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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-07

... for Economic and Clinical Health Act HMO--Health Maintenance Organization HOS--Health Outcomes Survey... rule by early 2014. The stages represent an initial graduated approach to arriving at the ultimate goal...

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

42 CFR 423.160 - Standards for electronic prescribing.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Standards for electronic prescribing. 423.160 Section 423.160 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Cost Control and Quality...

42 CFR 456.702 - Definitions.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Definitions. 456.702 Section 456.702 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Drug Use Review (DUR) Program and Electronic Claims Management System...

42 CFR 456.700 - Scope.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Scope. 456.700 Section 456.700 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Drug Use Review (DUR) Program and Electronic Claims Management System...

42 CFR 456.702 - Definitions.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Definitions. 456.702 Section 456.702 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Drug Use Review (DUR) Program and Electronic Claims Management System...

Are low income patients receiving the benefits of electronic health records? A statewide survey.

PubMed

Butler, Matthew J; Harootunian, Gevork; Johnson, William G

2013-06-01

There are concerns that physicians serving low-income, Medicaid patients, in the United States are less likely to adopt electronic health records and, if so, that Medicaid patients will be denied the benefits from electronic health record use. This study seeks to determine whether physicians treating Medicaid patients were less likely to have adopted electronic health records. Physician surveys completed during physicians' license renewal process in Arizona were merged with the physician licensing data and Medicaid administrative claims data. Survey responses were received from 50.7 percent (6,780 out of 13,380) of all physicians practicing in Arizona. Physician survey responses were used to identify whether the physician used electronic health records and the degree to which the physician exchanged electronic health records with other health-care providers. Medicaid claims data were used to identify which physicians provided health care to Medicaid beneficiaries. The primary outcome of interest was whether Medicaid providers were more or less likely to have adopted electronic health records. Logistic regression analysis was used to estimate average marginal effects. In multivariate analysis, physicians with 20 or more Medicaid patients during the survey cycle were 4.1 percent more likely to use an electronic health record and 5.2 percent more likely to be able to transmit electronic health records to at least one health-care provider outside of their practice. These effects increase in magnitude when the analysis is restricted to solo practice physicians This is the first study to find a pro-Medicaid gap in electronic health record adoption suggesting that the low income patients served by Arizona's Health Care Cost Containment System are not at a disadvantage with regard to electronic health record access and that Arizona's model of promoting electronic health record adoption merits further study.

42 CFR 456.716 - DUR Board.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false DUR Board. 456.716 Section 456.716 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Drug Use Review (DUR) Program and Electronic Claims Management System...

42 CFR 456.716 - DUR Board.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false DUR Board. 456.716 Section 456.716 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Drug Use Review (DUR) Program and Electronic Claims Management System...

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.

42 CFR 495.338 - Health information technology implementation advance planning document requirements (HIT IAPD).

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 5 2011-10-01 2011-10-01 false Health information technology implementation... CERTIFICATION STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.338 Health information technology implementation advance planning document...

42 CFR 495.338 - Health information technology implementation advance planning document requirements (HIT IAPD).

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 5 2012-10-01 2012-10-01 false Health information technology implementation... CERTIFICATION STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.338 Health information technology implementation advance planning document...

42 CFR 495.338 - Health information technology implementation advance planning document requirements (HIT IAPD).

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 5 2014-10-01 2014-10-01 false Health information technology implementation... CERTIFICATION STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.338 Health information technology implementation advance planning document...

42 CFR 495.338 - Health information technology implementation advance planning document requirements (HIT IAPD).

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 5 2013-10-01 2013-10-01 false Health information technology implementation... CERTIFICATION STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.338 Health information technology implementation advance planning document...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-01-13

... Information Technology for Economic and Clinical Health Act HMO Health Maintenance Organization HOS Health... Sponsored Organization RHC Rural Health Clinic RPPO Regional Preferred Provider Organization SMHP State... proposed rulemaking on the process for organizations to conduct the certification of EHR technology. DATES...

42 CFR 495.338 - Health information technology implementation advance planning document requirements (HIT IAPD).

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false Health information technology implementation... CERTIFICATION STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.338 Health information technology implementation advance planning document...

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...

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...

42 CFR 495.336 - Health information technology planning advance planning document requirements (HIT PAPD).

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 5 2011-10-01 2011-10-01 false Health information technology planning advance... STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.336 Health information technology planning advance planning document requirements...

42 CFR 495.336 - Health information technology planning advance planning document requirements (HIT PAPD).

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 5 2013-10-01 2013-10-01 false Health information technology planning advance... STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.336 Health information technology planning advance planning document requirements...

42 CFR 495.336 - Health information technology planning advance planning document requirements (HIT PAPD).

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 5 2012-10-01 2012-10-01 false Health information technology planning advance... STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.336 Health information technology planning advance planning document requirements...

42 CFR 495.336 - Health information technology planning advance planning document requirements (HIT PAPD).

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 5 2014-10-01 2014-10-01 false Health information technology planning advance... STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.336 Health information technology planning advance planning document requirements...

42 CFR 495.336 - Health information technology planning advance planning document requirements (HIT PAPD).

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false Health information technology planning advance... STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.336 Health information technology planning advance planning document requirements...

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.

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-11-30

...] Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee Amount... rule with comment period entitled: ``Medicare, Medicaid, and Children's Health Insurance Programs... entitled ``Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application...

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.

What Works for Whom? A Bayesian Approach to Channeling Big Data Streams for Public Program Evaluation

ERIC Educational Resources Information Center

Finucane, Mariel McKenzie; Martinez, Ignacio; Cody, Scott

2018-01-01

In the coming years, public programs will capture even more and richer data than they do now, including data from web-based tools used by participants in employment services, from tablet-based educational curricula, and from electronic health records for Medicaid beneficiaries. Program evaluators seeking to take full advantage of these data…

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.

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...

42 CFR 495.370 - Appeals process for a Medicaid provider receiving electronic health record incentive payments.

Code of Federal Regulations, 2011 CFR

2011-10-01

... STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the... in § 447.253(e) of this chapter for a provider or entity to appeal the following issues related to... entity) has an opportunity to challenge the State's determination under this Part by submitting documents...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-11-02

...] Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee Amount... period entitled: ``Medicare, Medicaid, and Children's Health Insurance Programs; Additional Screening... application fees as part of the Medicare, Medicaid, and Children's Health Insurance Program (CHIP) provider...

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...

42 CFR 495.334 - [Reserved

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false [Reserved] 495.334 Section 495.334 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-29

... ``Therefore, we revise this measure to require that at least one of the five rules be related to a clinical quality measure, assuming the EP, eligible hospital or CAH has at least one clinical quality measure... rule to a specific clinical quality measure.'' 4. On page 44359, a. First column, first partial...

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...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-12-02

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-6051-N] Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee Amount... period entitled ``Medicare, Medicaid, and Children's Health Insurance Programs; Additional Screening...

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...

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...

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…

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...

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.

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 ...

78 FR 34387 - Agency Information Collection Activities; Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2013-06-07

... Facility Survey CMS-3070--Intermediate Care Facility (ICF) for the Mentally Retarded (MR) or Persons with Related Conditions Survey Report Form CMS-10336--Medicare and Medicaid Programs: Electronic Health Record... Renal Disease (ESRD) Medical Information Facility Survey; Use: The End Stage Renal Disease (ESRD...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-03-23

... 0938-AQ99 Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application..., and Children's Health Insurance Programs; Additional Screening Requirements, Application Fees... application fees as part of the Medicare, Medicaid and Children's Health Insurance Program (CHIP) provider...

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...

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.

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...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-12-27

... records software or information technology and training services. The final rule for this exception was... involving interoperable electronic health records software or information technology and training services... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part 411...

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...

Practice Innovation, Health Care Utilization and Costs in a Network of Federally Qualified Health Centers and Hospitals for Medicaid Enrollees.

PubMed

Johnson, Tricia J; Jones, Art; Lulias, Cheryl; Perry, Anthony

2018-06-01

State Medicaid programs need cost-effective strategies to provide high-quality care that is accessible to individuals with low incomes and limited resources. Integrated delivery systems have been formed to provide care across the continuum, but creating a shared vision for improving community health can be challenging. Medical Home Network was created as a network of primary care providers and hospital systems providing care to Medicaid enrollees, guided by the principles of egalitarian governance, practice-level care coordination, real-time electronic alerts, and pay-for-performance incentives. This analysis of health care utilization and costs included 1,189,195 Medicaid enrollees. After implementation of Medical Home Network, a risk-adjusted increase of $9.07 or 4.3% per member per month was found over the 2 years of implementation compared with an increase of $17.25 or 9.3% per member per month, before accounting for the cost of care management fees and other financial incentives, for Medicaid enrollees within the same geographic area with a primary care provider outside of Medical Home Network. After accounting for care coordination fees paid to providers, the net risk-adjusted cost reduction was $11.0 million.

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.

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 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...

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...

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.

Health information technology: standards, implementation specifications, and certification criteria for electronic health record technology, 2014 edition; revisions to the permanent certification program for health information technology. Final rule.

PubMed

2012-09-04

With this final rule, the Secretary of Health and Human Services adopts certification criteria that establish the technical capabilities and specify the related standards and implementation specifications that Certified Electronic Health Record (EHR) Technology will need to include to, at a minimum, support the achievement of meaningful use by eligible professionals, eligible hospitals, and critical access hospitals under the Medicare and Medicaid EHR Incentive Programs beginning with the EHR reporting periods in fiscal year and calendar year 2014. This final rule also makes changes to the permanent certification program for health information technology, including changing the program's name to the ONC HIT Certification Program.

42 CFR 435.909 - 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... in the States and District of Columbia Applications § 435.909 Automatic entitlement to Medicaid...

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...

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...

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

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

2015 Edition Health Information Technology (Health IT) Certification Criteria, 2015 Edition Base Electronic Health Record (EHR) Definition, and ONC Health IT Certification Program Modifications. Final rule.

PubMed

2015-10-16

This final rule finalizes a new edition of certification criteria (the 2015 Edition health IT certification criteria or "2015 Edition'') and a new 2015 Edition Base Electronic Health Record (EHR) definition, while also modifying the ONC Health IT Certification Program to make it open and accessible to more types of health IT and health IT that supports various care and practice settings. The 2015 Edition establishes the capabilities and specifies the related standards and implementation specifications that Certified Electronic Health Record Technology (CEHRT) would need to include to, at a minimum, support the achievement of meaningful use by eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) under the Medicare and Medicaid EHR Incentive Programs (EHR Incentive Programs) when such edition is required for use under these programs.

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 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

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...

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)

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.

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.

Medicaid and Children's Health Insurance Programs; Mental Health Parity and Addiction Equity Act of 2008; the Application of Mental Health Parity Requirements to Coverage Offered by Medicaid Managed Care Organizations, the Children's Health Insurance Program (CHIP), and Alternative Benefit Plans. Final rule.

PubMed

2016-03-30

This final rule will address the application of certain requirements set forth in the Public Health Service Act, as amended by the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, to coverage offered by Medicaid managed care organizations, Medicaid Alternative Benefit Plans, and Children’s Health Insurance Programs.

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...

The cost of Medicaid annuities.

PubMed

Levy, Robert A; Nyman, John A; Gabay, Mary; Riley, William; Feldman, Roger

2006-01-01

Medicaid annuities are annuities that long-term care recipients use to shelter assets, thereby qualifying them early for Medicaid eligibility. As such, these annuities have the potential to increase Medicaid costs. This study estimates the cost of annuities to the Medicaid program. From a sample of Medicaid applications in five states, we found the rate at which annuities were used and simulated their cost to Medicaid. We estimated that in 2004, Medicaid annuities cost Medicaid about 197 million dollars, which represented a small proportion of Medicaid's almost 50 billion dollars cost for nursing home care.

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-26

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-2336-PN] Medicare and Medicaid Programs; Application by Det Norske Veritas Healthcare for Deeming Authority for... application from Det Norske Veritas Healthcare (DNVHC) for recognition as a national accrediting organization...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-23

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-3258-PN] Medicare and Medicaid Programs; Application From Det Norske Veritas Healthcare (DNVHC) for Continued... application from Det Norske Veritas Healthcare (DNVHC) for continued recognition as a national accrediting...

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

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

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...

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

77 FR 54163 - Health Information Technology: Standards, Implementation Specifications, and Certification...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-09-04

...With this final rule, the Secretary of Health and Human Services adopts certification criteria that establish the technical capabilities and specify the related standards and implementation specifications that Certified Electronic Health Record (EHR) Technology will need to include to, at a minimum, support the achievement of meaningful use by eligible professionals, eligible hospitals, and critical access hospitals under the Medicare and Medicaid EHR Incentive Programs beginning with the EHR reporting periods in fiscal year and calendar year 2014. This final rule also makes changes to the permanent certification program for health information technology, including changing the program's name to the ONC HIT Certification Program.

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...

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...

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...

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...

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.

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

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.

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

PubMed

2012-11-15

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

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

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.

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.

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).

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

Policy and system strategies in promoting child health information systems, including the role of Medicaid, the state children's health insurance program, and public financing.

PubMed

MacTaggart, Patricia; Bagley, Bruce

2009-01-01

Government, through its unique roles as regulator, purchaser, provider, and facilitator, has an opportunity and an obligation to play a major role in accelerating the implementation of electronic health record systems and electronic health information exchange. Providers, who are expected to deliver appropriate care at designated locations at an appropriate cost, are dependent on health information technology for efficient effective health care. As state and federal governments move forward with health care purchasing reforms, they must take the opportunity to leverage policy and structure and to align incentives that enhance the potential for provider engagement in electronic health record adoption.

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.

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...

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...

