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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-02-22

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

Is premium support the right medicine for Medicare?

PubMed

Oberlander, J

2000-01-01

This paper assesses the desirability of transforming Medicare into a premium-support system. I focus on three areas crucial to the future of Medicare: cost savings, beneficiary choice, and the stability of traditional Medicare. Based on my analysis of the Bipartisan Commission on the Future of Medicare plan, I find substantial problems with adopting premium support for Medicare. In particular, projections of premium-support savings are based on questionable assumptions that the slowdown in health spending during 1993-1997 can be sustained and extrapolated to future Medicare performance. Consequently, premium support may inadvertently destabilize public Medicare and erode beneficiary choice without achieving substantial savings.

An Economic History of Medicare Part C

PubMed Central

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

2011-01-01

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

The effect of insurance type on prescription drug use and expenditures among elderly Medicare beneficiaries.

PubMed

Saleh, Shadi S; Weller, Wendy; Hannan, Edward

2007-01-01

The debate over the impact of the new Medicare prescription drug benefit (Part D) has intensified in anticipation of its implementation. This paper contributes additional information related to the effect of different types of prescription drug coverage plans on use and expenditures among elderly Medicare beneficiaries. Cross-sectional design using data from the 2002 Medical Expenditures Panel Survey (MEPS). The two dependent variables were (1) prescription drug use and (2) expenditures. The main independent variable was the type of drug insurance (Medicare FFS only [no Rx insurance], Medicare FFS + Rx insurance and Medicare HMO). Bivariate and multivariate analyses were used to test the effect of insurance type, and beneficiaries' characteristics, on likelihood and level of drug use, as well as expenditures. The findings showed that average total drug expenditures among Medicare FFS enrollees who had Rx insurance (non-HMO) were higher ($182.51) than that of Medicare FFS enrollees with no Rx insurance. In addition, the former group had a higher likelihood (any use) of using prescribed medications. On the other hand, no differences in the likelihood of use were detected between Medicare HMO and Medicare FFS (no Rx insurance) enrollees. However, Medicare HMO enrollees had a higher level of drug use. In conclusion, The differences in drug use and expenditures by insurance type imply that each party (Medicare, Medicare Advantage plans, employers) will have a different set of disincentives for involvement in Medicare Part D.

Controlling prescription drug costs: regulation and the role of interest groups in Medicare and the Veterans Health Administration.

PubMed

Frakt, Austin B; Pizer, Steven D; Hendricks, Ann M

2008-12-01

Medicare and the Veterans Health Administration (VA) both finance large outpatient prescription drug programs, though in very different ways. In the ongoing debate on how to control Medicare spending, some suggest that Medicare should negotiate directly with drug manufacturers, as the VA does. In this article we relate the role of interest groups to policy differences between Medicare and the VA and, in doing so, explain why such a large change to the Medicare drug program is unlikely. We argue that key policy differences are attributable to stable differences in interest group involvement. While this stability makes major changes in Medicare unlikely, it suggests the possibility of leveraging VA drug purchasing to achieve savings in Medicare. This could be done through a VA-administered drug-only benefit for Medicare-enrolled veterans. Such a partnership could incorporate key elements of both programs: capacity to accept large numbers of enrollees (like Medicare) and leverage to negotiate prescription drug prices (like the VA). Moreover, it could be implemented at no cost to the VA while achieving savings for Medicare and beneficiaries.

Impact of the Medicare interim payment system on length of use in home care among patients with Medicare-only payment source.

PubMed

Han, Beth; Remsburg, Robin E

2005-01-01

Using data from the 1996 and 2000 National Home and Hospice Care Surveys (N = 2,455), we examined length of use in home care among patients with Medicare-only payment source before and during the Medicare interim payment system (IPS). Logistic regression analyses revealed that patients were 2.9 times more likely to be discharged within 60 days during IPS than before IPS. The impact of Medicare IPS on length of use in home care among patients with Medicare only was stronger than what the existing literature indicates, which combines Medicare patients with multiple payment sources and patients with Medicare-only together.

76 FR 62414 - Agency Information Collection Activities: Submission for OMB Review; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2011-10-07

... Collection: Collection of Encounter Data from Medicare Advantage Organizations; Use: The Centers for Medicare... delivered to an enrollee, from Medicare Advantage Organizations. Medicare Advantage organizations will obtain this data from providers. CMS would collect the data electronically from Medicare Advantage...

HOW MUCH FAVORABLE SELECTION IS LEFT IN MEDICARE ADVANTAGE?

