaid and uninsured patients.

PubMed Central

Jaén, C. R.; Cummings, K. M.; Shah, D.; Aungst, W.

1997-01-01

This study assessed the use and effectiveness of a free nicotine patch program among Medicaid and uninsured smokers. Patterns of patch use, associated behaviors with quit attempt, side effects, and self-reported abstinence from smoking for 6 months were evaluated prospectively among patients from five urban family practice offices and a nicotine dependence clinic located in a comprehensive cancer center in Western New York. Results indicated that the majority of participants used the program as intended, and 90% of the participants found the patch useful in their quit attempt. Fourteen percent of participants were abstinent for 6 months or more. We found no support for inappropriate use of transdermal nicotine patches among patients with no health insurance or those on Medicaid. Transdermal nicotine patches are an effective cessation aid for smokers. Given the tall of the consequences of smoking on health costs, barriers to access to effective treatment for smoking cessation among individuals covered by Medicaid for health insurance need to be eliminated. PMID:9170833

Psychiatric service utilization and cost for persons with schizophrenia in a Medicaid managed care program.

PubMed

Rothbard, Aileen B; Kuno, Eri; Hadley, Trevor R; Dogin, Judith

2004-01-01

A pre-post study design was used to look at changes in behavioral health care services and costs for Medicaid-eligible individuals with schizophrenia in a managed care (MC) carve-out compared to a fee-for-service (FFS) program in Pennsylvania between 1995 and 1998. Statistically significant reductions of 59% were found in hospital expenditures in the MC program compared to 18.3% in the FFS program. The decline in hospital costs was due to dramatic fee reductions in the MC site. No significant differences in overall ambulatory utilization were found in either program; however, ambulatory expenditures rose 57% in the MC program versus a decline of 11% in fee for service. The ambulatory cost increase resulted from a cost shift between county block grant funds, and Medicaid funds, with no additional revenues provided to outpatient providers. Study implications are that cost reductions from MC are mainly due to reducing utilization and payments to hospitals, similar to the findings for private sector programs.

The new Medicaid debate: expansion or retrenchment?

PubMed

2001-01-01

Health advocates are facing a sea-change in Washington. Comprehensive federal health care reform eluded the nation under the Clinton Administration, but incremental progress through state-based Medicaid expansions and new CHIP programs was widespread, giving rise to some innovative state efforts to cover more of the uninsured. Washington's support was instrumental in those efforts, but the second Bush Administration seems intent on reversing that direction. To protect--and build upon--these nascent Medicaid efforts, advocates will have to mount careful strategies in defense of Medicaid. This States of Health looks at the dangers that may lie ahead and suggests how advocates can respond to keep Medicaid moving in the right direction.

Medicaid information technology architecture: an overview.

PubMed

Friedman, Richard H

2006-01-01

The Medicaid Information Technology Architecture (MITA) is a roadmap and tool-kit for States to transform their Medicaid Management Information System (MMIS) into an enterprise-wide, beneficiary-centric system. MITA will enable State Medicaid agencies to align their information technology (IT) opportunities with their evolving business needs. It also addresses long-standing issues of interoperability, adaptability, and data sharing, including clinical data, across organizational boundaries by creating models based on nationally accepted technical standards. Perhaps most significantly, MITA allows State Medicaid Programs to actively participate in the DHHS Secretary's vision of a transparent health care market that utilizes electronic health records (EHRs), ePrescribing and personal health records (PHRs).

Medicaid's Role in the Many Markets for Health Care

PubMed Central

Quinn, Kevin; Kitchener, Martin

2007-01-01

To illuminate Medicaid's growing role as a health care purchaser, we estimated Medicaid spending and market shares for 30 markets defined by provider category of service. For approximately 15 markets, our estimates are more detailed than the data available from standard sources. Two-thirds of Medicaid spending occurs in markets where the program has a modest market share. The other one-third occurs in markets that Medicaid dominates, especially in the areas of long-term care (LTC), mental retardation, and mental health. We explore the implications of the different roles for payment policy, industry organization, data availability, and quality of care. PMID:17722752

Association Between Health Plan Exit From Medicaid Managed Care and Quality of Care, 2006-2014

PubMed Central

Schpero, William L.; Schlesinger, Mark J.; Trivedi, Amal N.