78 FR 26036 - Medicare and Medicaid Programs: Application From the Accreditation Commission for Health Care for...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-05-03

...] Medicare and Medicaid Programs: Application From the Accreditation Commission for Health Care for Continued... from the Accreditation Commission for Health Care (ACHC) for continued recognition as a national... program every 6 years or as determined by CMS. The Accreditation Commission for Health Care's (ACHC's...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-09-20

...] Medicare and Medicaid Programs; Application from the Compliance Team for Initial CMS-Approval of its Rural... Compliance Team for initial recognition as a national accrediting organization for rural health clinics (RHCs... Compliance Team's request for initial CMS approval of its RHC accreditation program. This notice also...

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...

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.

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.

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.

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.

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.

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...

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...

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...

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…

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.

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.

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...

77 FR 37680 - Medicare and Medicaid Programs; Application From the Accreditation Association for Ambulatory...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-22

...] Medicare and Medicaid Programs; Application From the Accreditation Association for Ambulatory Health Care... of an application from the Accreditation Association for Ambulatory Health Care for continued... by CMS. The Accreditation Association for Ambulatory Health Care (AAAHC) current term of approval for...

78 FR 66364 - Medicare & Medicaid Programs: Application From the Accreditation Commission for Health Care for...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-11-05

...] Medicare & Medicaid Programs: Application From the Accreditation Commission for Health Care for Continued... Accreditation Commission for Health Care (ACHC) for continued recognition as a national accrediting organization...) announcing Accreditation Commission for Health Care's request for approval of its hospice accreditation...

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...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-09-27

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-04-24

... increase organ donations; and (2) will ensure equitable treatment of patients referred for transplants...] 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...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-10-04

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-08-24

... expected to increase organ donations; and (2) will ensure equitable treatment of patients referred for...] Medicare and Medicaid Programs; Announcement of Application From a Hospital Requesting Waiver for Organ... the requirement to have an agreement with its designated Organ Procurement Organization (OPO). The...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-02-03

...--(1) is expected to increase organ donations; and (2) will ensure equitable treatment of patients...] Medicare and Medicaid Programs; Announcement of Applications From Hospitals Requesting Waiver for Organ... otherwise require the hospitals to enter into an agreement with their designated Organ Procurement...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-12-20

... must determine that the waiver--(1) is expected to increase organ donations; and (2) will ensure...] Medicare and Medicaid Programs; Announcement of Application From Hospital Requesting Waiver for Organ... Hospital to participate in an Organ Procurement Organization (OPO) outside of its designated OPO. The...

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.

76 FR 47592 - Agency Information Collection Activities: Submission for OMB Review; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2011-08-05

... Federal financial participation for expenditures under their Medicaid Electronic Health Record Incentive... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [Document...), Department of Health and Human Services, is publishing the following summary of proposed collections for...

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...

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...

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...

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

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

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

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.

75 FR 59272 - Medicare and Medicaid Programs; Announcement of an Application from a Hospital Requesting Waiver...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-09-27

... 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...

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...

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

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...

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…

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'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

75 FR 36157 - Establishment of the Temporary Certification Program for Health Information Technology

Federal Register 2010, 2011, 2012, 2013, 2014

2010-06-24

...This final rule establishes a temporary certification program for the purposes of testing and certifying health information technology. This final rule is established under the authority granted to the National Coordinator for Health Information Technology (the National Coordinator) by section 3001(c)(5) of the Public Health Service Act (PHSA), as added by the Health Information Technology for Economic and Clinical Health (HITECH) Act. The National Coordinator will utilize the temporary certification program to authorize organizations to test and certify Complete Electronic Health Records (EHRs) and/or EHR Modules, thereby making Certified EHR Technology available prior to the date on which health care providers seeking incentive payments available under the Medicare and Medicaid EHR Incentive Programs may begin demonstrating meaningful use of Certified EHR Technology.

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.

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.

Participation of Colorado pediatricians and family physicians in the Medicaid program.

PubMed Central

Berman, S.; Wasserman, S.; Grimm, S.

1991-01-01

The Pediatric Health Policy Group of the University of Colorado Health Sciences Center (Denver) surveyed 650 family physicians and 296 pediatricians in 1988, with 50% of family physicians and 48% of pediatricians responding. Half of the pediatricians in private practice and 35% of family physicians in private practice accepted all children who were Medicaid beneficiaries into their practice; 42% of pediatricians and 50% of family physicians accepted all non-Medicaid patients but only some new Medicaid patients; and 8% of pediatricians and 15% of family physicians accepted new non-Medicaid patients but no Medicaid patients. Practice location was associated with the level of Medicaid participation for these primary care physicians: Significantly more rural pediatricians and family physicians than those with urban practices accepted Medicaid patients. The average reimbursement level for these physicians was shown to be an important determinant of whether physicians would accept Medicaid patients. Nonparticipatory physicians were more concerned about excessive paperwork compared with physicians with limited participation. Among physicians with limited participation, family physicians and pediatricians both cited problems of excessive paperwork, reimbursement delays, and retroactive denials of payment as important deterrents to accepting Medicaid patients. PMID:1812643

Decrease in Statewide Antipsychotic Prescribing after Implementation of Child and Adolescent Psychiatry Consultation Services.

PubMed

Barclay, Rebecca P; Penfold, Robert B; Sullivan, Donna; Boydston, Lauren; Wignall, Julia; Hilt, Robert J

2017-04-01

To learn if a quality of care Medicaid child psychiatric consultation service implemented in three different steps was linked to changes in statewide child antipsychotic utilization. Washington State child psychiatry consultation program primary data and Medicaid pharmacy division antipsychotic utilization secondary data from July 1, 2006, through December 31, 2013. Observational study in which consult program data were analyzed with a time series analysis of statewide antipsychotic utilization. All consultation program database information involving antipsychotics was compared to Medicaid pharmacy division database information involving antipsychotic utilization. Washington State's total child Medicaid antipsychotic utilization fell from 0.51 to 0.25 percent. The monthly prevalence of use fell by a mean of 0.022 per thousand per month following the initiation of elective consults (p = .004), by 0.065 following the initiation of age/dose triggered mandatory reviews (p < .001), then by another 0.022 following the initiation of two or more concurrent antipsychotic mandatory reviews (p = .001). High-dose antipsychotic use fell by 57.8 percent in children 6- to 12-year old and fell by 52.1 percent in teens. Statewide antipsychotic prescribing for Medicaid clients fell significantly at different rates following each implementation step of a multilevel consultation and best-practice education service. © Health Research and Educational Trust.

The 2015 Long-Term Budget Outlook

DTIC Science & Technology

2015-06-17

and an increasing number of recipients of exchange subsidies and Medicaid benefits attributable to the Affordable Care Act would push up spending...for Social Security and the government’s major health care programs—Medicare, Medicaid , the Children’s Health Insurance Program, and subsidies for...number of recipients of exchange subsidies and Medicaid benefits attributable to the Affordable Care Act.  The government’s net outlays for

Medicaid and Financing of Health Care for Children in Foster Care: Findings from a National Survey. Health Services for Children in Foster Care. Number 1

ERIC Educational Resources Information Center

Inkelas, Moira; Halfon, Neal

2002-01-01

In recent years, state Medicaid programs have implemented significant change and innovation in delivering health and behavioral health services. Prepaid capitated financing and the provider networks created by Medicaid managed care expansions have altered systems of medical and mental/behavioral health. Most children in foster care receive…

An evaluation of Washington's Medicaid disease-management program.

PubMed

Lind, Alice; Kaplan, Louise

2007-10-01

In 2002, Washington State Medicaid implemented a disease-management program for clients with diagnoses of asthma, chronic obstructive pulmonary disease, heart failure, and diabetes. The program represented a unique attempt to manage disabled clients in a fee-for-services environment, and at its onset, was one of the first statewide programs in the United States. This article reviews the effectiveness of the program based on the results from two independent evaluations. Results of cost-savings measurements and health outcomes are presented for each of the conditions. These results were used to make program changes, which began in 2007.

A Cross-Sectional Cohort Study of a Large, Statewide Medicaid Home and Community-Based Services Autism Waiver Program

ERIC Educational Resources Information Center

Eskow, Karen Goldrich; Chasson, Gregory S.; Summers, Jean Ann

2015-01-01

State-specific 1915(c) Medicaid Home and Community-Based Services waiver programs have become central in the provision of services specifically tailored to children with autism spectrum disorders (ASD). Using propensity score matching, 130 families receiving waiver services for a child with ASD were matched with and compared to 130 families…

Marketing EPSDT to Clients: A Self-Instructional Module for Early Periodic Screening Diagnosis Treatment.

ERIC Educational Resources Information Center

Simon, John L.; McArdle, Patricia

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a program of preventive health services available to individuals under 21 years of age who are eligible for Medicaid benefits. As of July 1, 1973, all states operating a Medicaid program were required to provide EPSDT services to all those eligible. The purpose of this module is to…

"In the Driver's Seat": Parent Perceptions of Choice in a Participant-Directed Medicaid Waiver Program for Young Children with Autism

ERIC Educational Resources Information Center

Timberlake, Maria T.; Leutz, Walter N.; Warfield, Marji Erickson; Chiri, Giuseppina

2014-01-01

This study investigated families' experience of choice within a participant-directed Medicaid waiver program for young children with autism. Fourteen parents or grandparents participated in in-depth interviews about their experience of choosing personnel, directing in-home services, and managing the $25,000 annual allocation. Key findings…

EPSDT: Child Health. Child Health Information for Workers in the Medicaid Early and Periodic Screening Diagnosis and Treatment Program.

ERIC Educational Resources Information Center

Manela, Roger; And Others

One of six information booklets with accompanying training materials for the Medicaid Early and Periodic Screening Diagnosis and Treatment (EPSDT) program, this booklet describes the stages of child growth and development and some of the health problems which EPSDT clients might have. Section I describes tests commonly included in an EPSDT…

The net fiscal impact of a chronic disease management program: Indiana Medicaid.

PubMed

Holmes, Ann M; Ackermann, Ronald D; Zillich, Alan J; Katz, Barry P; Downs, Stephen M; Inui, Thomas S

2008-01-01

In 2003 the Indiana Office of Medicaid Policy and Planning implemented the Indiana Chronic Disease Management Program (ICDMP). This paper reports on the fiscal impact of the ICDMP from the state's perspective, as estimated from the outcomes of a randomized trial. Medicaid members with congestive heart failure (CHF) or diabetes, or both, were randomly assigned by practice site to chronic disease management services or standard care. The effect of the ICDMP varied by disease group and risk class: while cost savings were achieved in the CHF subgroup, disease management targeted to patients with only diabetes resulted in no significant fiscal impact.

Understanding the recent growth in Medicaid spending, 2000-2003.

PubMed

Holahan, John; Ghosh, Arunabh

2005-01-01

Growth in Medicaid spending averaged 10.2 percent per year between 2000 and 2003, resulting in a one-third increase in program spending. Spending growth was lower from 2002 to 2003 because of slower growth in enrollment and in spending per enrollee, particularly for acute care services, and declines in disproportionate-share hospital (DSH) payments and upper payment limit (UPL) programs. For the entire 2000-2003 period, Medicaid spending increases were largely driven by enrollment growth, much of which was attributable to the economic downturn. Increases in spending per enrollee over the period were faster than inflation but slower than increases in private insurance spending.

Effects of state-level medicaid policies and patient characteristics on time to breast cancer surgery among medicaid beneficiaries.

PubMed

Halpern, Michael T; Schrag, Deborah

2016-08-01

Medicaid beneficiaries with cancer are less likely to receive timely and high-quality care. This study examined whether differences in state-level Medicaid policies affect delays in time to surgery (TTS) among women diagnosed with breast cancer. Using 2006-2008 Medicaid data, we identified women aged 18-64 enrolled in Medicaid diagnosed with breast cancer. Analyses examined associations of state-specific Medicaid surgery reimbursements, Medicaid eligibility recertification period (annually vs. shorter) and required patient copayment on time from breast cancer diagnosis to receipt of breast surgery. Patients receiving neoadjuvant therapy were excluded. Separate multivariable regression analyses controlling for patient demographic characteristics and clustering by state were performed for breast conserving surgery (BCS), inpatient mastectomy, and outpatient mastectomy. The study included 7542 Medicaid beneficiaries with breast cancer: 3272 received BCS, 2156 outpatient mastectomy, and 2115 inpatient mastectomy. Higher Medicaid reimbursements for BCS were associated with decreased time from diagnosis to surgery. A 12-month (vs. <12 month) Medicaid eligibility recertification period was associated with decreased TTS for BCS and outpatient mastectomy. Black Medicaid beneficiaries (compared with non-Hispanic White beneficiaries) were more likely to experience delays for all three types of surgery, while Hispanic beneficiaries were more likely to experience delays only for outpatient mastectomy. State-level Medicaid policies and patient characteristics can affect receipt of timely surgery among Medicaid beneficiaries with breast cancer. As delays in surgery can increase morbidity and mortality, changes to state Medicaid policies and health system programs are needed to improve access to care for this vulnerable population.

Estimating Causal Effects in Observational Studies using Electronic Health Data: Challenges and (Some) Solutions

PubMed Central

Stuart, Elizabeth A.; DuGoff, Eva; Abrams, Michael; Salkever, David; Steinwachs, Donald

2013-01-01

Electronic health data sets, including electronic health records (EHR) and other administrative databases, are rich data sources that have the potential to help answer important questions about the effects of clinical interventions as well as policy changes. However, analyses using such data are almost always non-experimental, leading to concerns that those who receive a particular intervention are likely different from those who do not in ways that may confound the effects of interest. This paper outlines the challenges in estimating causal effects using electronic health data and offers some solutions, with particular attention paid to propensity score methods that help ensure comparisons between similar groups. The methods are illustrated with a case study describing the design of a study using Medicare and Medicaid administrative data to estimate the effect of the Medicare Part D prescription drug program on individuals with serious mental illness. PMID:24921064

Medicare Part D: successes and continuing challenges. Impact of Medicare Part D on Massachusetts health programs and beneficiaries.