PubMed Central

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

2015-01-01

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

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

PubMed

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

2013-12-01

More than a quarter of Medicare beneficiaries are enrolled in Medicare Advantage, which was created in large part to improve the efficiency of health care delivery by promoting competition among private managed care plans. This paper explores the spillover effects of the Medicare Advantage program on the traditional Medicare program and other patients, taking advantage of changes in Medicare Advantage payment policy to isolate exogenous increases in Medicare Advantage enrollment and trace out the effects of greater managed care penetration on hospital utilization and spending throughout the health care system. We find that when more seniors enroll in Medicare managed care, hospital costs decline for all seniors and for commercially insured younger populations. Greater managed care penetration is not associated with fewer hospitalizations, but is associated with lower costs and shorter stays per hospitalization. These spillovers are substantial - offsetting more than 10% of increased payments to Medicare Advantage plans. Copyright © 2013 Elsevier B.V. All rights reserved.

Medicare overpayments to private plans, 1985-2012: shifting seniors to private plans has already cost Medicare US$282.6 billion.

PubMed

Hellander, Ida; Himmelstein, David U; Woolhandler, Steffie

2013-01-01

Previous research has documented Medicare overpayments to the private Medicare Advantage (MA) plans that compete with traditional fee-for-service Medicare. This research has assessed individual categories of overpayment for, at most, a few years. However, no study has calculated the total overpayments to private plans since the program's inception. Prior to 2004, selective enrollment of healthier seniors was the major source of excess payments. We estimate this has added US$41 billion to Medicare's costs since 1985. Medicare adopted a risk-adjustment scheme in 2004, but this has not curbed private plans' ability to game the payment system. This has added US$122.5 billion to Medicare's costs since 2004. Congress mandated increased payment to private plans in the 2003 Medicare Modernization Act, which was mitigated, to a degree, by the subsequent Affordable Care Act. In total, we find that Medicare has overpaid private insurers by US$282.6 billion since 1985. Risk adjustment does not work in for-profit MA plans, which have a financial incentive, the data, and the ingenuity to game whatever system Medicare devises. It is time to end Medicare's costly experiment with privatization. The U.S. needs to adopt a single-payer national health insurance program with effective methods for controlling costs.

77 FR 72268 - Rules Relating to Additional Medicare Tax

Federal Register 2010, 2011, 2012, 2013, 2014

2012-12-05

... social security tax, and Hospital Insurance (HI) tax, also referred to as Medicare tax. The Medicare... finances different benefits. Tier 1 RRTA tax provides equivalent social security and Medicare benefits... social security and Medicare taxes on the self-employment income of every individual at the same combined...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-06-28

... national coverage determinations (NCDs) affecting specific medical and health care services under Medicare... notification, such as a particular clinical trial or research study that qualifies for Medicare coverage.... 93.773, Medicare--Hospital Insurance, Program No. 93.774, Medicare-- Supplementary Medical Insurance...

42 CFR 411.108 - Taking into account entitlement to Medicare.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Limitations... basis of ESRD, age, or disability (or eligible on the basis of ESRD) include, but are not limited to... Medicare on the basis of disability without denying or terminating coverage for similarly situated...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-03-25

... Assurance for Medicare Advantage Health Maintenance Organizations and Local Preferred Provider Organizations... notice announces the decision to renew the Medicare Advantage Deeming Authority of the National Committee... Medicare program, eligible beneficiaries may receive covered services through a Medicare Advantage (MA...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-02-24

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-16

...] Medicare Program; Request for Nominations for Members for the Medicare Evidence Development & Coverage... notice announces the request for nominations for consideration for membership on the Medicare Evidence... serve on the MEDCAC. Nominees are selected based upon their individual qualifications and not as...

Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program. Final rule.

PubMed

2017-11-15

This major final rule addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies such as changes to the Medicare Shared Savings Program, to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. In addition, this final rule includes policies necessary to begin offering the expanded Medicare Diabetes Prevention Program model.

Pharmacy students' knowledge of the Medicare drug benefit and intention to provide Medicare medication therapy management services.

PubMed

Urmie, Julie M; Farris, Karen B; Herbert, Kathleen E

2007-06-15

To examine PharmD students' knowledge about Medicare Part D and their attitudes toward and intention to provide Medicare medication therapy management services (MTMS). Fourth-professional year students were given a self-administered survey instrument that assessed: (1) knowledge about Medicare Part D; (2) attitudes, perceived behavioral control, subjective norms, and intention to provide Medicare MTMS; and (3) demographic and experience information. Ninety-five students responded for a response rate of 94%. Students showed good basic knowledge about Medicare Part D, with a mean score of 94%. Almost 60% of students agreed that they intended to provide Medicare MTMS, but agreement dropped to 37% when they were asked if they were willing to take initiative to provide MTMS. The lack of willingness to take initiative to provide Medicare MTMS suggests that colleges and schools of pharmacy must strengthen efforts to encourage students to take on the role of service provider.

Medicaid

MedlinePlus

... other care that Medicare doesn’t cover. Who pays first—Medicaid or Medicare? Medicaid never pays first for services covered by Medicare . It only pays after Medicare, employer group health plans, and/or ...

Traditional Medicare Versus Private Insurance: How Spending, Volume, And Price Change At Age Sixty-Five.