2017-01-01

Importance State Medicaid programs have increasingly contracted with insurers to provide medical care services for enrollees (Medicaid managed care plans). Insurers that provide these plans can exit Medicaid programs each year, with unclear effects on quality of care and health care experiences. Objective To determine the frequency and interstate variation of health plan exit from Medicaid managed care and evaluate the relationship between health plan exit and market-level quality. Design, Setting, and Participants Retrospective cohort of all comprehensive Medicaid managed care plans (N = 390) during the interval 2006-2014. Exposures Plan exit, defined as the withdrawal of a managed care plan from a state’s Medicaid program. Main Outcomes and Measures Eight measures from the Healthcare Effectiveness Data and Information Set were used to construct 3 composite indicators of quality (preventive care, chronic disease care management, and maternity care). Four measures from the Consumer Assessment of Healthcare Providers and Systems were combined into a composite indicator of patient experience, reflecting the proportion of beneficiaries rating experiences as 8 or above on a 0-to-10–point scale. Outcome data were available for 248 plans (68% of plans operating prior to 2014, representing 78% of beneficiaries). Results Of the 366 comprehensive Medicaid managed care plans operating prior to 2014, 106 exited Medicaid. These exiting plans enrolled 4 848 310 Medicaid beneficiaries, with a mean of 606 039 beneficiaries affected by plan exits annually. Six states had a mean of greater than 10% of Medicaid managed care recipients enrolled in plans that exited, whereas 10 states experienced no plan exits. Plans that exited from a state’s Medicaid market performed significantly worse prior to exiting than those that remained in terms of preventive care (57.5% vs 60.4%; difference, 2.9% [95% CI, 0.3% to 5.5%]), maternity care (69.7% vs 73.6%; difference, 3.8% [95% CI, 1.7% to 6.0%]), and patient experience (73.5% vs 74.8%; difference, 1.3% [95% CI, 0.6% to 1.9%]). There was no significant difference between exiting and nonexiting plans for the quality of chronic disease care management (76.2% vs 77.1%; difference, 1.0% [95% CI, −2.1% to 4.0%]). There was also no significant change in overall market performance before and after the exit of a plan: 0.7–percentage point improvement in preventive care quality (95% CI, −4.9 to 6.3); 0.2–percentage point improvement in chronic disease care management quality (95% CI, −5.8 to 6.2); 0.7–percentage point decrease in maternity care quality (95% CI, −6.4 to 5.0]); and a 0.6–percentage point improvement in patient experience ratings (95% CI, −3.9 to 5.1). Medicaid beneficiaries enrolled in exiting plans had access to coverage for a higher-quality plan, with 78% of plans in the same county having higher quality for preventive care, 71.1% for chronic disease management, 65.5% for maternity care, and 80.8% for patient experience. Conclusions and Relevance Between 2006 and 2014, health plan exit from the US Medicaid program was frequent. Plans that exited generally had lower quality ratings than those that remained, and the exits were not associated with significant overall changes in quality or patient experience in the plans in the Medicaid market. PMID:28655014

Association Between Health Plan Exit From Medicaid Managed Care and Quality of Care, 2006-2014.