PubMed

Thomas, Cindy Parks; Sussman, Jeffrey

2007-05-30

On January 1, 2006, the Centers for Medicare and Medicaid Services (CMS) implemented the Medicare Drug Benefit, or "Medicare Part D." The program offers prescription drug coverage for the one million Medicare beneficiaries in Massachusetts. Part D affects Massachusetts state health programs and beneficiaries in a number of ways. The program: (1) provides prescription drug insurance, including catastrophic coverage, through a choice of private prescription drug plans (PDPs) or integrated Medicare Advantage (MA-PD) health plans; (2) shifts prescription drug coverage for dual-eligible Medicare / Medicaid beneficiaries from Medicaid to Medicare Part D drug plans; (3) requires a maintenance-of-effort, or "clawback" payments from states to CMS designed to capture a portion of states' Medicaid savings to help finance the benefit; (4) offers additional help for premiums and cost sharing to low income beneficiaries through the Low Income Subsidy (LIS); and (5) provides a subsidy to employer groups that maintain their own prescription drug coverage for retired beneficiaries. This paper summarizes the activities involved in implementing Medicare Part D, the impact it has had on Massachusetts health programs, and the experiences of beneficiaries and others conducting outreach and enrollment. The data are drawn from interviews with officials and documents provided by state health programs, CMS and the Social Security Administration, and representatives of provider and advocacy groups involved in the enrollment and ongoing support of Medicare beneficiaries.

Coordination of health coverage for Medicare enrollees: living with HIV/AIDS in California.

PubMed

Eichner, J; Kahn, J G

2001-08-01

Because Medicare does not cover a large part of the health care that its enrollees living with HIV/AIDS require, they need other coverage to supplement Medicare. Medicaid is a major source of that supplemental coverage. In California, Medicare enrollees with HIV/AIDS who were also enrolled in Medi-Cal (California's Medicaid program) had total payments from both programs of $177 million, or an average of $28,956 per person in the fee-for-service-system in 1998. Of that total, Medicare paid for 38 percent, mainly for inpatient visits and ambulatory care, while Medi-Cal paid 62 percent, mainly for prescription drugs. For these dual enrollees, many of Medicare's benefit gaps--including a large share of prescription drugs, nursing facility services and home care--are being filled by Medi-Cal. Data in this Medicare Brief indicate that the incremental cost to the federal government of filling gaps in the Medicare benefits package would be considerably less than the full cost of the additional benefits. Through Medicaid and other programs, the federal government is already paying a substantial part of public program expenditures for dual enrollees with HIV/AIDS. Other issues to consider are how the dual Medicare-Medicaid funding streams affect the programs' cost efficiency, and from the perspective of Medicare enrollees and providers, how well the dual programs coordinate to meet the needs of people with HIV/AIDS and other chronic conditions.

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.

Study of participating and nonparticipating states' telemedicine Medicaid reimbursement status: Its impact on Idaho's policymaking process.

PubMed

Gray, Gayle A; Stamm, B Hudnall; Toevs, Sarah; Reischl, Uwe; Yarrington, Diane

2006-12-01

Although Medicare currently reimburses for telemedicine services, advocates are struggling to increase state Medicaid reimbursement. This study provides data from a national study of Medicaid telemedicine reimbursement policies and examines Idaho as a case study for developing telemedicine reimbursement policies. Idahoans have actively advocated for Medicaid telemedicine reimbursement by forming a statewide network. Working with policymakers, Idaho Medicaid and telemedicine advocates established interpersonal connections, providing policymakers information and support. With developing academic, private, and legislative interest, a window of opportunity opened to allow for positive, albeit minimal, movement. To establish protocols for Idaho's use of telemedicine, a national electronic policy survey was conducted to evaluate the direction of telemedicine policy in state Medicaid agencies. Surveys to explore Medicaid reimbursement status were sent to states that were both participating and non-participating in telemedicine. Responses were received from 10 of the 25 states providing Medicaid telemedicine reimbursement and 17 of the 25 states and one U.S. territory not providing reimbursement. Issues common among participating states included provider and reimbursement complications, allowable services, and modification of reimbursement codes. Nonparticipating states indicated an interest in reimbursing for telemedicine and a need to enhance advocate and state Medicaid agency relationships. In addition, the survey results demonstrated the need to provide cost-benefit analysis on the viability of Medicaid reimbursement for telemedicine. Research outcomes were used to develop Idaho's Interactive Video Telemedicine Protocols. These address identified barriers and fears regarding Medicare reimbursement and state budgetary concerns--the additional major issue identified for state Medicaid agencies.

Effect of Outreach Messages on Medicaid Enrollment

PubMed Central

Stillson, Christian; Rosin, Roy; Cahill, Rachel; Kruger, Evelyne; Grande, David

2017-01-01

Objectives. To measure the impact of different outreach messages on health insurance enrollment among Medicaid-eligible adults. Methods. Between March 2015 and April 2016, we conducted a series of experiments using mail-based outreach that encouraged individuals to enroll in Pennsylvania’s expanded Medicaid program. Recipients were randomized to receive 1 of 4 different messages describing the benefits of health insurance. The primary outcome was the response rate to each letter. Results. We mailed outreach letters to 32 993 adults in Philadelphia. Messages that emphasized the dental benefits of insurance were significantly more likely to result in a response than messages emphasizing the health benefits (odds ratio = 1.33; 95% confidence interval = 1.10, 1.61). Conclusions. Medicaid enrollment outreach messages that emphasized the dental benefits of insurance were more effective than those that emphasized the health-related benefits. Public Health Implications. Although the structure and eligibility of the Medicaid program are likely to change, testing and identifying successful outreach and enrollment strategies remains important. Outreach messages that emphasize dental benefits may be more effective at motivating enrollment among individuals of low socioeconomic status. PMID:28661816

The Center For Medicare And Medicaid Innovation's blueprint for rapid-cycle evaluation of new care and payment models.

PubMed

Shrank, William

2013-04-01

The Affordable Care Act established the Center for Medicare and Medicaid Innovation to test innovative payment and service delivery models. The goal is to reduce program expenditures while preserving or improving the quality of care provided to beneficiaries of Medicare, Medicaid, and the Children's Health Insurance Program. Central to the success of the Innovation Center is a new, rapid-cycle approach to evaluation. This article describes that approach--setting forth how the Rapid Cycle Evaluation Group aims to deliver frequent feedback to providers in support of continuous quality improvement, while rigorously evaluating the outcomes of each model tested. This article also describes the relationship between the group's work and that of the Office of the Actuary at the Centers for Medicare and Medicaid Services, which plays a central role in the assessment of new models.

Medicaid care management: description of high-cost addictions treatment clients.

PubMed

Neighbors, Charles J; Sun, Yi; Yerneni, Rajeev; Tesiny, Ed; Burke, Constance; Bardsley, Leland; McDonald, Rebecca; Morgenstern, Jon

2013-09-01

High utilizers of alcohol and other drug treatment (AODTx) services are a priority for healthcare cost control. We examine characteristics of Medicaid-funded AODTx clients, comparing three groups: individuals <90th percentile of AODTx expenditures (n=41,054); high-cost clients in the top decile of AODTx expenditures (HC; n=5,718); and 1760 enrollees in a chronic care management (CM) program for HC clients implemented in 22 counties in New York State. Medicaid and state AODTx registry databases were combined to draw demographic, clinical, social needs and treatment history data. HC clients accounted for 49% of AODTx costs funded by Medicaid. As expected, HC clients had significant social welfare needs, comorbid medical and psychiatric conditions, and use of inpatient services. The CM program was successful in enrolling some high-needs, high-cost clients but faced barriers to reaching the most costly and disengaged individuals. Copyright © 2013 Elsevier Inc. All rights reserved.

An Examination of the Medicaid Undercount in the Current Population Survey: Preliminary Results from Record Linking

PubMed Central

Davern, Michael; Klerman, Jacob Alex; Baugh, David K; Call, Kathleen Thiede; Greenberg, George D

2009-01-01

Objective To assess reasons why survey estimates of Medicaid enrollment are 43 percent lower than raw Medicaid program enrollment counts (i.e., “Medicaid undercount”). Data Sources Linked 2000–2002 Medicaid Statistical Information System (MSIS) and the 2001–2002 Current Population Survey (CPS). Data Collection Methods Centers for Medicare and Medicaid Services provided the Census Bureau with its MSIS file. The Census Bureau linked the MSIS to the CPS data within its secure data analysis facilities. Study Design We analyzed how often Medicaid enrollees incorrectly answer the CPS health insurance item and imperfect concept alignment (e.g., inclusion in the MSIS of people who are not included in the CPS sample frame and people who were enrolled in Medicaid in more than one state during the year). Principal Findings The extent to which the Medicaid enrollee data were adjusted for imperfect concept alignment reduces the raw Medicaid undercount considerably (by 12 percentage points). However, survey response errors play an even larger role with 43 percent of Medicaid enrollees answering the CPS as though they were not enrolled and 17 percent reported being uninsured. Conclusions The CPS is widely used for health policy analysis but is a poor measure of Medicaid enrollment at any time during the year because many people who are enrolled in Medicaid fail to report it and may be incorrectly coded as being uninsured. This discrepancy should be considered when using the CPS for policy research. PMID:19187185

Medicare and Medicaid programs; waiver of disapproval of nurse aide training program in certain cases. Final rule.

PubMed

2010-04-23

This final rule will permit a waiver of a nurse aide training disapproval as it applies to skilled nursing facilities, in the Medicare program, and nursing facilities, in the Medicaid program, that are assessed a civil money penalty of at least $5,000 for noncompliance that is not related to quality of care. This is a statutory provision enacted by section 932 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173, enacted December 8, 2003).

Identifying hospitals that may be at most financial risk from Medicaid disproportionate-share hospital payment cuts.

PubMed

Cole, Evan S; Walker, Daniel; Mora, Arthur; Diana, Mark L

2014-11-01

Medicaid disproportionate-share hospital (DSH) payments are expected to decline by $35.1 billion between fiscal years 2017 and 2024, a reduction brought about by the Affordable Care Act (ACA) and recent congressional action. DSH payments have long been a feature of the Medicaid program, intended to partially offset uncompensated care costs incurred by hospitals that treat uninsured and Medicaid populations. The DSH payment cuts were predicated on the expectation that the ACA's expansion of health insurance to millions of Americans would bring about a decline in many hospitals' uncompensated care costs. However, the decision of twenty-five states not to expand their Medicaid programs, combined with residual coverage gaps, may leave as many as thirty million people uninsured, and hospitals will bear the burden of their uncompensated care costs. We sought to identify the hospitals that may be the most financially vulnerable to reductions in Medicaid DSH payments. We found that of the 529 acute care hospitals that will be particularly affected by the cuts, 225 (42.5 percent) are in weak financial condition. Policy makers should recognize that decreases in revenue may affect these hospitals' ability to give vulnerable populations access to care. Project HOPE—The People-to-People Health Foundation, Inc.

Abortion Providers' Experiences with Medicaid Abortion Coverage Policies: A Qualitative Multistate Study

PubMed Central

Dennis, Amanda; Blanchard, Kelly

2013-01-01

Objective To evaluate the implementation of state Medicaid abortion policies and the impact of these policies on abortion clients and abortion providers. Data Source From 2007 to 2010, in-depth interviews were conducted with representatives of 70 abortion-providing facilities in 15 states. Study Design In-depth interviews focused on abortion providers' perceptions regarding Medicaid and their experiences working with Medicaid and securing reimbursement in cases that should receive federal funding: rape, incest, and life endangerment. Data Extraction Data were transcribed verbatim before being coded. Principal Findings In two study states, abortion providers reported that 97 percent of submitted claims for qualifying cases were funded. Success receiving reimbursement was attributed to streamlined electronic billing procedures, timely claims processing, and responsive Medicaid staff. Abortion providers in the other 13 states reported reimbursement for 36 percent of qualifying cases. Providers reported difficulties obtaining reimbursement due to unclear rejections of qualifying claims, complex billing procedures, lack of knowledgeable Medicaid staff with whom billing problems could be discussed, and low and slow reimbursement rates. Conclusions Poor state-level implementation of Medicaid coverage of abortion policies creates barriers for women seeking abortion. Efforts to ensure policies are implemented appropriately would improve women's health. PMID:22742741

Abortion providers' experiences with Medicaid abortion coverage policies: a qualitative multistate study.

PubMed

Dennis, Amanda; Blanchard, Kelly

2013-02-01

To evaluate the implementation of state Medicaid abortion policies and the impact of these policies on abortion clients and abortion providers. From 2007 to 2010, in-depth interviews were conducted with representatives of 70 abortion-providing facilities in 15 states. In-depth interviews focused on abortion providers' perceptions regarding Medicaid and their experiences working with Medicaid and securing reimbursement in cases that should receive federal funding: rape, incest, and life endangerment. Data were transcribed verbatim before being coded. In two study states, abortion providers reported that 97 percent of submitted claims for qualifying cases were funded. Success receiving reimbursement was attributed to streamlined electronic billing procedures, timely claims processing, and responsive Medicaid staff. Abortion providers in the other 13 states reported reimbursement for 36 percent of qualifying cases. Providers reported difficulties obtaining reimbursement due to unclear rejections of qualifying claims, complex billing procedures, lack of knowledgeable Medicaid staff with whom billing problems could be discussed, and low and slow reimbursement rates. Poor state-level implementation of Medicaid coverage of abortion policies creates barriers for women seeking abortion. Efforts to ensure policies are implemented appropriately would improve women's health. © Health Research and Educational Trust.