PubMed

Wallace, Jacob; Song, Zirui

2016-05-01

To slow the growth of Medicare spending, some policy makers have advocated raising the Medicare eligibility age from the current sixty-five years to sixty-seven years. For the majority of affected adults, this would delay entry into Medicare and increase the time they are covered by private insurance. Despite its policy importance, little is known about how such a change would affect national health care spending, which is the sum of health care spending for all consumers and payers-including governments. We examined how spending differed between Medicare and private insurance using longitudinal data on imaging and procedures for a national cohort of individuals who switched from private insurance to Medicare at age sixty-five. Using a regression discontinuity design, we found that spending fell by $38.56 per beneficiary per quarter-or 32.4 percent-upon entry into Medicare at age sixty-five. In contrast, we found no changes in the volume of services at age sixty-five. For the previously insured, entry into Medicare led to a large drop in spending driven by lower provider prices, which may reflect Medicare's purchasing power as a large insurer. These findings imply that increasing the Medicare eligibility age may raise national health care spending by replacing Medicare coverage with private insurance, which pays higher provider prices than Medicare does. Project HOPE—The People-to-People Health Foundation, Inc.

Traditional Medicare Versus Private Insurance: How Spending, Volume, And Price Change At Age Sixty-Five

PubMed Central

Wallace, Jacob; Song, Zirui

2016-01-01

To slow the growth of Medicare spending, some policy makers have advocated raising the Medicare eligibility age from the current sixty-five years to sixty-seven years. For the majority of affected adults, this would delay entry into Medicare and increase the time they are covered by private insurance. Despite its policy importance, little is known about how such a change would affect national health care spending, which is the sum of health care spending for all consumers and payers—including governments. We examined how spending differed between Medicare and private insurance using longitudinal data on imaging and procedures for a national cohort of individuals who switched from private insurance to Medicare at age sixty-five. Using a regression discontinuity design, we found that spending fell by $38.56 per beneficiary per quarter—or 32.4 percent—upon entry into Medicare at age sixty-five. In contrast, we found no changes in the volume of services at age sixty-five. For the previously insured, entry into Medicare led to a large drop in spending driven by lower provider prices, which may reflect Medicare's purchasing power as a large insurer. These findings imply that increasing the Medicare eligibility age may raise national health care spending by replacing Medicare coverage with private insurance, which pays higher provider prices than Medicare does. PMID:27140993

76 FR 21372 - Medicare Program; Solicitation for Proposals for the Medicare Community-Based Care Transitions...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-04-15

...] Medicare Program; Solicitation for Proposals for the Medicare Community-Based Care Transitions Program... interested parties of an opportunity to apply to participate in the Medicare Community-based Care Transitions Program, which was authorized by section 3026 of the Affordable Care Act. DATES: Proposals will be...

42 CFR 460.90 - PACE benefits under Medicare and Medicaid.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false PACE benefits under Medicare and Medicaid. 460.90 Section 460.90 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... FOR THE ELDERLY (PACE) PACE Services § 460.90 PACE benefits under Medicare and Medicaid. If a Medicare...

77 FR 2724 - CVS Caremark Corporation; Analysis of Proposed Consent Order To Aid Public Comment

Federal Register 2010, 2011, 2012, 2013, 2014

2012-01-19

... Medicare drug plans and Medicare Part D drugs. CVSC currently owns multiple subsidiaries, including RxAmerica, that offer Medicare Part D prescription drug plans. Medicare Part D is a prescription drug... Part D benefits, beneficiaries must enroll in a Medicare drug plan administered by an insurer or other...

2 CFR 376.370 - What are the obligations of Medicare carriers and intermediaries?

Code of Federal Regulations, 2010 CFR

2010-01-01

... responsibilities on behalf of the Medicare program (Title XVIII of the Social Security Act), these entities assume the same obligations and responsibilities as the HHS Medicare officials responsible for the Medicare... Responsibilities of Participants Regarding Transactions § 376.370 What are the obligations of Medicare carriers and...

How to think clearly about Medicare administrative costs: data sources and measurement.

PubMed

Sullivan, Kip

2013-06-01

The Centers for Medicare and Medicaid Services (CMS) annually publishes two measures of Medicare's administrative expenditures. One of these appears in the reports of the Medicare Boards of Trustees and the other in the National Health Expenditure Accounts (NHEA). The latest trustees' report indicates Medicare's administrative expenditures are 1 percent of total Medicare spending, while the latest NHEA indicates the figure is 6 percent. The debate about Medicare's administrative expenditures, which emerged several years ago, reflects widespread confusion about these data. Critics of Medicare argue that the official reports on Medicare's overhead ignore or hide numerous types of administrative spending, such as the cost of collecting taxes and Part B premiums. Defenders of Medicare claim the official statistics are accurate. But participants on both sides of this debate fail to cite the official documents and do not analyze CMS's methodology. This article examines the controversy over the methodology CMS uses to calculate the trustees' and NHEA's measures and the sources of confusion and ignorance about them. It concludes with a discussion of how the two measures should be used.