PubMed

Ndumele, Chima D; Schpero, William L; Schlesinger, Mark J; Trivedi, Amal N

2017-06-27

State Medicaid programs have increasingly contracted with insurers to provide medical care services for enrollees (Medicaid managed care plans). Insurers that provide these plans can exit Medicaid programs each year, with unclear effects on quality of care and health care experiences. To determine the frequency and interstate variation of health plan exit from Medicaid managed care and evaluate the relationship between health plan exit and market-level quality. Retrospective cohort of all comprehensive Medicaid managed care plans (N = 390) during the interval 2006-2014. Plan exit, defined as the withdrawal of a managed care plan from a state's Medicaid program. Eight measures from the Healthcare Effectiveness Data and Information Set were used to construct 3 composite indicators of quality (preventive care, chronic disease care management, and maternity care). Four measures from the Consumer Assessment of Healthcare Providers and Systems were combined into a composite indicator of patient experience, reflecting the proportion of beneficiaries rating experiences as 8 or above on a 0-to-10-point scale. Outcome data were available for 248 plans (68% of plans operating prior to 2014, representing 78% of beneficiaries). Of the 366 comprehensive Medicaid managed care plans operating prior to 2014, 106 exited Medicaid. These exiting plans enrolled 4 848 310 Medicaid beneficiaries, with a mean of 606 039 beneficiaries affected by plan exits annually. Six states had a mean of greater than 10% of Medicaid managed care recipients enrolled in plans that exited, whereas 10 states experienced no plan exits. Plans that exited from a state's Medicaid market performed significantly worse prior to exiting than those that remained in terms of preventive care (57.5% vs 60.4%; difference, 2.9% [95% CI, 0.3% to 5.5%]), maternity care (69.7% vs 73.6%; difference, 3.8% [95% CI, 1.7% to 6.0%]), and patient experience (73.5% vs 74.8%; difference, 1.3% [95% CI, 0.6% to 1.9%]). There was no significant difference between exiting and nonexiting plans for the quality of chronic disease care management (76.2% vs 77.1%; difference, 1.0% [95% CI, -2.1% to 4.0%]). There was also no significant change in overall market performance before and after the exit of a plan: 0.7-percentage point improvement in preventive care quality (95% CI, -4.9 to 6.3); 0.2-percentage point improvement in chronic disease care management quality (95% CI, -5.8 to 6.2); 0.7-percentage point decrease in maternity care quality (95% CI, -6.4 to 5.0]); and a 0.6-percentage point improvement in patient experience ratings (95% CI, -3.9 to 5.1). Medicaid beneficiaries enrolled in exiting plans had access to coverage for a higher-quality plan, with 78% of plans in the same county having higher quality for preventive care, 71.1% for chronic disease management, 65.5% for maternity care, and 80.8% for patient experience. Between 2006 and 2014, health plan exit from the US Medicaid program was frequent. Plans that exited generally had lower quality ratings than those that remained, and the exits were not associated with significant overall changes in quality or patient experience in the plans in the Medicaid market.

Rethinking Medicaid Coverage and Payment Policy to Promote High Value Care: The Case of Long-Acting Reversible Contraception.

PubMed

Vela, Veronica X; Patton, Elizabeth W; Sanghavi, Darshak; Wood, Susan F; Shin, Peter; Rosenbaum, Sara

Long-acting reversible contraception (LARC) is the most effective reversible method to prevent unplanned pregnancies. Variability in state-level policies and the high cost of LARC could create substantial inconsistencies in Medicaid coverage, despite federal guidance aimed at enhancing broad access. This study surveyed state Medicaid payment policies and outreach activities related to LARC to explore the scope of services covered. Using publicly available information, we performed a content analysis of state Medicaid family planning and LARC payment policies. Purposeful sampling led to a selection of nine states with diverse geographic locations, political climates, Medicaid expansion status, and the number of women covered by Medicaid. All nine states' Medicaid programs covered some aspects of LARC. However, only a single state's payment structure incorporated all core aspects of high-quality LARC service delivery, including counseling, device, insertion, removal, and follow-up care. Most states did not explicitly address counseling, device removal, or follow-up care. Some states had strategies to enhance access, including policies to increase device reimbursement, stocking and delivery programs to remove cost barriers, and covering devices and insertion after an abortion. Although Medicaid policy encourages LARC methods, state payment policies frequently fail to address key aspects of care, including counseling, follow-up care, and removal, resulting in highly variable state-level practices. Although some states include payment policy innovations to support LARC access, significant opportunities remain. Published by Elsevier Inc.

Medicaid expansion under the Affordable Care Act. Implications for insurance-related disparities in pulmonary, critical care, and sleep.