Medicaid integrity program; limitation on contractor liability. Final rule.

PubMed

2007-11-30

The Medicaid Integrity Program (the Program) provides that the Secretary promote the integrity of the Medicaid program by entering into contracts with contractors that will review the actions of individuals or entities furnishing items or services (whether fee-for-service, risk, or other basis) for which payment may be made under an approved State plan and/or any waiver of the plan approved under section 1115 of the Social Security Act; audit claims for payment of items or services furnished, or administrative services furnished, under a State plan; identify overpayments of individuals or entities receiving Federal funds; and 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 for limitations on a contractor's liability while performing these services under the Program. The final rule will, to the extent possible, employ the same or comparable standards and other substantive and procedural provisions as are contained in section 1157 (Limitation on Liability) of the Social Security Act.

Providing More Home-Delivered Meals Is One Way To Keep Older Adults With Low Care Needs Out Of Nursing Homes

PubMed Central

Thomas, Kali S.; Mor, Vincent

2014-01-01

Programs that help older adults live independently in the community can also deliver net savings to states on the costs of long-term supports and services. We estimate that if all states had increased by 1 percent the number of adults age sixty-five or older who received home-delivered meals in 2009 under Title III of the Older Americans Act, total annual savings to states’ Medicaid programs could have exceeded $109 million. The projected savings primarily reflect decreased Medicaid spending for an estimated 1,722 older adults with low-care needs who would no longer require nursing home care— instead, they could remain at home, sustained by home-delivered meals. Twenty-six states could have realized net savings in 2009 from the expansion of their home-delivered meals programs, while twenty-two states would have incurred net costs. Programs such as home-delivered meals have the potential to provide substantial savings to some states’ Medicaid programs. PMID:24101071

Access is Not Enough: Characteristics of Physicians Who Treat Medicaid Patients.

PubMed

Geissler, Kimberley H; Lubin, Benjamin; Marzilli Ericson, Keith M

2016-04-01

Access to physicians is a major concern for Medicaid programs. However, little is known about relationships between physician participation in Medicaid and the individual-level and practice-level characteristics of physicians. We used the 2011 Massachusetts All Payer Claims Database, containing all commercial and Medicaid claims; we linked with data on physician characteristics. We measured Medicaid participation intensity (fraction of the physician's patient panel with Medicaid) for primary care physicians (PCPs) and medical specialists. We measured influence of physicians within a patient referral network using eigenvector centrality. We used regression models to associate Medicaid intensity with physician individual-level and practice-level characteristics. About 92.6% of physicians treated at least 1 Medicaid patient, but the median physician's panel contained only 5.7% Medicaid patients. Medicaid intensity was associated with physician training and influence for PCPs and specialists. For medical specialists, a 1 percentage point increase in Medicaid intensity was associated with a lower probability of being board certified (-0.22 percentage points; 95% CI, -0.30, -0.14), lower probability of attending a domestic medical school (-0.14 percentage points; 95% CI, -0.22, -0.05), having attended a less well-ranked domestic medical school (0.23 ranks; 95% CI, 0.15, 0.30), and having slightly less influence in the referral network. PCPs displayed similar results but high Medicaid intensity physicians had substantially less influence in the referral network. Medicaid participation intensity shows substantial variation across physicians, indicating limits of binary participation measures. Physicians with more Medicaid patients had characteristics often perceived by patients to be of lower quality.

Do welfare caseload declines make the Medicaid risk pool sicker?

PubMed

Garrett, Bowen; Holahan, John

2002-01-01

Declining welfare caseloads may lead to a sicker population remaining in the Medicaid program, which could increase per enrollee costs and the level of adequate capitation rates. Using data from the 1997 National Survey of America's Families for adults and children, we examine differences in health status and utilization among welfare recipients and welfare leavers who did and did not retain Medicaid. We adjust utilization differences for insurance status and factors often used to adjust capitation rates. We conclude that declining welfare caseloads likely will result in a sicker and more expensive adult Medicaid risk pool.

How Does Cash and Counseling Affect Costs?

PubMed Central

Dale, Stacy B; Brown, Randall S

2007-01-01

Objective To test the effect of a consumer-directed model (Cash and Counseling) of Medicaid personal care services (PCS) or home-and community-based waiver services (HCBS) on the cost of Medicaid services. Data Sources/Study Setting Medicaid claims data were collected for all enrollees in the Cash and Counseling demonstration. Demonstration enrollees included those eligible for PCS (in Arkansas), those assessed to receive such services (in New Jersey), and recipients of Medicaid HCBS (in Florida). Enrollment occurred from December 1998 through April 2001. The follow-up period covered up to 24 months after enrollment. Study Design Demonstration volunteers were randomly assigned to have the option to participate in Cash and Counseling (the treatment group), or to receive Medicaid services as usual from an agency (the control group). Ordinary least squares regressions were used to estimate the effect of the program on costs for Medicaid PCS/waiver services and other Medicaid services, while controlling for consumers' preenrollment characteristics and preenrollment Medicaid spending. Models were estimated separately for nonelderly and elderly adults in each state and for children in Florida. Data Extraction Methods Each state supplied claims data for demonstration enrollees. Principal Findings Largely because the program increased consumers' ability to get the authorized amount of paid care, expenditures for personal care/waiver services were higher for the treatment group than for the control group in each state and age group, except among the elderly in Florida. Higher costs for personal care/waiver services were partially offset by savings in other Medicaid services, particularly those related to long-term care. During year 1, total Medicaid costs were generally higher for the treatment group than for the control group, with treatment–control cost differences ranging from 1 percent (and statistically insignificant) for the elderly in Florida to 17 percent for the elderly in Arkansas. In year 2, these cost differences were generally greater than in year 1. Only in Arkansas did the treatment–control difference in total cost shrink over time—to less than 5 percent (and statistically insignificant) in year 2. Conclusions Medicaid costs were generally higher under Cash and Counseling because those in the traditional system did not get the services they were entitled to. Compared with the treatment group, (1) control group members were less likely to receive any services at all (despite being authorized for them), and (2) service recipients received a lower proportion of the amount of care that was authorized. In addition, a flaw in Florida's reassessment procedures led to treatment group members receiving more generous benefit amounts than control group members. To keep total Medicaid costs per recipient at the level incurred under the traditional system, consumer-directed programs need to be carefully designed and closely monitored. PMID:17244294

How does Cash and Counseling affect costs?

PubMed

Dale, Stacy B; Brown, Randall S

2007-02-01

To test the effect of a consumer-directed model (Cash and Counseling) of Medicaid personal care services (PCS) or home- and community-based waiver services (HCBS) on the cost of Medicaid services. Medicaid claims data were collected for all enrollees in the Cash and Counseling demonstration. Demonstration enrollees included those eligible for PCS (in Arkansas), those assessed to receive such services (in New Jersey), and recipients of Medicaid HCBS (in Florida). Enrollment occurred from December 1998 through April 2001. The follow-up period covered up to 24 months after enrollment. Demonstration volunteers were randomly assigned to have the option to participate in Cash and Counseling (the treatment group), or to receive Medicaid services as usual from an agency (the control group). Ordinary least squares regressions were used to estimate the effect of the program on costs for Medicaid PCS/waiver services and other Medicaid services, while controlling for consumers' preenrollment characteristics and preenrollment Medicaid spending. Models were estimated separately for nonelderly and elderly adults in each state and for children in Florida. Each state supplied claims data for demonstration enrollees. Largely because the program increased consumers' ability to get the authorized amount of paid care, expenditures for personal care/waiver services were higher for the treatment group than for the control group in each state and age group, except among the elderly in Florida. Higher costs for personal care/waiver services were partially offset by savings in other Medicaid services, particularly those related to long-term care. During year 1, total Medicaid costs were generally higher for the treatment group than for the control group, with treatment-control cost differences ranging from 1 percent (and statistically insignificant) for the elderly in Florida to 17 percent for the elderly in Arkansas. In year 2, these cost differences were generally greater than in year 1. Only in Arkansas did the treatment-control difference in total cost shrink over time-to less than 5 percent (and statistically insignificant) in year 2. Medicaid costs were generally higher under Cash and Counseling because those in the traditional system did not get the services they were entitled to. Compared with the treatment group, (1) control group members were less likely to receive any services at all (despite being authorized for them), and (2) service recipients received a lower proportion of the amount of care that was authorized. In addition, a flaw in Florida's reassessment procedures led to treatment group members receiving more generous benefit amounts than control group members. To keep total Medicaid costs per recipient at the level incurred under the traditional system, consumer-directed programs need to be carefully designed and closely monitored.

Medicaid Expansion and ACA Repeal: Evidence From Ohio.

PubMed

Seiber, Eric E; Berman, Micah L

2017-06-01

To examine the health insurance coverage options for Medicaid expansion enrollees if the Affordable Care Act (ACA) is repealed, using evidence from Ohio, where more than half a million adults have enrolled in the state's Medicaid program through the ACA expansion. The Ohio Medicaid Assessment Survey interviewed 42 000 households in 2015. We report data from a unique battery of questions designed to identify insurance coverage immediately prior to Medicaid enrollment. Ninety-five percent of new Medicaid enrollees in Ohio did not have a private health insurance option immediately before enrollment. These new enrollees are predominantly older, low-income Whites with a high school education or less. Only 5% of new Medicaid enrollees were eligible for an employer-sponsored insurance plan to which they could potentially return in the case of repeal of the ACA. The vast majority of Medicaid expansion enrollees would have no plausible pathway to obtaining private-sector insurance if the ACA were repealed. Demographic similarities between the expansion population and 2016 exit polls suggest that coverage losses would fall disproportionately on members of the winning Republican coalition.

The burden of rotavirus hospitalizations among Medicaid and non-Medicaid children younger than 5 years old.

PubMed

Ma, Liyuan; El Khoury, Antoine C; Itzler, Robbin F

2009-10-01

We sought to compare the burden of hospitalizations associated with rotavirus gastroenteritis (RGE) in children younger than 5 years in US Medicaid and non-Medicaid populations in 2000 and 2003. We used the Kids' Inpatient Database (KID) to examine the burden of RGE-associated hospitalizations in terms of numbers and rates of hospitalizations, lengths of stay, and hospital charges. Two indirect methods were also used to estimate RGE-associated hospitalizations, because rotavirus testing is not routinely performed. Approximately 40% of children younger than 5 years were enrolled in Medicaid in 2003, but this population accounted for nearly 50% of all RGE-associated hospitalizations and 60% of total charges. Children enrolled in Medicaid had significantly greater hospitalization rates, average lengths of stay, and average charges per stay than did those not enrolled. Although RGE affects all socioeconomic groups, the Medicaid population accounted for a disproportionate number of the hospitalizations. With the inclusion of rotavirus vaccines in the pediatric immunization schedule, it is important that US children, especially those enrolled in Medicaid programs, are vaccinated to reduce the burden of RGE.

Medicaid dental coverage alone may not lower rates of dental emergency department visits.

PubMed

Fingar, Kathryn R; Smith, Mark W; Davies, Sheryl; McDonald, Kathryn M; Stocks, Carol; Raven, Maria C

2015-08-01

Medicaid was expanded to millions of individuals under the Affordable Care Act, but many states do not provide dental coverage for adults under their Medicaid programs. In the absence of dental coverage, patients may resort to costly emergency department (ED) visits for dental conditions. Medicaid coverage of dental benefits could help ease the burden on the ED, but ED use for dental conditions might remain a problem in areas with a scarcity of dentists. We examined county-level rates of ED visits for nontraumatic dental conditions in twenty-nine states in 2010 in relation to dental provider density and Medicaid coverage of nonemergency dental services. Higher density of dental providers was associated with lower rates of dental ED visits by patients with Medicaid in rural counties but not in urban counties, where most dental ED visits occurred. County-level Medicaid-funded dental ED visit rates were lower in states where Medicaid covered nonemergency dental services than in other states, although this difference was not significant after other factors were adjusted for. Providing dental coverage alone might not reduce Medicaid-funded dental ED visits if patients do not have access to dental providers. Project HOPE—The People-to-People Health Foundation, Inc.

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

PubMed

1993-04-05

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

42 CFR 423.910 - Requirements.

Code of Federal Regulations, 2010 CFR

2010-10-01

... PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Special Rules for States-Eligibility Determinations... to defray a portion of the Medicare drug expenditures for individuals whose projected Medicaid drug... capita Medicaid expenditures for prescription drugs for 2003 for full-benefit dual eligibles not...

The effect of access restrictions on the vintage of drugs used by Medicaid enrollees.

PubMed

Lichtenberg, Frank R

2005-01-01

To examine the extent to which recent Medicaid drug access restrictions, such as preferred drug lists (PDLs), may affect the vintage (or time since Food and Drug Administration approval) of 6 types of drugs used by Medicaid beneficiaries. Retrospective claims database analysis using National Drug Code pharmacy claims data. A regression model was developed to analyze the effect that Medicaid access restrictions had on the vintage of medications prescribed in 6 different therapeutic categories. A "difference in differences" approach was used to compare the change in vintage of medications prescribed in Medicaid versus non-Medicaid patients between the January-June 2001 and July-December 2003 study periods. The results of the regression model showed that PDLs increased the age of Medicaid prescriptions by less than 1 year for drugs in 5 of the 6 therapeutic classes analyzed. In the case of pain management medications, the increase was more than 1.2 years. The results of the regression model suggest that Medicaid drug access restriction programs (e.g., PDLs) have resulted in an increase in the age of drugs prescribed for Medicaid beneficiaries versus non-Medicaid patients. Since previous research has suggested a clinical and economic advantage to utilizing newer versus older drugs, further research should be conducted to explore how these medication restriction policies may unduly affect Medicaid beneficiaries compared with privately insured patients.