Less Intense Postacute Care, Better Outcomes For Enrollees In Medicare Advantage Than Those In Fee-For-Service.

PubMed

Huckfeldt, Peter J; Escarce, José J; Rabideau, Brendan; Karaca-Mandic, Pinar; Sood, Neeraj

2017-01-01

Traditional fee-for-service (FFS) Medicare's prospective payment systems for postacute care provide little incentive to coordinate care or control costs. In contrast, Medicare Advantage plans pay for postacute care out of monthly capitated payments and thus have stronger incentives to use it efficiently. We compared the use of postacute care in skilled nursing and inpatient rehabilitation facilities by enrollees in Medicare Advantage and FFS Medicare after hospital discharge for three high-volume conditions: lower extremity joint replacement, stroke, and heart failure. After accounting for differences in patient characteristics at discharge, we found lower intensity of postacute care for Medicare Advantage patients compared to FFS Medicare patients discharged from the same hospital, across all three conditions. Medicare Advantage patients also exhibited better outcomes than their FFS Medicare counterparts, including lower rates of hospital readmission and higher rates of return to the community. These findings suggest that payment reforms such as bundling in FFS Medicare may reduce the intensity of postacute care without adversely affecting patient health. Project HOPE—The People-to-People Health Foundation, Inc.

Medicare

MedlinePlus

... get about Medicare Lost/incorrect Medicare card Report fraud & abuse File a complaint Identity theft: protect yourself ... the U.S. Centers for Medicare & Medicaid Services. 7500 Security Boulevard, Baltimore, MD 21244 Sign Up / Change Plans ...

Doctors as Stewards of medicare, or not: CAMSI, MRG, CDM, DRHC and the thin alphabet soup of physician support.

PubMed

Duffin, Jacalyn

2018-07-01

Physicians are deeply involved in Canadian medicare because it is through medicare that they are paid. However, from its origins to the present physicians -as a profession - have not been strong supporters of medicare. Fearing loss of income and individual autonomy, they have frequently opposed it with criticisms, strikes, threatened job action and lawsuits. Some opponents are unaware that medicare was a boon to physician income, and many fail to connect medicare with responsibility for improving the health status of the country. This paper will trace physician involvement, support and opposition to medicare from its inception to the present, with special attention to small physician organizations that have supported medicare. It will close with a proposal for how doctors could display greater stewardship.

Primary care quality in the Medicare Program: comparing the performance of Medicare health maintenance organizations and traditional fee-for-service medicare.

PubMed

Safran, Dana Gelb; Wilson, Ira B; Rogers, William H; Montgomery, Jana E; Chang, Hong

2002-04-08

Since 1972, Medicare beneficiaries have had the option of enrolling in a Medicare-qualified health maintenance organization (HMO). Little information exists to inform beneficiaries' choices between the traditional fee-for-service (FFS) Medicare program and an HMO. To compare the primary care received by seniors in Medicare HMOs with that of seniors in the traditional FFS Medicare program, and among HMOs, and to examine performance differences associated with HMO model-type and profit status. Data were derived from a cross-sectional observational survey of Medicare beneficiaries 65 years or older in the 13 states with mature, substantial Medicare HMO markets. Only beneficiaries continuously enrolled for 12 months or more in traditional FFS Medicare or a qualified Medicare HMO were eligible. Data were obtained using a 5-stage protocol involving mail and telephone (64% response rate). Analyses included respondents who identified a primary physician and had all required data elements (N = 8828). We compared FFS and HMO performance on 11 summary scales measuring 7 defining characteristics of primary care: (1) access, (2) continuity, (3) integration, (4) comprehensiveness, (5) "whole-person" orientation, (6) clinical interaction, and (7) sustained clinician-patient partnership. For 9 of 11 indicators, performance favored traditional FFS Medicare over HMOs (P<.001). Financial access favored HMOs (P<.001). Preventive counseling did not differ by system. Network-model HMOs performed more favorably than staff/group-model HMOs on 9 of 11 indicators (P<.001). Few differences were associated with HMO profit status. The findings are consistent with previous comparisons of indemnity insurance and network-model and staff/group-model HMOs in elderly and nonelderly populations. The stability of results across time, geography, and populations suggests that the relative strengths and weaknesses of each system are enduring attributes of their care. Medicare enrollees seem to face the perennial cost-quality trade-off: that is, deciding whether the advantages of primary care under traditional FFS Medicare are worth the higher out-of-pocket costs.

Medicare's private plans: a report card on Medicare Advantage.

PubMed

Gold, Marsha

2009-01-01

With higher payments and expanded private-plan authority, Medicare Advantage (MA) has caused the market to grow. One in three Medicare beneficiaries with Part D now gets this coverage through MA. Analysis of the sources of and reasons for enrollment growth suggest a troubling report card. Clearly, the Medicare Modernization Act (MMA) has expanded choice and the private-sector role. But it also has added to Medicare's complexity and costs and has created potential inequities, without apparent improvements in quality. However the debate ends, a stronger system of performance monitoring and accountability is needed to meet Medicare's essential fiduciary requirements and oversight responsibilities.