PubMed

Lyon, Sarah M; Douglas, Ivor S; Cooke, Colin R

2014-05-01

The Affordable Care Act was intended to address systematic health inequalities for millions of Americans who lacked health insurance. Expansion of Medicaid was a key component of the legislation, as it was expected to provide coverage to low-income individuals, a population at greater risk for disparities in access to the health care system and in health outcomes. Several studies suggest that expansion of Medicaid can reduce insurance-related disparities, creating optimism surrounding the potential impact of the Affordable Care Act on the health of the poor. However, several impediments to the implementation of Medicaid's expansion and inadequacies within the Medicaid program itself will lessen its initial impact. In particular, the Supreme Court's decision to void the Affordable Care Act's mandate requiring all states to accept the Medicaid expansion allowed half of the states to forego coverage expansion, leaving millions of low-income individuals without insurance. Moreover, relative to many private plans, Medicaid is an imperfect program suffering from lower reimbursement rates, fewer covered services, and incomplete acceptance by preventive and specialty care providers. These constraints will reduce the potential impact of the expansion for patients with respiratory and sleep conditions or critical illness. Despite its imperfections, the more than 10 million low-income individuals who gain insurance as a result of Medicaid expansion will likely have increased access to health care, reduced out-of-pocket health care spending, and ultimately improvements in their overall health.

77 FR 26361 - Medicaid Program; State Plan Home and Community-Based Services, 5-Year Period for Waivers...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-05-03

... services and receive Federal matching funds. As a result, States will be better able to design and tailor... design and tailor Medicaid services to better accommodate individual needs. This may result in improved... States to design and implement HCBS under the Medicaid State Plan. In April 4, 2008, we published a...

Allowing Spouses to Be Paid Personal Care Providers: Spouse Availability and Effects on Medicaid-Funded Service Use and Expenditures

ERIC Educational Resources Information Center

Newcomer, Robert J.; Kang, Taewoon; Doty, Pamela

2012-01-01

Purpose of the Study: Medicaid service use and expenditure and quality of care outcomes in California's personal care program known as In-Home Supportive Service (IHSS) are described. Analyses investigated Medicaid expenditures, hospital use, and nursing home stays, comparing recipients who have paid spouse caregivers with those having other…

42 CFR 447.294 - Medicaid disproportionate share hospital (DSH) allotment reductions for Federal fiscal year 2014...

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Medicaid disproportionate share hospital (DSH) allotment reductions for Federal fiscal year 2014 and Federal fiscal year 2015. 447.294 Section 447.294 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PAYMENTS FOR...

42 CFR 447.294 - Medicaid disproportionate share hospital (DSH) allotment reductions for Federal fiscal year 2014...

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 4 2013-10-01 2013-10-01 false Medicaid disproportionate share hospital (DSH) allotment reductions for Federal fiscal year 2014 and Federal fiscal year 2015. 447.294 Section 447.294 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PAYMENTS FOR...

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

... System AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice of Single Source Award... care system through a single source award. The Indian Health Service (IHS), Tribes and Tribal... adoption and impact of these new authorities on the Indian health care system. Amount of the Award The...

78 FR 10525 - Assistance to States for the Education of Children With Disabilities

Federal Register 2010, 2011, 2012, 2013, 2014

2013-02-14

... public benefits or insurance (e.g., Medicaid) to pay for a specified type, amount, and cost of services... cost of services billed to the public benefits or insurance program, the public agency must provide the... cost of services to be billed to the public benefits or insurance program (e.g., Medicaid). However...

Smile Alabama! Initiative: Interim Results from a Program To Increase Children's Access to Dental Care.

ERIC Educational Resources Information Center

Greene-McIntyre, Mary; Finch, Mary Hayes; Searcy, John

2003-01-01

An Alabama initiative aimed to improve access to oral health care for Medicaid-eligible children through four components: improved Medicaid claims processing, increased reimbursement for providers, outreach and educational activities to support providers, and parent and patient education about children's oral health. In the first 3 program years,…

The Stigma of Public Programs: Does a Separate S-CHIP Program Reduce It?

ERIC Educational Resources Information Center

Ketsche, Patricia; Adams, E. Kathleen; Minyard, Karen; Kellenberg, Rebecca

2007-01-01

Previous studies suggest access to and satisfaction with care may be different for enrollees in S-CHIP and Medicaid, but it is unclear whether those differences are fully explained by socioeconomic characteristics of the enrollees. We analyze access and satisfaction of three groups of children: Medicaid enrolled, S-CHIP enrolled, and children who…

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-03-18

... Nursing Homes; Final Rule #0;#0;Federal Register / Vol. 76 , No. 53 / Friday, March 18, 2011 / Rules and... Services 42 CFR Part 488 [CMS-2435-F] Medicare and Medicaid Programs; Civil Money Penalties for Nursing... collection of civil money penalties by CMS when nursing homes are not in compliance with Federal...