Medicaid's role in financing health care for children with behavioral health care needs in the special education system: implications of the Deficit Reduction Act.

PubMed

Mandell, David S; Machefsky, Aliza; Rubin, David; Feudtner, Chris; Pati, Susmita; Pita, Susmita; Rosenbaum, Sara

2008-10-01

Recent changes to Medicaid policy may have unintended consequences in the education system. This study estimated the potential financial impact of the Deficit Reduction Act (DRA) on school districts by calculating Medicaid-reimbursed behavioral health care expenditures for school-aged children in general and children in special education in particular. Medicaid claims and special education records of youth ages 6 to 18 years in Philadelphia, PA, were merged for calendar year 2002. Behavioral health care volume, type, and expenditures were compared between Medicaid-enrolled children receiving and not receiving special education. Significant overlap existed among the 126,533 children who were either Medicaid enrolled (114,257) or received special education (27,620). Medicaid-reimbursed behavioral health care was used by 21% of children receiving special education (37% of those Medicaid enrolled) and 15% of other Medicaid-enrolled children. Total expenditures were $197.8 million, 40% of which was spent on the 5728 children in special education and 60% of which was spent on 15,092 other children. Medicaid-reimbursed behavioral health services disproportionately support special education students, with expenditures equivalent to 4% of Philadelphia's $2 billion education budget. The results suggest that special education programs depend on Medicaid-reimbursed services, the financing of which the DRA may jeopardize.

Community Health Center Utilization Following the 2008 Medicaid Expansion in Oregon: Implications for the Affordable Care Act.

PubMed

Hatch, Brigit; Bailey, Steffani R; Cowburn, Stuart; Marino, Miguel; Angier, Heather; DeVoe, Jennifer E

2016-04-01

To assess longitudinal patterns of community health center (CHC) utilization and the effect of insurance discontinuity after Oregon's 2008 Medicaid expansion (the Oregon Experiment). We conducted a retrospective cohort study with electronic health records and Medicaid data. We divided individuals who gained Medicaid in the Oregon Experiment into those who maintained (n = 788) or lost (n = 944) insurance coverage. We compared these groups with continuously insured (n = 921) and continuously uninsured (n = 5416) reference groups for community health center utilization rates over a 36-month period. Both newly insured groups increased utilization in the first 6 months. After 6 months, use among those who maintained coverage stabilized at a level consistent with the continuously insured, whereas it returned to baseline for those who lost coverage. Individuals who maintained coverage through Oregon's Medicaid expansion increased long-term utilization of CHCs, whereas those with unstable coverage did not. This study predicts long-term increase in CHC utilization following Affordable Care Act Medicaid expansion and emphasizes the need for policies that support insurance retention.

Impact of Maine's Medicaid drug formulary change on non-Medicaid markets: spillover effects of a restrictive drug formulary.

PubMed

Wang, Y Richard; Pauly, Mark V; Lin, Y Aileen

2003-10-01

Market penetration of HMOs affect physician practice styles for non-HMO patients. To study the impact of a restrictive Medicaid drug formulary on prescribing patterns for other patients, ie, so-called spillover effects. A before-and-after, 3-state comparison study. On January 1, 2001, Maine's Medicaid program implemented a restrictive drug formulary for the proton pump inhibitor class, with pantoprazole as the only preferred drug. The Medicaid and non-Medicaid market shares of pantoprazole in Maine (vs New Hampshire and Vermont and among Maine physicians with different Medicaid share of practice. After 3 months, the market share of pantoprazole in Maine (vs 2 control states) increased 79% among Medicaid prescriptions (vs 1%-2%), 10% among cash prescriptions (vs 3%), and 7% among other third-party payer prescriptions (vs 1%). The market shares increased more among Maine physicians with a higher Medicaid share of practice (high vs middle vs low [market]: 16% vs 8% vs 5% [cash]; 11% vs 5% vs 4% [other third-party payers]). Linear regression results indicate that practicing medicine in Maine leads to a 72% increase in pantoprazole share among Medicaid prescriptions (P < .001). In addition, for each 10% Medicaid share of practice in Maine, the share of pantoprazole increases 1.8% among cash prescriptions (P = .01) and 1.4% among other third-party payer prescriptions (P < .001). Maine's Medicaid drug formulary generated spillover effects in cash and other third-party payer markets, with somewhat stronger effects in the cash market.

How Will Section 1115 Medicaid Expansion Demonstrations Inform Federal Policy?

PubMed

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

2016-05-01

Section 1115 of the Social Security Act allows the U.S. Department of Health and Human Services and states to test innovations in Medicaid and other public welfare programs without formal legislative action. Six states currently operate their Medicaid expansions as demonstrations and several more are expected to seek permission to do so. While the current Medicaid expansion demonstrations vary, they share a major focus: increasing beneficiaries' financial responsibility for the cost of coverage and care. Demonstrations include requirements that Medicaid beneficiaries pay enrollment fees and cost-sharing that exceed traditional Medicaid limits. Others propose tying beneficiaries' financial responsibility to behavioral changes in health and wellness, while still others impose penalties for nonpayment of enrollment fees. Evaluations must consider the impact of these requirements on access, use of care, and health status, as well as the feasibility of demonstration reforms and their impact on administrative efficiency, providers, and health plans.

The extent of physician participation in Medicaid: a comparison of physician estimates and aggregated patient records.

PubMed Central

Kletke, P R; Davidson, S M; Perloff, J D; Schiff, D W; Connelly, J P

1985-01-01

This article compares two measures of the extent of physician participation in Medicaid programs. The first, which has been used in most research to date on the subject, is based on physician estimates of the proportion of their patients who are Medicaid patients. The second derives from encounter forms for a sample of visits to the interviewed physicians. The comparison shows that physicians in the sample tended to overestimate by 40 percent the extent of their Medicaid participation. Because the two measures are highly correlated, the analysis of the determinants of Medicaid participation was not affected by the measure used. However, since physicians tended to overstate the proportion of Medicaid patients in their practices, interview data should not be used to measure the amount of physician participation or to calculate elasticities for the effects of policy changes on the extent of participation. PMID:3910615

75 FR 82397 - Medicaid Program: Initial Core Set of Health Quality Measures for Medicaid-Eligible Adults

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-30

............ NA........ RAND Schizophrenia 2: ........ Annual assessment of weight/BMI, glycemic control, lipids. 41......... NA........ RAND Schizophrenia B: ........ Proportion of schizophrenia patients with long- term utilization of antipsychotic medications. 42......... NA........ RAND Schizophrenia C...

Value Analysis of Digital Breast Tomosynthesis for Breast Cancer Screening in a US Medicaid Population.

PubMed

Miller, Jeffrey D; Bonafede, Machaon M; Herschorn, Sally D; Pohlman, Scott K; Troeger, Kathleen A; Fajardo, Laurie L

2017-04-01

Better understanding regarding the clinical-economic value of digital breast tomosynthesis (DBT) for breast cancer screening for Medicaid enrollees is needed to help inform sound, value-based decision making. The objective of this study was to conduct a clinical-economic value analysis of DBT for breast cancer screening among women enrolled in Medicaid to assess the potential clinical benefits, associated expenditures, and net budget impact of DBT. Two annual screening mammography scenarios were evaluated with an economic model: (1) full-field digital mammography and (2) combined full-field digital mammography and DBT. The model focused on two main drivers of DBT value: (1) capacity for DBT to reduce the number of women recalled for additional follow-up imaging and diagnostic services and (2) capacity of DBT to facilitate earlier diagnosis of cancer at earlier stages, when treatment costs are lower. Model analysis results showed that the use of DBT as a mammographic screening modality by Medicaid enrollees potentially reduces the need for follow-up diagnostic services and improves the detection of invasive cancers, allowing earlier, less costly treatment. With the modest incremental reimbursement of $37 for DBT expected for a typical Medicaid claim, annual cost savings from DBT predicted by the model amounts to $8.14 per patient, potentially translating into more than $12,000 savings per year for an average-sized Medicaid plan and as much as $207,000 savings per year for a typical state Medicaid program. Wider adoption of DBT presents an opportunity to deliver value-based care to Medicaid programs and to help address disparities and barriers to accessing preventive care by some of the nation's most vulnerable citizens. Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Insurance coverage and prenatal care among low-income pregnant women: an assessment of states' adoption of the "Unborn Child" option in Medicaid and CHIP.

PubMed

Jarlenski, Marian P; Bennett, Wendy L; Barry, Colleen L; Bleich, Sara N

2014-01-01

The "Unborn Child" (UC) option provides state Medicaid/Children's Health Insurance Program (CHIP) programs with a new strategy to extend prenatal coverage to low-income women who would otherwise have difficulty enrolling in or would be ineligible for Medicaid. To examine the association of the UC option with the probability of enrollment in Medicaid/CHIP during pregnancy and probability of receiving adequate prenatal care. We use pooled cross-sectional data from the Pregnancy Risk Assessment Monitoring System from 32 states between 2004 and 2010 (n = 81,983). Multivariable regression is employed to examine the association of the UC option with Medicaid/CHIP enrollment during pregnancy among eligible women who were uninsured preconception (n = 45,082) and those who had insurance (but not Medicaid) preconception (n = 36,901). Multivariable regression is also employed to assess the association between the UC option and receipt of adequate prenatal care, measured by the Adequacy of Prenatal Care Utilization Index. Residing in a state with the UC option is associated with a greater probability of Medicaid enrollment during pregnancy relative to residing in a state without the policy both among women uninsured preconception (88% vs. 77%, P < 0.01) and among women insured (but not in Medicaid) preconception (40% vs. 31%, P < 0.01). Residing in a state with the UC option is not significantly associated with receiving adequate prenatal care, among both women with and without insurance preconception. The UC option provides states a key way to expand or simplify prenatal insurance coverage, but further policy efforts are needed to ensure that coverage improves access to high-quality prenatal care.

Effect of Medicaid Disease Management Programs on Emergency Admissions and Inpatient Costs

PubMed Central

Conti, Matthew S

2013-01-01

Objective To determine the impact of state Medicaid diabetes disease management programs on emergency admissions and inpatient costs. Data National InPatient Sample sponsored by the Agency for Healthcare Research and Quality Project for the years from 2000 to 2008 using 18 states. Study Design A difference-in-difference methodology compares costs and number of emergency admissions for Washington, Texas, and Georgia, which implemented disease management programs between 2000 and 2008, to states that did not undergo the transition to managed care (N = 103). Data Extraction Costs and emergency admissions were extracted for diabetic Medicaid enrollees diagnosed in the reform and non-reform states and collapsed into state and year cells. Principal Findings In the three treatment states, the implementation of disease management programs did not have statistically significant impacts on the outcome variables when compared to the control states. Conclusions States that implemented disease management programs did not achieve improvements in costs or the number of emergency of admissions; thus, these programs do not appear to be an effective way to reduce the burden of this chronic disease. PMID:23278435

Effect of Medicaid disease management programs on emergency admissions and inpatient costs.

PubMed

Conti, Matthew S

2013-08-01

To determine the impact of state Medicaid diabetes disease management programs on emergency admissions and inpatient costs. National InPatient Sample sponsored by the Agency for Healthcare Research and Quality Project for the years from 2000 to 2008 using 18 states. A difference-in-difference methodology compares costs and number of emergency admissions for Washington, Texas, and Georgia, which implemented disease management programs between 2000 and 2008, to states that did not undergo the transition to managed care (N = 103). Costs and emergency admissions were extracted for diabetic Medicaid enrollees diagnosed in the reform and non-reform states and collapsed into state and year cells. In the three treatment states, the implementation of disease management programs did not have statistically significant impacts on the outcome variables when compared to the control states. States that implemented disease management programs did not achieve improvements in costs or the number of emergency of admissions; thus, these programs do not appear to be an effective way to reduce the burden of this chronic disease. © Health Research and Educational Trust.

Medicaid and CHIP: Opportunities Exist to Improve U.S. Insular Area Demographic Data That Could Be Used to Help Determine Federal Funding. GAO-09-558R

ERIC Educational Resources Information Center

Kohn, Linda T.

2009-01-01

The five largest insular areas of the United States--American Samoa, the Commonwealth of the Northern Mariana Islands (CNMI), Guam, Puerto Rico, and the U.S. Virgin Islands--receive federal funding through Medicaid and the State Children's Health Insurance Program (CHIP), joint federal-state programs that finance health care for certain low-income…

Evaluation of Demonstrations of National School Lunch Program and School Breakfast Program Direct Certification of Children Receiving Medicaid Benefits: Access Evaluation Report

ERIC Educational Resources Information Center

Hulsey, Lara; Gordon, Anne; Leftin, Joshua; Beyler, Nicholas; Schirm, Allen; Smither-Wulsin, Claire; Crumbley, Will

2015-01-01

This report presents findings from the Access Evaluation, a study component that is designed to assess the potential impacts of direct certification-Medicaid (DC-M) on students' access to free school meals by conducting retrospective simulations of DC-M in school year 2011-2012, the year before the demonstration began. For the Access Evaluation,…

Designing the Cash and Counseling Demonstration and Evaluation.