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-05-04

...] Medicare Program; Meeting of the Medicare Economic Index Technical Advisory Panel--May 21, 2012 AGENCY... announces that a public meeting of the Medicare Economic Index Technical Advisory Panel (``the Panel'') will... Economic Index (MEI). This first meeting will focus on MEI inputs and input weights. This meeting is open...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-05-11

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-8050-N] Medicare Program; Meeting of the Medicare Economic Index Technical Advisory Panel--May 21, 2012 Correction In notice document 2012-10702 appearing on pages 26553-26554 in the issue of Friday, May 4, 2012 make...

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.

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.

Inpatient Utilization and Costs for Medicare Fee-for-Service Beneficiaries with Heart Failure.

PubMed

Fitch, Kathryn; Pelizzari, Pamela M; Pyenson, Bruce

2016-04-01

Although the medical and economic burden of heart failure in the United States is already substantial, it will likely grow as the population ages and life expectancy increases. Not surprisingly, most of the heart failure burden is borne by individuals aged ≥65 years, many of whom are in the Medicare population. The population-based utilization and costs of inpatient care for Medicare beneficiaries with heart failure are not well understood by payers and providers. To create a real-world view of utilization and costs associated with inpatient admissions, readmissions, and admissions to skilled nursing facilities among Medicare fee-for-service (FFS) beneficiaries with heart failure. The study used the 2011 and 2012 Medicare 5% sample limited data set to perform a retrospective analysis of claims data. The look-back year that was used to identify certain patient characteristics was 2011, and 2012 was the analysis period for the study. Beneficiaries with heart failure were defined as those who had ≥1 acute inpatient, emergency department, nonacute inpatient, or outpatient claims in 2012 containing an International Classification of Diseases, Ninth Revision code for heart failure. To be included in the study, beneficiaries with heart failure had to have eligibility for ≥1 months in 2012 and in all 2011 months, with Part A and Part B eligibility in all the study months, and no enrollment in an HMO (Medicare Advantage plan). Utilization of inpatient admissions, inpatient readmissions, and skilled nursing facility admissions in 2012 were reported for Medicare FFS beneficiaries with heart failure and for all Medicare FFS beneficiaries. The costs for key metrics included all allowed Medicare payments in 2012 US dollars. The 2012 Medicare FFS population for this study consisted of 1,461,935 patients (1,301,545 without heart failure; 160,390 with heart failure); the heart failure prevalence was 11%. The Medicare-allowed cost per member per month (PMPM) was $3395 for a patient with heart failure, whereas the allowed cost for the total Medicare population was $1045 PMPM. The Medicare-allowed amounts for the population with heart failure accounted for 34% of the total annual Medicare FFS population-allowed amounts. The heart failure population constituted 41.5%, 55.3%, and 49.5% of total Medicare FFS inpatient admissions, readmissions, and admissions to skilled nursing facilities, respectively. The costs of inpatient admissions, readmissions, and admissions to skilled nursing facilities among the heart failure population contributed $182 PMPM (17.5%), $58 PMPM (5.6%), and $46 PMPM (4.4%), respectively, to the total Medicare FFS population-allowed cost of $1045 PMPM. Medicare FFS beneficiaries with heart failure have high inpatient admission and readmission rates and generate substantial costs. Because a substantial portion of all inpatient admissions are for Medicare beneficiaries with heart failure, it is reasonable for hospitals in Medicare accountable care organizations to focus on more aggressive post-acute care management, including a focus on reducing readmissions for the population with heart failure. Our study findings highlight areas of high service utilization and cost for Medicare patients with heart failure that can be of value to Medicare, Medicare Advantage plans, and providers.

Medicare program; requirements for providers and suppliers to establish and maintain Medicare enrollment. Final rule.

PubMed

2006-04-21

This final rule requires that all providers and suppliers (other than physicians or practitioners who have elected to "opt-out" of the Medicare program) complete an enrollment form and submit specific information to us. This final rule also requires that all providers and suppliers periodically update and certify the accuracy of their enrollment information to receive and maintain billing privileges in the Medicare program. In addition, this final rule implements provisions in the statute that require us to ensure that all Medicare providers and suppliers are qualified to provide the appropriate health care services. These statutory provisions include requirements meant to protect beneficiaries and the Medicare Trust Funds by preventing unqualified, fraudulent, or excluded providers and suppliers from providing items or services to Medicare beneficiaries or billing the Medicare program or its beneficiaries.

Conducting research on the Medicare market: the need for better data and methods.