Premium assistance in Medicaid and SCHIP: ace in the hole or house of cards?

PubMed

Shirk, Cynthia; Ryan, Jennifer

2006-07-17

This issue brief explores the use of premium assistance in publicly financed health insurance coverage programs. In the context of Medicaid and the State Children's Health Insurance Program (SCHIP), premium assistance entails using federal and state funds to subsidize the premiums for the purchase of private insurance coverage for eligible individuals. This paper considers the evolution of premium assistance and some of the statutory and administrative limitations, as well as private market factors, that have prevented widespread enrollment in Medicaid or SCHIP premium assistance programs. Finally, this issue brief offers some ideas for potential legislative and/or programmatic changes that could facilitate the use of premium assistance as a mechanism for health coverage expansion.

Savings opportunities through Medicaid disease management.

PubMed

Lewis, Alfred

2004-01-01

In their attempts to control spending in Medicaid, a few states have looked beyond the obvious reductions in reimbursement, tightened eligibility requirements, and institution of copays to disease management outsourcing. While the traditional panoply of cutbacks will save money the year they are instituted, they tend to have trade-offs. Reducing reimbursement, for example, may encourage providers to leave the program. As a result, several states are implementing outsourced medical management programs, which together at maturity will, as shown below, noticeably reduce Medicaid spending by improving the way health care is delivered. These purely voluntary, quality-enhancing outsourced medical management programs are also fully guaranteed by a wide variety of vendors to save money starting in the first year they are implemented.

Long-term disease and economic outcomes of prior authorization criteria for Hepatitis C treatment in Pennsylvania Medicaid.

PubMed

Kabiri, Mina; Chhatwal, Jagpreet; Donohue, Julie M; Roberts, Mark S; James, A Everette; Dunn, Michael A; Gellad, Walid F

2017-09-01

Several highly effective but costly therapies for hepatitis C virus (HCV) are available. As a consequence of their high price, 36 state Medicaid programs limited treatment coverage to patients with more advanced HCV stages. States have only limited information available to predict the long-term impact of these decisions. We adapted a validated hepatitis C microsimulation model to the Pennsylvania Medicaid population to estimate the existing HCV prevalence in Pennsylvania Medicaid and estimate the impact of various HCV drug coverage policies on disease outcomes and costs. Outcome measures included rates of advanced-stage HCV outcomes and treatment and disease costs in both Medicaid and Medicare. We estimated that 46,700 individuals in Pennsylvania Medicaid were infected with HCV in 2015, 33% of whom were still undiagnosed. By expanding treatment to include mild fibrosis stage (Metavir F2), Pennsylvania Medicaid will spend an additional $273 million on medications in the next decade with no substantial reduction in the incidence of liver cancer or liver-related death. Medicaid patients who are not eligible for treatment under restricted policies would get treatment once they transition to the Medicare program, which would incur 10% reduction in HCV-related costs due to early treatment in Medicaid. Further expanding treatment to patients with early fibrosis stages (F0 or F1) would cost Medicaid an additional $693 million during the next decade but would reduce the number of individuals in need of treatment in Medicare by 46% and decrease Medicare treatment costs by 23%. In some scenarios, outcomes could worsen with eligibility expansion if there is inadequate capacity to treat all patients. Expansion of HCV treatment coverage to less severe stages of liver disease may not substantially improve liver related outcomes for patients in Pennsylvania Medicaid in scenarios in which coverage through Medicare is widely available. Published by Elsevier Inc.

Diabetes disease management results in Hispanic Medicaid patients.