PubMed

Doty, Pamela; Mahoney, Kevin J; Simon-Rusinowitz, Lori

2007-02-01

The Cash and Counseling Demonstration and Evaluation (CCDE) was designed as an experiment in shifting the paradigm in home and community-based long-term care from a professional/bureaucratic model of service delivery to one emphasizing consumer choice and control. The experimental intervention was an individualized budget offered in lieu of traditional Medicaid-covered services, such as agency-delivered aide services or a plan of care developed and coordinated by a professional case-manager, which typically involves authorization for several different providers to deliver a range of services. Within the spending limits established by their budgets, program participants were largely free to choose the types and amounts of paid services and supports they judged best able to meet their disability-related personal assistance needs. Medicaid beneficiaries in selected states who volunteered to participate. In all of the participating state Medicaid programs, beneficiaries eligible to participate included elders and younger adults with chronic disabilities and, in one state, adults and children with mental retardation/developmental disabilities could also participate. Minor children and adults with cognitive impairment could participate via representatives (family or friends who agreed to assist them in managing their services or to act as their surrogate decision-makers). Members of the CCDE management team describe the rationale for and implications of key design decisions. Key design decisions included the choice of research methodology (random assignment of CCDE participants in each state to treatment and control groups), selection of the state sites (AR, FL, NJ, NY), and the need for the CCDE to comply with federal waiver requirements for Medicaid research and demonstration projects. Principle Findings. The CCDE design was successfully implemented in three of the four state Medicaid programs selected for participation. The successful implementation of the CCDE (results from the evaluation are reported elsewhere) led to replication efforts in other states. The CCDE also inspired changes in Medicaid law and policy, including the 2002 "Independence Plus" Initiative by the Centers for Medicare and Medicaid and sections of the Deficit Reduction Act of 2005 intended to promote consumer-direction in Medicaid.

Designing the Cash and Counseling Demonstration and Evaluation

PubMed Central

Doty, Pamela; Mahoney, Kevin J; Simon-Rusinowitz, Lori

2007-01-01

Ojective The Cash and Counseling Demonstration and Evaluation (CCDE) was designed as an experiment in shifting the paradigm in home and community-based long-term care from a professional/bureaucratic model of service delivery to one emphasizing consumer choice and control. The experimental intervention was an individualized budget offered in lieu of traditional Medicaid-covered services, such as agency-delivered aide services or a plan of care developed and coordinated by a professional case-manager, which typically involves authorization for several different providers to deliver a range of services. Within the spending limits established by their budgets, program participants were largely free to choose the types and amounts of paid services and supports they judged best able to meet their disability-related personal assistance needs. Study Population Medicaid beneficiaries in selected states who volunteered to participate. In all of the participating state Medicaid programs, beneficiaries eligible to participate included elders and younger adults with chronic disabilities and, in one state, adults and children with mental retardation/developmental disabilities could also participate. Minor children and adults with cognitive impairment could participate via representatives (family or friends who agreed to assist them in managing their services or to act as their surrogate decision-makers). Data Sources Members of the CCDE management team describe the rationale for and implications of key design decisions. Study Design Key design decisions included the choice of research methodology (random assignment of CCDE participants in each state to treatment and control groups), selection of the state sites (AR, FL, NJ, NY), and the need for the CCDE to comply with federal waiver requirements for Medicaid research and demonstration projects. Principle Findings The CCDE design was successfully implemented in three of the four state Medicaid programs selected for participation. Conclusions The successful implementation of the CCDE (results from the evaluation are reported elsewhere) led to replication efforts in other states. The CCDE also inspired changes in Medicaid law and policy, including the 2002 “Independence Plus” Initiative by the Centers for Medicare and Medicaid and sections of the Deficit Reduction Act of 2005 intended to promote consumer-direction in Medicaid. PMID:17244289

42 CFR 456.21 - Scope.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Scope. 456.21 Section 456.21 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: All Medicaid Services § 456.21 Scope. This...

Using Medicaid/SCHIP to insure working families: the Massachusetts experience.

PubMed

Mitchell, Janet B; Osber, Deborah S

2002-01-01

Massachusetts was the first State to implement a premium subsidy program for employer-sponsored health insurance, using both Medicaid and State Children's Health Insurance Program (SCHIP) funding. The Insurance Partnership (IP) provides subsidies directly to small employers, and the Premium Assistance Program provides subsidies to their low-income employees. Approximately 3,500 small firms currently participate, most of them offering health insurance coverage for the first time. Approximately 10,000 adults and children are covered through the program, the majority of whom had been uninsured prior to enrolling. Massachusetts' successful experience with premium subsidies offers important lessons for other States wishing to implement similar programs.

Medicaid policy and the substitution of hospital outpatient care for physician care.

PubMed

Cohen, J W

1989-04-01

This article explores the effects of reimbursement and utilization control policies on utilization patterns and spending for physician and hospital outpatient services under state Medicaid programs. The empirical work shows a negative relationship between the level of Medicaid physician fees relative to Medicare and private fees, and the numbers of outpatient care recipients, suggesting that outpatient care substitutes for physician care in states with low fee levels. In addition, it shows a positive relationship between Medicaid physician fees and outpatient spending per recipient, suggesting that in low-fee states outpatient departments are providing some types of care that could be provided in a physician's office. Finally, the analysis demonstrates that reimbursement and utilization control policies have significant effects in the expected directions on aggregate Medicaid spending for physician and outpatient services.

Receipt of Preventive Services After Oregon's Randomized Medicaid Experiment.

PubMed

Marino, Miguel; Bailey, Steffani R; Gold, Rachel; Hoopes, Megan J; O'Malley, Jean P; Huguet, Nathalie; Heintzman, John; Gallia, Charles; McConnell, K John; DeVoe, Jennifer E

2016-02-01

It is predicted that gaining health insurance via the Affordable Care Act will result in increased rates of preventive health services receipt in the U.S., primarily based on self-reported findings from previous health insurance expansion studies. This study examined the long-term (36-month) impact of Oregon's 2008 randomized Medicaid expansion ("Oregon Experiment") on receipt of 12 preventive care services in community health centers using electronic health record data. Demographic data from adult (aged 19-64 years) Oregon Experiment participants were probabilistically matched to electronic health record data from 49 Oregon community health centers within the OCHIN community health information network (N=10,643). Intent-to-treat analyses compared receipt of preventive services over a 36-month (2008-2011) period among those randomly assigned to apply for Medicaid versus not assigned, and instrumental variable analyses estimated the effect of actually gaining Medicaid coverage on preventive services receipt (data collected in 2012-2014; analysis performed in 2014-2015). Intent-to-treat analyses revealed statistically significant differences between patients randomly assigned to apply for Medicaid (versus not assigned) for 8 of 12 assessed preventive services. In intent-to-treat analyses, Medicaid coverage significantly increased the odds of receipt of most preventive services (ORs ranging from 1.04 [95% CI=1.02, 1.06] for smoking assessment to 1.27 [95% CI=1.02, 1.57] for mammography). Rates of preventive services receipt will likely increase as community health center patients gain insurance through Affordable Care Act expansions. Continued effort is needed to increase health insurance coverage in an effort to decrease health disparities in vulnerable populations. Copyright © 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

Receipt of Preventive Services After Oregon’s Randomized Medicaid Experiment

PubMed Central

Marino, Miguel; Bailey, Steffani R.; Gold, Rachel; Hoopes, Megan J.; O’Malley, Jean P.; Huguet, Nathalie; Heintzman, John; Gallia, Charles; McConnell, K. John; DeVoe, Jennifer E.

2015-01-01

Introduction It is predicted that gaining health insurance via the Affordable Care Act will result in increased rates of preventive health services receipt in the U.S, primarily based on self-reported findings from previous health insurance expansion studies. This study examined the long-term (36-month) impact of Oregon’s 2008 randomized Medicaid expansion (“Oregon Experiment”) on receipt of 12 preventive care services in community health centers using electronic health record data. Methods Demographic data from adult (aged 19–64 years) Oregon Experiment participants were probabilistically matched to electronic health record data from 49 Oregon community health centers within the OCHIN community health information network (N=10,643). Intent-to-treat analyses compared receipt of preventive services over a 36-month (2008–2011) period among those randomly assigned to apply for Medicaid versus not assigned, and instrumental variable analyses estimated the effect of actually gaining Medicaid coverage on preventive services receipt (data collected in 2012–2014; analysis performed in 2014–2015). Results Intent-to-treat analyses revealed statistically significant differences between patients randomly assigned to apply for Medicaid (versus not assigned) for eight of 12 assessed preventive services. In intent-to-treat[MM1] analyses, Medicaid coverage significantly increased the odds of receipt of most preventive services (ORs ranging from 1.04 [95% CI=1.02, 1.06] for smoking assessment to 1.27 [95% CI=1.02, 1.57] for mammography). Conclusions Rates of preventive services receipt will likely increase as community health center patients gain insurance through Affordable Care Act expansions. Continued effort is needed to increase health insurance coverage in an effort to decrease health disparities in vulnerable populations. PMID:26497264

Medicaid program: adjustment of federal share for uncashed or cancelled (voided) checks--HCFA. Proposed rule.

PubMed

1985-05-31

These proposed regulations require a State agency to refund to the Federal government the Federal share of Medicaid checks issued by the State or its fiscal agent that remain uncashed 180 days after the date of issuance. In addition, we would require that the Federal share of cancelled (voided) Medicaid checks be refunded quarterly since there has been no expenditure by the State. This proposal is intended to implement in part a 1981 General Accounting Office recommendation that procedures be established for States to credit the Federal government for its portion of uncashed Medicaid checks issues by the State or its fiscal agent.

Medicaid program; adjustment of federal share for uncashed or cancelled (voided) checks--HCFA. Final rule.

PubMed

1986-10-09

These final regulations require that a State agency refund to the Federal Government the Federal share of Medicaid checks issued by the State or its fiscal agent that remain uncashed 180 days after the date of issuance. In addition, we are requiring that the Federal share of cancelled (voided) Medicaid checks be refunded quarterly since there has been no expenditure by the State. These regulations implement, in part, a 1981 General Accounting Office recommendation that procedures be established for States to credit the Federal Government for the Federal portion of uncashed Medicaid checks issued by the State or its fiscal agent.

Is Medicaid sustainable? Spending projections for the program's second forty years.

PubMed

Kronick, Richard; Rousseau, David

2007-01-01

We constructed long-term projections of Medicaid spending and compared projected growth in spending with that of state and federal revenues. Notwithstanding the anticipated decline in employer-sponsored insurance and the long-term care needs of the baby boomers, we project that Medicaid spending as a share of national health spending will average 16.6 percent from 2006 to 2025--roughly unchanged from 16.5 percent in 2005--and then increase slowly to 19.0 percent by 2045. Growth in government revenues is projected to be large enough to sustain both Medicaid spending increases and substantial real growth in spending for other services.

The effect of consumer incentives on Medicaid beneficiaries' compliance with well-child visit guidelines.

PubMed

Nyman, John A; Abraham, Jean M; Riley, William

2013-01-01

The Affordable Care Act of 2010 recommends that consumer incentives be employed to increase the use of preventive care by Medicaid beneficiaries, but few evaluative studies exist. This study evaluates a Target gift card incentive employed by a Minnesota health plan serving Medicaid beneficiaries over the period 2002-2003. Lacking a contemporaneous control group, the proximity between the child's residence and the nearest Target store was used as the intervention variable. Using alternative specifications for the intervention variable, results of the difference-in-differences equations suggest that the incentive program significantly increased the likelihood that a Medicaid beneficiary would have a well-child visit.

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

PubMed

2016-09-16

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

Recent changes in Medicaid policy and their possible effects on mental health services.

PubMed

Buck, Jeffrey A

2009-11-01

As Medicaid has emerged as the primary funder of public mental health services, its character has affected the organization and delivery of such services. Recent changes to the program, however, promise to further affect the direction of changes in states' mental health service systems. One group of changes will further limit the flexibility of Medicaid mental health funding, while increasing provider accountability and the authority of state Medicaid agencies. Others will increase incentives for deinstitutionalization and community-based care and promote person-centered treatment principles. These changes will likely affect state mental health systems, mental health providers, and the nature of service delivery.

Poor oral health as an obstacle to employment for Medicaid beneficiaries with disabilities.

PubMed

Hall, Jean P; Chapman, Shawna L Carroll; Kurth, Noelle K

2013-01-01

To inform policy with better information about the oral health-care needs of a Medicaid population that engages in employment, that is, people ages 16 to 64 with Social Security-determined disabilities enrolled in a Medicaid Buy-In program. Statistically test for significant differences among responses to a Medicaid Buy-In program satisfaction survey that included oral health questions from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System and the Oral Health Impact Profile (OHIP) to results for the state's general population and the US general population. All measures of dental care access and oral health were significantly worse for the study population as compared with a state general population or a US general population. Differences were particularly pronounced for the OHIP measure for difficulty doing one's job due to dental problems, which was almost five times higher for the study population. More comprehensive dental benefits for the study population could result in increased oral and overall health, and eventual cost savings to Medicaid as more people work, have improved health, and pay premiums for coverage. © 2012 American Association of Public Health Dentistry.

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.

77 FR 31499 - Medicaid and Children's Health Insurance Programs; Disallowance of Claims for FFP and Technical...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-05-29

...This final rule reflects the Centers for Medicare & Medicaid Services' commitment to the general principles of the President's Executive Order 13563 released January 18, 2011, entitled ``Improving Regulation and Regulatory Review.'' This rule will: implement a new reconsideration process for administrative determinations to disallow claims for Federal financial participation (FFP) under title XIX of the Act (Medicaid); lengthen the time States have to credit the Federal government for identified but uncollected Medicaid provider overpayments and provide that interest will be due on amounts not credited within that time period; make conforming changes to the Medicaid and Children's Health Insurance Program (CHIP) disallowance process to allow States the option to retain disputed Federal funds through the new administrative reconsideration process; revise installment repayment standards and schedules for States that owe significant amounts; and provide that interest charges may accrue during the new administrative reconsideration process if a State chooses to retain the funds during that period. This final rule will also make a technical correction to reporting requirements for disproportionate share hospital payments, revise internal delegations of authority to reflect the term ``Administrator or current Designee,'' remove obsolete language, and correct other technical errors.