PubMed

Wong, H S; Hellinger, F J

2001-04-01

To highlight data limitations, the need to improve data collection, the need to develop better analytic methods, and the need to use alternative data sources to conduct research related to the Medicare program. Objectives were achieved by reviewing existing studies on risk selection in Medicare HMOs, examining their data limitations, and introducing a new approach that circumvents many of these shortcomings. Data for years 1995-97 for five states (Arizona, Florida, Massachusetts, New York, and Pennsylvania) from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SIDs), maintained by the Agency for Healthcare Research and Quality; and the Health Care Financing Administration's Medicare Managed Care Market Penetration Data Files and Medicare Provider Analysis and Review Files. Analysis of hospital utilization rates for Medicare beneficiaries in the traditional fee-for-service (FFS) Medicare and Medicare HMO sectors and examination of the relationship between these rates and the Medicare HMO penetration rates. Medicare HMOs have lower hospital utilization rates than their FFS counterparts, differences in utilization rates vary across states, and HMO penetration rates are inversely related to our rough measure of favorable selection. Substantial growth in Medicare HMO enrollment and the implementation of a new risk-adjusted payment system have led to an increasing need for research on the Medicare program. Improved data collection, better methods, new creative approaches, and alternative data sources are needed to address these issues in a timely and suitable manner.

Overview of employer capitation activities

PubMed Central

Moley, Kevin E.

1986-01-01

This article addresses a new initiative of the Health Care Financing Administration (HCFA) to contract on a group basis with: employer self-insurance plans, unions, group health insurance companies, and Taft-Hartley Health and Welfare Funds for groups of Medicare beneficiaries. Under this new concept, Medicare beneficiaries may elect in the future to obtain Medicare coverage through their group insurance plan rather than through traditional Medicare, with HCFA paying the premiums. This Medicare demonstration will bridge the gap between employer plans, which coordinate with traditional Medicare coverage, and employer-sponsored health benefit plans. This will make available to Medicare-eligible retirees similar, if not the same, managed-care alternatives as are currently available to active employees. PMID:10311924

Knowledge and opinions regarding Medicare reimbursement for laparoscopic cholecystectomy.

PubMed

Madan, Atul K; Tichansky, David S; Barton, Ginny E; Taddeucci, Raymond J

2007-11-01

Medicare, via its fee schedule, determines amount of payment to physicians for services for its beneficiaries. Because many private insurance companies base their payment schedule on Medicare rates, it is important for physicians to know the rates of commonly performed procedures. In addition, it seems that public perception is that physicians receive substantial payments for procedures. This investigation explores patient, student, resident, and surgeon knowledge and opinion of Medicare reimbursements for laparoscopic cholecystectomy. Patients, students, residents, and surgeons filled out an IRB-exempted survey. The survey included a written description of a laparoscopic cholecystectomy. All participants were asked to give their thoughts of what Medicare currently reimburses for a laparoscopic cholecystectomy ($622) and what they thought Medicare should reimburse for a laparoscopic cholecystectomy for our geographic area. There were 105 participants (47 patients, 17 medical students, 33 surgical residents, and 8 attending surgeons) in the investigation. The reported mean reimbursements of what each group thought Medicare pays were patients, $9,396; students, $3,077; residents, $800; and surgeons, $711. The reported mean reimbursements of what each group thought Medicare should pay were patients, $8,067; students, $3,971; residents, $1,444; and surgeons, $1,600. The mean reimbursements were statistically different between all groups in both the amount Medicare currently pays and the amount Medicare should pay. Most of our participants overestimated what Medicare currently pays for laparoscopic cholecystectomy. Even the mean amount reported in the attending surgeon group was greater than the actual payment. All groups felt Medicare should pay more than the current rate; however, only patients thought Medicare should pay less than they currently pay (probably because of the incorrect perception of the current fee schedule).

Medicare annual preventive care visits: use increased among fee-for-service patients, but many do not participate.

PubMed

Chung, Sukyung; Lesser, Lenard I; Lauderdale, Diane S; Johns, Nicole E; Palaniappan, Latha P; Luft, Harold S

2015-01-01

Under the Affordable Care Act (ACA), Medicare coverage expanded in 2011 to fully cover annual preventive care visits. We assessed the impact of coverage expansion, using 2007-13 data from primary care patients of Medicare-eligible age at the Palo Alto Medical Foundation (204,388 patient-years), which serves people in four counties near San Francisco, California. We compared trends in preventive visits and recommended preventive services among Medicare fee-for-service and Medicare health maintenance organization (HMO) patients as well as non-Medicare patients ages 65-75 who were covered by private fee-for-service and private HMO plans. Among Medicare fee-for-service patients, the annual use of preventive visits rose from 1.4 percent before the implementation of the ACA to 27.5 percent afterward. This increase was significantly larger than was seen for patients in the other insurance groups. Nevertheless, rates of annual preventive care visit use among Medicare fee-for-service patients remained 10-20 percentage points lower than was the case for people with private coverage (43-44 percent) or those in a Medicare HMO (53 percent). ACA policy changes led to increased preventive service use by Medicare fee-for-service beneficiaries, which suggests that Medicare coverage expansion is an effective way to increase seniors' use of preventive services. Project HOPE—The People-to-People Health Foundation, Inc.