PubMed

Berg, Gregory D; Wadhwa, Sandeep

2009-05-01

To investigate outcomes of a telephonic nursing disease management program for Medicaid patients with diabetes residing in Puerto Rico. A 12-month, matched-cohort study. Four hundred and ninety (490) intervention group members matched to 490 controls. Disease management diabetes program. For those in the intervention group, the disease management program customized a self-management intervention plan. Medical service utilization, including hospitalizations, emergency department visits, physician evaluation and management visits, selected clinical indicators, and financial impact. The intervention group showed significant effects compared with the control group, including a 48% reduction in inpatient bed days, and a 23% increase in ACE inhibitor use, resulting in a return on investment estimate of 3.8:1. The study demonstrates that a nursing disease management program for diabetes can significantly improve hospitalizations, drug compliance, and vaccinations in a Hispanic Medicaid population.

Antipsychotic polypharmacy prescribing patterns and costs in the Florida adult and child Medicaid populations.

PubMed

Becker, Edmund R; Constantine, Robert J; McPherson, Marie A; Jones, Mary Elizabeth

2013-01-01

The rapid growth in the use of antipsychotic medications and their related costs have resulted in states developing programs to measure, monitor, and insure their beneficial relevance to public program populations. One such program developed in the state of Florida has adopted an evidence-based approach to identify prescribers with unusual psychotherapeutic prescription patterns and track their utilization and costs among Florida Medicaid patients. This study reports on the prescriber prescription and cost patterns for adults and children using three measures of unusual antipsychotic prescribing patterns: (1) two antipsychotics for 60 days (2AP60), (2) three antipsychotics for 60 days (3AP60), and (2) two antipsychotics for 90 or more days (2AP90). We find that over the four-year study period there were substantial increases in several aspects of the Florida Medicaid behavioral drug program. Overall, for adults and children, patient participation increased by 29 percent, the number of prescriptions grew by 30 percent, and the number of prescribers that wrote at least one prescription grew 48.5 percent, while Medicaid costs for behavioral drugs increased by 32 percent. But the results are highly skewed. We find that a relatively small number of prescribers account for a disproportionately large share of prescriptions and costs of the unusual antipsychotic prescriptions. In general, the top 350 Medicaid prescribers accounted for more than 70 percent of the unusual antipsychotic prescriptions, and we find that this disparity in unusual prescribing patterns appears to be substantially more pronounced in adults than in children prescribers. For just the top 13 adult and children prescribers, their practice patterns accounted for 11 percent to 21 percent of the unusual prescribing activity and, overall, these 13 top prescribers accounted for 13 percent of the total spent on antipsychotics by the Florida Medicaid program and 9.3 percent of the total expenditure by the state for all drugs. Our findings suggest that a strategy to monitor and ensure patient safety and prescribing patterns that targets a relatively small number of Medicaid providers could have a substantial benefit and prove to be cost effective.

Expanding Medicaid managed care: the right choice for Texas?

PubMed

Reddy, Swapna; Finley, Marisa; Posey, Dan; Rohack, James J

2012-10-01

We set out to determine whether expanding Medicaid managed care in Texas is the solution to the challenges faced by the state of meeting the healthcare needs of a rapidly growing Medicaid population while addressing its own fiscal limitations. We reviewed the Texas Medicaid program, the potential effects of federal healthcare reform, and the state political climate through the perspectives (advantages and disadvantages) of the primary stakeholders: patients, practitioners, hospitals, and insurers. Research was performed through online, federal and state regulatory, and legislative review. In addition, we reviewed government and peer-reviewed reports and articles pertaining to issues related to Medicaid populations, healthcare practitioners, and hospitals that serve them. Each primary stakeholder had potential advantages and disadvantages associated with the expansion of Medicaid managed care. We conclude that expanding Medicaid managed care, if done in a manner responsive to the needs of recipients, can meet enrollees' healthcare needs while controlling the state's costs.

Medicaid Long-Term Care: State Variation and the Intergovernmental Lobby.