Medicaid: State and Federal Actions Have Been Taken to Improve Children's Access to Dental Services, but Gaps Remain. Report to Congressional Requesters. GAO-09-723

ERIC Educational Resources Information Center

US Government Accountability Office, 2009

2009-01-01

Children's access to Medicaid dental services is a long-standing concern. The tragic case of a 12-year-old boy who died from an untreated infected tooth that led to a fatal brain infection renewed attention to this issue. He was enrolled in Medicaid--a joint federal and state program that provides health care coverage, including dental care, for…

Dental Homes for Children With Autism: A Longitudinal Analysis of Iowa Medicaid's I-Smile Program.

PubMed

Chi, Donald L; Momany, Elizabeth T; Mancl, Lloyd A; Lindgren, Scott D; Zinner, Samuel H; Steinman, Kyle J

2016-05-01

Medicaid-enrolled children with autism spectrum disorder (ASD) encounter significant barriers to dental care. Iowa's I-Smile Program was implemented in 2006 to improve dental use for all children in Medicaid. This study compared dental home and preventive dental utilization rates for Medicaid-enrolled children by ASD status and within three time periods (pre-implementation, initial implementation, maturation) and determined I-Smile's longitudinal influence on ASD-related dental use disparities. Data from 2002-2011 were analyzed for newly Medicaid-enrolled children aged 3-17 years (N=30,059); identified each child's ASD status; and assessed whether the child had a dental home or utilized preventive dental care. Log-linear regression models were used to generate rate ratios. Analyses were conducted in 2015. In 2003-2011, 9.8% of children with ASD had dental homes compared with 8% of children without ASD; 36.3% of children with ASD utilized preventive care compared to 45.7% of children without ASD. There were no significant differences in dental home rates by ASD status during pre-implementation, initial implementation, or maturation. There were no significant differences in preventive dental utilization by ASD status during pre-implementation or initial implementation, but children with ASD were significantly less likely to utilize preventive care during maturation (rate ratio=0.79, p<0.001). Longitudinal trends in dental home and preventive dental utilization rates were not significant (p=0.54 and p=0.71, respectively). Among newly Medicaid-enrolled children in Iowa's I-Smile Program, those with ASDs were not less likely than those without ASD to have dental homes but were significantly less likely to utilize preventive dental care. Copyright © 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

Outpatient Office Wait Times and Quality of Care for Medicaid Patients

PubMed Central

Oostrom, Tamar; Einav, Liran; Finkelstein, Amy

2018-01-01

Time spent in the doctor’s waiting room captures an important aspect of the healthcare experience. We analyzed data on 21 million outpatient visits obtained from electronic health record systems, allowing us to measure time spent in the waiting room beyond the scheduled appointment time. Median wait time was just over 4 minutes. Almost one-fifth of visits had waits longer than 20 minutes, and 10% were over 30 minutes. Waits were shorter for early morning appointments, younger patients, and at larger practices. Median wait time was 4.1 minutes for privately-insured and 4.6 minutes for Medicaid patients; adjusting for patient and appointment characteristics, Medicaid patients were 20% more likely than the privately-insured to wait longer than 20 minutes (P<0.001), with most of this disparity explained by differences in practices and providers they saw. Wait time for Medicaid patients relative to the privately-insured was longer in states with relatively lower Medicaid reimbursement rates. PMID:28461348

Medicaid’s Role in Financing Health Care for Children With Behavioral Health Care Needs in the Special Education System: Implications of the Deficit Reduction Act

PubMed Central

Mandell, David S.; Machefsky, Aliza; Rubin, David; Feudtner, Chris; Pita, Susmita; Rosenbaum, Sara

2010-01-01

BACKGROUND Recent changes to Medicaid policy may have unintended consequences in the education system. This study estimated the potential financial impact of the Deficit Reduction Act (DRA) on school districts by calculating Medicaid-reimbursed behavioral health care expenditures for school-aged children in general and children in special education in particular. METHODS Medicaid claims and special education records of youth ages 6 to 18 years in Philadelphia, PA, were merged for calendar year 2002. Behavioral health care volume, type, and expenditures were compared between Medicaid-enrolled children receiving and not receiving special education. RESULTS Significant overlap existed among the 126,533 children who were either Medicaid enrolled (114,257) or received special education (27,620). Medicaid-reimbursed behavioral health care was used by 21% of children receiving special education (37% of those Medicaid enrolled) and 15% of other Medicaid-enrolled children. Total expenditures were $197.8 million, 40% of which was spent on the 5728 children in special education and 60% of which was spent on 15,092 other children. CONCLUSIONS Medicaid-reimbursed behavioral health services disproportionately support special education students, with expenditures equivalent to 4% of Philadelphia’s $2 billion education budget. The results suggest that special education programs depend on Medicaid-reimbursed services, the financing of which the DRA may jeopardize. PMID:18808472

Crossing Boundaries

PubMed Central

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

2017-01-01

Objectives: Previous state interagency collaborations have led to successful tobacco cessation initiatives. The objective of this study was to assess the roles and interaction of state Medicaid and public health agency efforts to support tobacco cessation for low-income Medicaid beneficiaries. Methods: We interviewed Medicaid and state public health agency officials in 8 states in September and October 2015 about collaborations in policy development and implementation for Medicaid tobacco cessation, including Medicaid coverage policies, quitlines, and monitoring. Results: Collaboration between Medicaid and public health agencies was limited. Smoking cessation quitlines were the most common area of collaboration cited. Public health officials were typically not involved in developing Medicaid coverage policies. States covered a range of US Food and Drug Administration–approved tobacco cessation medications, but 7 of the 8 states imposed limitations, such as charging copayments or requiring previous authorization. States generally lacked data to monitor implementation of tobacco cessation efforts and had little ability to determine the effectiveness of their policies. Conclusions: To strengthen efforts to reduce smoking and tobacco-related health burdens and to monitor the effectiveness of policies and programs, Medicaid and public health agencies should prioritize tobacco cessation and develop and analyze data about smoking and cessation efforts among Medicaid beneficiaries. Recent multistate initiatives from the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services seek to promote stronger collaborations in clinical prevention activities, including tobacco cessation. PMID:28192676

Impact of economic policies on reducing tobacco use among Medicaid clients in New York.

PubMed

Murphy, Jill M; Shelley, Donna; Repetto, Patricia M; Cummings, K Michael; Mahoney, Martin C

2003-07-01

New York State (NYS) recently implemented Medicaid coverage for prescription pharmacologic adjuncts for cessation and a 55-cent excise tax on a pack of cigarettes. This study examined awareness and use of stop smoking medications and changes in smoking/purchasing behavior among Medicaid clients. Participants (n = 173) were English-speaking Medicaid clients ages 18-64 years who currently smoked cigarettes and volunteered to be interviewed while waiting to reregister with the NYC Medicaid Office during early 2001. Data were collected using a brief (10-min) interviewer-administered questionnaire. Over 80% of Medicaid clients reported some desire to stop smoking and 40% intended to stop smoking in the next 6 months. Awareness of Medicaid coverage for tobacco cessation pharmacotherapy was 7% for nicotine replacement therapy and 13% for bupropion. Use of these stop smoking medications varied across products but in general was low (<10%). Half of the Medicaid clients reported changing their smoking behavior as a result of the cigarette tax increase. The majority of Medicaid clients report a desire to stop smoking, but these economic influences alone are insufficient to substantially reduce smoking in this population. These findings emphasize the importance of allocating a portion of tobacco tax revenue to promote both expanded awareness of this prescription benefit among Medicaid clients and to support programs to further assist low-income smokers in their attempts to stop smoking.

Ideologies of aid, practices of power: lessons for Medicaid managed care.

PubMed

Nelson, Nancy L

2005-03-01

The articles in this special issue teach valuable lessons based on what happened in New Mexico with the shift to Medicaid managed care. By reframing these lessons in broader historical and cultural terms with reference to aid programs, we have the opportunity to learn a great deal more about the relationship between poverty, public policy, and ideology. Medicaid as a state and federal aid program in the United States and economic development programs as foreign aid provide useful analogies specifically because they exhibit a variety of parallel patterns. The increasing concatenation of corporate interests with state and nongovernmental interests in aid programs is ultimately producing a less centralized system of power and responsibility. This process of decentralization, however, is not undermining the sources of power behind aid efforts, although it does make the connections between intent, planning, and outcome less direct. Ultimately, the devolution of power produces many unintended consequences for aid policy. But it also reinforces the perspective that aid and the need for it are nonpolitical issues.

Generic Drug Cost Containment in Medicaid: Lessons from Five State MAC Programs

PubMed Central

Abramson, Richard G.; Harrington, Catherine A.; Missmar, Raad; Li, Susan P.; Mendelson, Daniel N.

2004-01-01

In Medicaid, generic drug cost containment revolves around two programs: the Federal upper limit (FUL) program and State maximum allowable cost (MAC) programs. This article analyzes MAC programs in five States and finds considerable variation between these programs and the FUL program in both size and pricing aggressiveness. We conclude that expansion of existing MAC programs and creation of new ones could contribute to cost containment efforts nationwide. Options for States seeking to optimize their efforts include focusing on pricing for drugs with high sales volumes, ensuring that MAC lists include prices for all forms and dosages of listed drug entities, and collaborating with other States or the Federal Government on MAC list operations. PMID:15229994

Impact of Medicaid copayments on patients with cancer: lessons for Medicaid expansion under health reform.

PubMed

Subramanian, Sujha

2011-09-01

The Medicaid program plays a critical role in providing insurance coverage for many low-income beneficiaries who are diagnosed with cancer. Several states have increased their copayment requirements in the past few years and this provides a natural experiment to study the impact of copayments. We used Medicaid administrative data linked with cancer registry data for the years 1999 to 2004 from Georgia (intervention state with increases in copayments), Texas (control state A), and South Carolina (control state B) to study the impact of copayments on adult (aged from 18 to 64 y) Medicaid beneficiaries diagnosed with cancer (n=10,241). We report both pre/post and difference-in-difference assessments controlling for confounding factors including demographics, comorbidities, cancer site, and stage at diagnosis. After copayments were imposed, the number of days of supply of prescription drugs in the intervention state decreased by 127.4 and 150.1 days compared with control state A and B, respectively. Those with multiple comorbidities reduced their use of prescription drug the most. The proportion of beneficiaries with emergency room visits also increased in the intervention state compared with the control states. Overall, total 6-month cost was more than $2000 higher per patient in the intervention than the control states. The results show that Medicaid patients with cancer when faced with even moderate copayments change their health-seeking behavior. State Medicaid programs should reconsider the use of copayments as they do not decrease overall cost, but instead could potentially result in negative consequences.

Projecting the Unmet Need and Costs for Contraception Services After the Affordable Care Act

PubMed Central

Steinmetz, Erika; Gavin, Lorrie; Rivera, Maria I.; Pazol, Karen; Moskosky, Susan; Weik, Tasmeen; Ku, Leighton

2016-01-01

Objectives. We estimated the number of women of reproductive age in need who would gain coverage for contraceptive services after implementation of the Affordable Care Act, the extent to which there would remain a need for publicly funded programs that provide contraceptive services, and how that need would vary on the basis of state Medicaid expansion decisions. Methods. We used nationally representative American Community Survey data (2009), to estimate the insurance status for women in Massachusetts and derived the numbers of adult women at or below 250% of the federal poverty level and adolescents in need of confidential services. We extrapolated findings to simulate the impact of the Affordable Care Act nationally and by state, adjusting for current Medicaid expansion and state Medicaid Family Planning Expansion Programs. Results. The number of low-income women at risk for unintended pregnancy is expected to decrease from 5.2 million in 2009 to 2.5 million in 2016, based on states’ current Medicaid expansion plans. Conclusions. The Affordable Care Act increases women’s insurance coverage and improves access to contraceptive services. However, for women who remain uninsured, publicly funded family planning programs may still be needed. PMID:26691128

The Burden of Rotavirus Hospitalizations Among Medicaid and Non-Medicaid Children Younger Than 5 Years Old

PubMed Central

El Khoury, Antoine C.; Itzler, Robbin F.

2009-01-01

Objectives. We sought to compare the burden of hospitalizations associated with rotavirus gastroenteritis (RGE) in children younger than 5 years in US Medicaid and non-Medicaid populations in 2000 and 2003. Methods. We used the Kids' Inpatient Database (KID) to examine the burden of RGE-associated hospitalizations in terms of numbers and rates of hospitalizations, lengths of stay, and hospital charges. Two indirect methods were also used to estimate RGE-associated hospitalizations, because rotavirus testing is not routinely performed. Results. Approximately 40% of children younger than 5 years were enrolled in Medicaid in 2003, but this population accounted for nearly 50% of all RGE-associated hospitalizations and 60% of total charges. Children enrolled in Medicaid had significantly greater hospitalization rates, average lengths of stay, and average charges per stay than did those not enrolled. Conclusions. Although RGE affects all socioeconomic groups, the Medicaid population accounted for a disproportionate number of the hospitalizations. With the inclusion of rotavirus vaccines in the pediatric immunization schedule, it is important that US children, especially those enrolled in Medicaid programs, are vaccinated to reduce the burden of RGE. PMID:19797754

Medicaid Waivers and Public Sector Mental Health Service Penetration Rates for Youth.