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.

MEDICARE CURRENT BENEFICIARY SURVEY (MCBS) DATA

EPA Science Inventory

The Medicare Current Beneficiary Survey (MCBS) is a continuous, multipurpose survey of a nationally representative sample of aged, disabled, and institutionalized Medicare beneficiaries. MCBS, which is sponsored by the Centers for Medicare & Medicaid Services (CMS), is a comprehe...

Transitioning From Medicaid Disability Coverage to Long-Term Medicare Coverage: The Case of People Living With HIV/AIDS in California.

PubMed

Comulada, Warren S; Desmond, Katherine A; Gildner, Jennifer L; Leibowitz, Arleen A

2017-02-01

Medicaid can serve as a bridge to Medicare coverage for the long-term disabled with sufficient covered work experience. We perform multinomial logistic regression on 2007-2010 Medicare and Medicaid claims data to examine transitions to Medicare for people living with HIV/AIDS (PLWHA) in California who had Medicaid coverage in 2007. We find only 16% had obtained Medicare coverage by 2010. African-Americans, women, individuals with schizophrenia diagnoses, alcohol or substance abuse disorders, and any physical comorbidity were significantly less likely than others to obtain Medicare (p < 0.001). This study contributes new information on the impact of eligibility requirements for Medicare long-term disability insurance for PLWHA. About one-third of PLWHA under age 65 are covered by Medicaid. Many PLWHA get stuck in Medicaid because their disability prevents them from obtaining the additional employment experience needed to qualify for Medicare.

Individualizing Medicare.

PubMed

Chollet, D J

1999-05-01

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

Collision course? Donald Trump, Paul Ryan, and the fate of Medicare.

PubMed

Oberlander, Jonathan

2018-04-10

The election of Donald Trump as president of the United States raises questions about the future of Medicare. How will Medicare fare under Republican-led government? There are several compelling reasons that the Trump administration and Congressional Republicans might avoid Medicare reform, including the political risks of taking on a popular program, the difficulties the party has encountered in trying to dismantle the Patient Protection and Affordable Care Act (ACA), the importance of older Americans to the GOP coalition, and President Trump's views about Medicare. However, because of fiscal pressures and the commitment of Speaker of the House Paul Ryan and other Republicans to entitlement reform, the GOP nonetheless could end up attempting to make major changes in Medicare. Alternatively, Republican efforts to repeal and undermine the ACA could unintentionally enhance the political fortunes of proposals to expand Medicare. Consequently, the fate of Medicare during the Trump administration remains highly uncertain.

TRANSITIONING FROM MEDICAID DISABILITY COVERAGE TO LONG-TERM MEDICARE COVERAGE: THE CASE OF PEOPLE LIVING WITH HIV/AIDS IN CALIFORNIA

PubMed Central

Comulada, Warren S.; Desmond, Katherine A.; Gildner, Jennifer L.; Leibowitz, Arleen A

2017-01-01

Medicaid can serve as a bridge to Medicare coverage for the long-term disabled with sufficient covered work experience. We perform multinomial logistic regression on 2007–2010 Medicare and Medicaid claims data to examine transitions to Medicare for people living with HIV/AIDS (PLWHA) in California who had Medicaid coverage in 2007. We find only 16% had obtained Medicare coverage by 2010. African-Americans, women, individuals with schizophrenia diagnoses, alcohol or substance abuse disorders, and any physical comorbidity were significantly less likely than others to obtain Medicare (p < 0.001). This study contributes new information on the impact of eligibility requirements for Medicare long-term disability insurance for PLWHA. About one-third of PLWHA under age 65 are covered by Medicaid. Many PLWHA get stuck in Medicaid because their disability prevents them from obtaining the additional employment experience needed to qualify for Medicare. PMID:28195778

Will managed care's role in Medicare expand?

PubMed

Grimaldi, P L

1996-10-01

Managed care's penetration of the Medicare market has grown dramatically over the last several years. Nevertheless, most beneficiaries remain with fee-for-service providers and most health maintenance organizations (HMOs) do not contract with Medicare. Because of the program's dire financial outlook, Medicare almost certainly will be restructured soon to encourage more beneficiaries to enroll with HMOs and entice more managed care plans into becoming Medicare risk contractors.

Changes in Initial Expenditures for Benign Prostatic Hyperplasia Evaluation in the Medicare Population: A Comparison to Overall Medicare Inflation

PubMed Central

Bellinger, Adam S.; Elliott, Sean P.; Yang, Liu; Wei, John T.; Saigal, Christopher S.; Smith, Alexandria; Wilt, Timothy J.; Strope, Seth A.