PubMed

Thompson, Frank J; Cantor, Joel C; Farnham, Jennifer

2016-08-01

Medicaid is vastly more important than Medicare or private insurance in funding long-term care (LTC). However, states vary tremendously in their commitment to Medicaid LTC. This article advances knowledge of the origins, nature, and implications of this variation. After examining the degree of variation in state spending on Medicaid LTC, we show how federal policy has over the past fifty years steadily increased state discretion to shape these services. This decentralization largely reflects the potency of the intergovernmental lobby-governors and other state officials-in influencing federal policy. While fueling state variation, the intergovernmental lobby has also provided valuable political support that has helped Medicaid grow and resist retrenchment. After considering policy options that could mitigate Medicaid LTC inequities rooted in state differences, we assess how the catalytic forces that have fueled growth in Medicaid LTC may be insufficient to protect the program from future erosion. Copyright © 2016 by Duke University Press.

Water fluoridation and costs of Medicaid treatment for dental decay--Louisiana, 1995-1996.

PubMed

1999-09-03

Treatment costs for dental decay in young children can be substantial, especially if extensive dental procedures and general anesthesia in a hospital operating room (OR) are needed. Because caries in the primary dentition disproportionately affect children from low-income households, the cost for care frequently is reimbursed by state Medicaid programs. To determine whether the average treatment cost for Medicaid-eligible children in Louisiana differed by community fluoridation status, the Louisiana Department of Health and Hospitals (LDHH) and CDC analyzed Medicaid dental reimbursements and Medicaid eligibility records from July 1995 through June 1996 for children aged 1-5 years. Findings suggest that Medicaid-eligible children in communities without fluoridated water were three times more likely than Medicaid-eligible children in communities with fluoridated water to receive dental treatment in a hospital OR, and the cost of dental treatment per eligible child was approximately twice as high.

75 FR 44972 - Medicare and Medicaid Programs; Announcement of an Application From a Hospital Seeking To Enter...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-30

... waiver under section 1138(a)(2) of the Social Security Act (the Act), has requested to enter into an... change is likely to increase organ donation and will ensure equitable treatment for patients in both...)(1)(C) of the Social Security Act (the Act) and our regulations at Sec. 482.45. Section 1138(a)(1)(A...

42 CFR 456.506 - Waiver options for Medicaid agency.

Code of Federal Regulations, 2011 CFR

2011-10-01

... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Review Plans: FFP, Waivers... options for Medicaid agency. (a) The agency may apply for a waiver at any time it has the procedures...

75 FR 30243 - Medicaid Program; Premiums and Cost Sharing

Federal Register 2010, 2011, 2012, 2013, 2014

2010-05-28

... commenters urged CMS to fulfill its responsibilities for early Tribal consultation, which did not occur with... and the Center for Medicaid, CHIP and Survey and Certification within CMS jointly hosted two All...

On Medicaid and the Affordable Care Act in Connecticut

PubMed Central

Manthous, Constantine A.; Sofair, Andre N.

2014-01-01

Background: Medicaid is the federal program, administered by states, for health care for the poor. The Affordable Care Act (ACA) has added a large number of new recipients to this program. Hypothesis: Medicaid programs in some, if not many, states do not provide patients uniform access to subspecialty care guaranteed by the federal statutes. Insofar as the ACA does not address this pre-existing “sub-specialty gap” and more patients are now covered by Medicaid under the ACA, the gap is likely to increase and may contribute to disparities of health care access and outcomes. Methods: A brief description of previous studies demonstrating or suggesting a subspecialty gap in Medicaid services is accompanied by perspectives of the authors, using published literature — most notably the Denver, Colorado health care system — to propose various solutions that may be deployed to address gaps in subspecialty coverage. Results: All published studies describing the Medicaid subspecialty gap are qualitative, survey designs. There are no authoritative objective data regarding the exact prevalence of gaps for each subspecialty in each state. However, surveys of caregivers suggest that gaps were prevalent in the United States prior to initiation of the ACA. Even fewer papers have addressed solutions (in light of the paucity of data describing the magnitude of the problem), and proposed solutions remain speculative and not grounded in objective data. Conclusions: There is reason to believe that a substantial proportion of U.S. citizens — those who are guaranteed a full complement of health services through Medicaid — have difficult or no access to some subspecialty services, many of which other citizens take for granted. This problem deserves greater attention to verify its existence, quantify its magnitude, and develop solutions. PMID:25506291

Medicaid At 50: Remarkable Growth Fueled By Unexpected Politics.