PubMed

Graaf, Genevieve; Snowden, Lonnie

2018-01-22

To assist families of youth with serious emotional disturbance in financing youth's comprehensive care, some states have sought and received Medicaid waivers. Medicaid waivers waive or relax the Medicaid means test for eligibility to provide insurance coverage to nonpoor families for expensive, otherwise out-of-reach treatment for youth with Serious Emotional Disturbance (SED). Waivers promote treatment access for the most troubled youth, and the present study investigated whether any of several Medicaid waiver options-and those that completely omit the means test in particular-are associated with higher state-wide public sector treatment penetration rates. The investigators obtained data from the U.S. Census, SAMHSA's Uniform Reporting System, and the Centers for Medicare and Medicaid Services. Analysis employed random intercept and random slope linear regression models, controlling for a variety of state demographic and fiscal variables, to determine whether a relationship between Medicaid waiver policies and state-level public sector penetration rates could be observed. Findings indicate that, whether relaxing or completely waiving Medicaid's qualifying income limits, waivers increase public sector penetration rates, particularly for youth under age 17. However, completely waiving Medicaid income limits did not uniquely contribute to penetration rate increases. States offering Medicaid waivers that either relax or completely waive Medicaid's means test to qualify for health coverage present higher public sector treatment rates for youth with behavioral health care needs. There is no evidence that restricting the program to waiving the means test for accessing Medicaid would increase treatment access. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Medicare, Medicaid, and Maternal and Child Health Block Grant Budget Issues. Hearing before the Committee on Finance. United States Senate, One Hundredth Congress, First Session (July 8 and 9, 1987). Part 1 of 2.

ERIC Educational Resources Information Center

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

This document presents witnesses' testimonies and prepared statements from two of three Senate hearings called to examine budget issues affecting the Medicare, Medicaid, and Maternal and Child Health Block Grant programs, including changes in the Medicare program necessary to reduce spending in accordance with the budget resolution and expansions…

Design and Implementation of the Texas Medicaid DSRIP Program.

PubMed

Begley, Charles; Hall, Jessica; Shenoy, Amrita; Hanke, June; Wells, Rebecca; Revere, Lee; Lievsay, Nicole

2017-04-01

Texas is one of 8 states that have received a Medicaid 1115 Transformation Waiver in which federal supplemental payments are being used to incentivize delivery system reform. Under the Texas Transformation Waiver's 5-year Delivery System Reform Incentive Payment (DSRIP) program, hospitals and other providers have established regional health care partnerships, conducted regional needs assessments, and developed and implemented projects addressing local gaps in service. The projects were selected from menus, supplied by the Texas Health and Human Services Commission and the Centers for Medicare & Medicaid Services, which defined acceptable infrastructure development and/or program innovation and redesign initiatives. Providers receive payment for planning the projects and achieving metrics and milestones related to project implementation and performance. This article describes the major features of the Texas DSRIP model and the resulting implementation and performance to date in the most populous region of the state.

A disease-specific Medicaid expansion for women. The Breast and Cervical Cancer Prevention and Treatment Act of 2000.

PubMed

Lantz, Paula M; Weisman, Carol S; Itani, Zena

2003-01-01

The Breast and Cervical Cancer Prevention and Treatment Act of 2000 (BCCPTA) allows states the option of extending Medicaid eligibility to women diagnosed with breast or cervical cancer through a large federal screening program that does not include resources for treatment. Using qualitative data from interviews with 22 key informants and other sources, we present an analysis of the history and passage of the BCCPTA as a policy response to a perceived "treatment gap" in a national screening program. The results suggest that organizational policy entrepreneurs-primarily the National Breast Cancer Coalition-constructed an effective problem definition (that the government screening program was "unethical" and "broken") with a viable policy solution (an optional disease-specific Medicaid expansion), and pushed this proposal through a policy window opened by a budget surplus and an election year in which women's health issues had broad bipartisan appeal.

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.

The ACA Medicaid Expansion Waiver in the Keystone State: Do the Medically Uninsured "Got a Friend in Pennsylvania"?

PubMed

Olson, Laura Katz

2015-06-01

Medicaid is fundamental to near universal health insurance coverage under the 2010 Affordable Care Act (ACA). Its goal of broadening the program to all households with income at or below 138 percent of the federal poverty level was thwarted in 2012 by a Supreme Court decision that allowed the states to choose whether or not they would join. This essay seeks to assess the status of Pennsylvania with regard to the Medicaid expansion controversy. It briefly describes the Keystone State's existing Medicaid program and the potential impact of the ACA on its growth. It then discusses Governor Tom Corbett's market-based alternative and what he achieved in his deliberations with the Obama administration. The article also discusses some of the financial considerations facing Pennsylvania policy makers in the expansion decision, the role of three of the more influential lobby groups, and the problematic situation of the medically uninsured population. Copyright © 2015 by Duke University Press.

Sustainability of school-located influenza vaccination programs in Florida

PubMed Central

Tran, Cuc H.; Brew, Joe; Johnson, Nicholas; Ryan, Kathleen A.; Martin, Brittany; Cornett, Catherine; Caron, Brad; Duncan, R. Paul; Small, Parker A.; Myers, Paul D.; Morris, J. Glenn

2018-01-01

Background School-located influenza vaccination (SLIV) programs are a promising strategy for increasing vaccination coverage among schoolchildren. However, questions of economic sustainability have dampened enthusiasm for this approach in the United States. We evaluated SLIV sustainability of a health department led, county-wide SLIV program in Alachua County, Florida. Based on Alachua’s outcome data, we modeled the sustainability of SLIV programs statewide using two different implementation costs and at different vaccination rates, reimbursement amount, and Vaccines for Children (VFC) coverage. Methods Mass vaccination clinics were conducted at 69 Alachua County schools in 2013 using VFC (for Medicaid and uninsured children) and non-VFC vaccines. Claims were processed after each clinic and submitted to insurance providers for reimbursement ($5 Medicaid and $47.04 from private insurers). We collected programmatic expenditures and volunteer hours to calculate fixed and variable costs for two different implementation costs (with or without in-kind costs included). We project program sustainability for Florida using publicly available county-specific student populations and health insurance enrollment data. Results Approximately 42% (n = 12,853) of pre-kindergarten – 12th grade students participated in the SLIV program in Alachua. Of the 13,815 doses provided, 58% (8042) were non-VFC vaccine. Total implementation cost was $14.95/dose or $7.93/dose if “in-kind” costs were not included. The program generated a net surplus of $24,221, despite losing $4.68 on every VFC dose provided to Medicaid and uninsured children. With volunteers, 99% of Florida counties would be sustainable at a 50% vaccination rate and average reimbursement amount of $3.25 VFC and $37 non-VFC. Without volunteers, 69% of counties would be sustainable at 50% vaccination rate if all VFC recipients were on Medicaid and its reimbursement increased from $5 to $10 (amount private practices receive). Conclusions and relevance Key factors that contributed to the sustainability and success of an SLIV program are: targeting privately insured children and reducing administration cost through volunteers. Counties with a high proportion of VFC eligible children may not be sustainable without subsidies at $5 Medicaid reimbursement. PMID:27126875

Financing adolescent health care: the role of Medicaid and CHIP.

PubMed

English, A; Kaplan, D; Morreale, M

2000-02-01

Financing health care for adolescents involves a combination of public and private sources of payment and, in the public sector, a combination of insurance coverage and categorical programs. In recent years, the importance of health insurance coverage has increased along with the potential for insuring more adolescents. Medicaid and the new State Children's Health Insurance Program (CHIP) offer numerous options for reducing the proportion of uninsured adolescents and for increasing adolescents' access to necessary health care. This article explores the potential of Medicaid and CHIP for meeting adolescents' needs, the extent to which they have done so already, and the gaps or missing links that remain. It also reviews issues that cut across funding sources related to managed care, consent, and confidentiality.

Episode-Based Payment for Perinatal Care in Medicaid: Implications for Practice and Policy.

PubMed

Jarlenski, Marian; Borrero, Sonya; La Charité, Trey; Zite, Nikki B

2016-06-01

Medicaid is an important source of health insurance coverage for low-income pregnant women and covers nearly half of all deliveries in the United States. In the face of budgetary pressures, several state Medicaid programs have implemented or are considering implementing episode-based payments for perinatal care. Under the episode-based payment model, Medicaid programs make a single payment for all pregnancy-related medical services provided to women with low- and medium-risk pregnancies from 40 weeks before delivery through 60 days postpartum. The health care provider who delivers a live birth is assigned responsibility for all care and must meet certain quality metrics and stay within delineated cost-per-episode parameters. Implementation of cost- and quality-dependent episode-based payments for perinatal care is notable because there is no published evidence about the effects of such initiatives on pregnancy or birth outcomes. In this article, we highlight challenges and potential adverse consequences related to defining the perinatal episode and assigning a responsible health care provider. We also describe concerns that perinatal care quality metrics may not address the most pressing health care issues that are likely to improve health outcomes and reduce costs. In their current incarnations, Medicaid programs' episode-based payments for perinatal care may not improve perinatal care delivery and subsequent health outcomes. Rigorous evaluation of the new episode-based payment initiatives is critically needed to inform policymakers about the intended and unintended consequences of implementing episode-based payments for perinatal care.

Methods University Health System Can Use to Expand Medicaid Coverage to Uninsured Poor Parents with Medicaid Eligible Children: Policy Analysis

DTIC Science & Technology

2006-03-15

benefits that are monitored by a gatekeeper (J. Simmons personal communication, July 2005). 31 Bexar County Medicaid 32 Bexar County is committed to...and Ella, for their love and support during my residency year. Without you, my life would be empty. I would like to acknowledge the guidance and... Benefits . Carelink Program University Health System Table 7. Evaluation Options For Increasing Access To Care For Uninsured Low-Income Parents Of

Medicare and Medicaid Physician Payment Incentives

PubMed Central

Burney, Ira L.; Schieber, George J.; Blaxall, Martha O.; Gabel, Jon R.

1979-01-01

The incentives in the Medicare and Medicaid physician payment systems and their effects on six interrelated aspects of health care costs and beneficiary access to care were analyzed. Research results and data presented indicate that Medicare and Medicaid physician payment incentives are inconsistent with current public policy goals of (1) containing inflation in fees and expenditures, (2) encouraging physician participation in public programs, (3) improving the geographic and specialty distributions of physicians, (4) encouraging primary care instead of surgery, and also outpatient rather than inpatient treatment. PMID:10309053

A descriptive study of California hospice providers' perceptions of public reporting of quality data using the Family Evaluation of Hospice Care Survey.

PubMed

Nelson, Marsha; Gale, Randall C; Naierman, Naomi; DeViney, Meredith

2014-06-01

The Affordable Care Act requires US hospices to report quality data to the Centers for Medicare and Medicaid Services (CMS) in 2013 with data eventually being made public. There may be some benefit to participating in a voluntary public-reporting program prior to public disclosure by CMS; therefore, we developed and conducted an electronic survey exploring California hospices' perceptions of public reporting. The majority (78.1%) of respondents reported current use of the Family Evaluation of Hospice Care tool and a willingness to consider voluntary participation in a public-reporting program outside of what is being implemented by CMS (58.6%). Tax status of responding hospices was not predictive of a willingness to participate in a statewide public-reporting program of hospice quality in our study.

42 CFR 456.23 - Post-payment review process.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Post-payment review process. 456.23 Section 456.23 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...

42 CFR 435.134 - Individuals who would be eligible except for the increase in OASDI benefits under Pub. L. 92-336...

Code of Federal Regulations, 2010 CFR

2010-10-01

... programs if he were not in a medical institution or intermediate care facility, and the Medicaid plan... institution or intermediate care facility, and the State's Medicaid plan covers this optional group. [43 FR...

42 CFR 435.134 - Individuals who would be eligible except for the increase in OASDI benefits under Pub. L. 92-336...

Code of Federal Regulations, 2012 CFR

2012-10-01

... programs if he were not in a medical institution or intermediate care facility, and the Medicaid plan... institution or intermediate care facility, and the State's Medicaid plan covers this optional group. [43 FR...

42 CFR 433.206 - Threshold methodology.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 4 2013-10-01 2013-10-01 false Threshold methodology. 433.206 Section 433.206 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STATE FISCAL ADMINISTRATION Methodologies for Determining Federal Share of Medicaid Expenditures for Adult Eligibilit...

42 CFR 433.206 - Threshold methodology.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Threshold methodology. 433.206 Section 433.206 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STATE FISCAL ADMINISTRATION Methodologies for Determining Federal Share of Medicaid Expenditures for Adult Eligibilit...

Community Health Center Utilization Following the 2008 Medicaid Expansion in Oregon: Implications for the Affordable Care Act

PubMed Central

Bailey, Steffani R.; Cowburn, Stuart; Marino, Miguel; Angier, Heather; DeVoe, Jennifer E.

2016-01-01

Objectives. To assess longitudinal patterns of community health center (CHC) utilization and the effect of insurance discontinuity after Oregon’s 2008 Medicaid expansion (the Oregon Experiment). Methods. We conducted a retrospective cohort study with electronic health records and Medicaid data. We divided individuals who gained Medicaid in the Oregon Experiment into those who maintained (n = 788) or lost (n = 944) insurance coverage. We compared these groups with continuously insured (n = 921) and continuously uninsured (n = 5416) reference groups for community health center utilization rates over a 36-month period. Results. Both newly insured groups increased utilization in the first 6 months. After 6 months, use among those who maintained coverage stabilized at a level consistent with the continuously insured, whereas it returned to baseline for those who lost coverage. Conclusions. Individuals who maintained coverage through Oregon’s Medicaid expansion increased long-term utilization of CHCs, whereas those with unstable coverage did not. Policy implications. This study predicts long-term increase in CHC utilization following Affordable Care Act Medicaid expansion and emphasizes the need for policies that support insurance retention. PMID:26890164

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

PubMed

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

2015-01-01

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