PubMed

Sparer, Michael S

2015-07-01

Medicaid has grown exponentially since the mid-1980s, during both conservative Republican and liberal Democratic administrations. How has this happened? The answer is rooted in three political variables: interest groups, political culture, and American federalism. First, interest-group support (from hospitals, nursing homes, and insurers) is more influential than the fragmented group opposition (from underpaid office-based physicians). Second, Medicaid provides a partial counterweight to conservative charges of a federal health care takeover because of the states' roles in administering the program. Third, Medicaid's intergovernmental fiscal partnership creates financial incentives for state and federal officials to expand enrollment-expansions that these policy makers often favor, given the program's increasingly important role in the nation's health care system. This institutional dynamic is here called catalytic federalism. Project HOPE—The People-to-People Health Foundation, Inc.

Seizing opportunities under the Affordable Care Act for transforming the mental and behavioral health system.

PubMed

Mechanic, David

2012-02-01

The Affordable Care Act, along with Medicaid expansions, offers the opportunity to redesign the nation's highly flawed mental health system. It promotes new programs and tools, such as health homes, interdisciplinary care teams, the broadening of the Medicaid Home and Community-Based Services option, co-location of physical health and behavioral services, and collaborative care. Provisions of the act offer extraordinary opportunities, for instance, to insure many more people, reimburse previously unreimbursed services, integrate care using new information technology tools and treatment teams, confront complex chronic comorbidities, and adopt underused evidence-based interventions. The Centers for Medicare and Medicaid Services and its Center for Medicare and Medicaid Innovation should work intensively with the states to implement these new programs and other arrangements and begin to fulfill the many unmet promises of community mental health care.

An evaluation of the impact of maternity care coordination on Medicaid birth outcomes in North Carolina.

PubMed Central

Buescher, P A; Roth, M S; Williams, D; Goforth, C M

1991-01-01

BACKGROUND. Care coordination is an important component of the enhanced prenatal care services provided under the recent expansions of the Medicaid program. The effect of maternity care coordination services on birth outcomes in North Carolina was assessed by comparing women on Medicaid who did and did not receive these services. METHODS. Health program data files, including Medicaid claims paid for maternity care coordination, were linked to 1988 and 1989 live birth certificates. Simple comparisons of percentages and rates were supplemented by a logistic regression analysis. RESULTS. Among women on Medicaid who did not receive maternity care coordination services, the low birth weight rate was 21% higher, the very low birth weight rate was 62% higher, and the infant mortality rate was 23% higher than among women on Medicaid who did receive such services. It was estimated that, for each $1.00 spent on maternity care coordination, Medicaid saved $2.02 in medical costs for newborns up to 60 days of age. Among the women who did receive maternity care coordination, those receiving it for 3 or more months had better outcomes than those receiving it for less than 3 months. CONCLUSIONS: These results suggest that maternity care coordination can be effective in reducing low birth weight, infant mortality, and newborn medical care costs among babies born to women in poverty. PMID:1746659

An evaluation of the impact of maternity care coordination on Medicaid birth outcomes in North Carolina.

PubMed

Buescher, P A; Roth, M S; Williams, D; Goforth, C M

1991-12-01

Care coordination is an important component of the enhanced prenatal care services provided under the recent expansions of the Medicaid program. The effect of maternity care coordination services on birth outcomes in North Carolina was assessed by comparing women on Medicaid who did and did not receive these services. Health program data files, including Medicaid claims paid for maternity care coordination, were linked to 1988 and 1989 live birth certificates. Simple comparisons of percentages and rates were supplemented by a logistic regression analysis. Among women on Medicaid who did not receive maternity care coordination services, the low birth weight rate was 21% higher, the very low birth weight rate was 62% higher, and the infant mortality rate was 23% higher than among women on Medicaid who did receive such services. It was estimated that, for each $1.00 spent on maternity care coordination, Medicaid saved $2.02 in medical costs for newborns up to 60 days of age. Among the women who did receive maternity care coordination, those receiving it for 3 or more months had better outcomes than those receiving it for less than 3 months. These results suggest that maternity care coordination can be effective in reducing low birth weight, infant mortality, and newborn medical care costs among babies born to women in poverty.