2012-01-01

Introduction Benign prostatic hyperplasia (BPH) creates significant expenses for the Medicare program. We sought to determine trends in expenditures for BPH evaluative testing after urologist consultation, and place these trends in the context of overall Medicare expenditures. Methods Using a 5% national sample of Medicare beneficiaries from 2000 to 2007, we developed a cohort of men with claims for new visits to urologists for diagnoses consistent with symptomatic BPH (n=40,253). We assessed trends in initial expenditures (within 12 months of diagnosis; inflation and geography adjusted) by categories of evaluative tests derived from the 2003 AUA Guideline on the Management of BPH. Using governmental reports on Medicare expenditures, trends in BPH expenditures were compared to overall and imaging-specific Medicare expenditures. Comparisons were assessed by Z-tests and regression analysis for linear trends as appropriate. Results Between 2000 and 2007 inflation adjusted total Medicare expenditure per patient for the initial evaluation of BPH patients seen by urologists increased from $255.44 to $343.98 (p<0.0001). Increases in BPH related imaging (55%), were significantly less than increases in overall Medicare expenditures on imaging (104%; p<0.001). The 35% increase in per patient expenditures for BPH was significantly lower than the increase in overall Medicare expenditure per enrollee (45%; p=0.0.0015). Conclusion From 2000 to 2007, inflation adjusted expenditures on BPH related evaluations increased. This growth was slower than overall growth in Medicare expenditures, and increases in imaging expenditures related to BPH were restrained compared to the Medicare program as a whole. PMID:22425128

Estimating Medicare and patient savings from the use of bevacizumab for the treatment of exudative age-related macular degeneration.

PubMed

Rosenfeld, Philip J; Windsor, Matthew A; Feuer, William J; Sun, Sissi J J; Frick, Kevin D; Swanson, Eric A; Huang, David

2018-04-12

The Medicare cost savings from the use of bevacizumab in the United States for the treatment of exudative age-related macular degeneration (AMD) were estimated by replacing the use of bevacizumab with ranibizumab and aflibercept. Retrospective trend study. Main outcome measures were spending by Medicare as tracked by Current Procedural Terminology (CPT) codes for intravitreal injections (67028) and treatment-specific J-codes (J0178, J2778, J9035, J3490 and J3590) for inhibitors of vascular endothelial growth factor. These claims were identified from the Medicare Provider Utilization and Payment Data from the Centers for Medicare and Medicaid Services among fee-for-service (FFS) Medicare beneficiaries from 2012 - 2015. The 2008 claims were acquired from the 100% fee-for-service (FFS) Part B Medicare Claims File. The use of bevacizumab from 2008 to 2015 resulted in an estimated savings of $17.3 billion, which corresponded to a $13.8 billion savings to Medicare and a $3.5 billion savings to patients. This amount underestimated the actual cost-savings to Medicare providers since approximately 30% of Medicare-eligible recipients received care within Medicare Advantage plans and were not included in this analysis. The cost savings from the use of bevacizumab from 2008-2015 for Medicare fee-for-service patients undergoing treatment for exudative AMD was estimated at $17.3 billion. Additional savings over the $17.3 billion would have accrued from the use of bevacizumab if diagnostic categories such as diabetic macular edema and retinal vein occlusion were included in this study. Copyright © 2018. Published by Elsevier Inc.

Your Guide to Medicare Special Needs Plans (SNPs)

MedlinePlus

... Needs Plans Where Are Medicare SNPs Offered? Each year, different types of Medicare SNPs may be available in different parts of the country. Insurance companies decide where they will do business, so Medicare SNPs may not be available in ...

Less Intense Postacute Care, Better Outcomes For Enrollees In Medicare Advantage Than Those In Fee-For-Service

PubMed Central

Huckfeldt, Peter J.; Escarce, Jose J.; Rabideau, Brendan; Karaca-Mandic, Pinar; Sood, Neeraj

2017-01-01

Traditional fee-for-service (FFS) Medicare’s prospective payment systems for postacute care provide little incentive to coordinate care or control costs. In contrast, Medicare Advantage plans pay for postacute care out of monthly capitated payments and thus have stronger incentives to use it efficiently. We compared the use of postacute care in skilled nursing and inpatient rehabilitation facilities by enrollees in Medicare Advantage and FFS Medicare after hospital discharge for three high-volume conditions: lower extremity joint replacement, stroke, and heart failure. After accounting for differences in patient characteristics at discharge, we found lower intensity of postacute care for Medicare Advantage patients compared to FFS Medicare patients discharged from the same hospital, across all three conditions. Medicare Advantage patients also exhibited better outcomes than their FFS Medicare counterparts, including lower rates of hospital readmission and higher rates of return to the community. These findings suggest that payment reforms such as bundling in FFS Medicare may reduce the intensity of postacute care without adversely affecting patient health. PMID:28069851

Problem-based Learning Using the Online Medicare Part D Plan Finder Tool

PubMed Central

Stebbins, Marilyn R.; Lai, Eric; Smith, Amanda R.; Lipton, Helene Levens

2008-01-01

Objectives To implement didactic and problem-based learning curricular innovations aimed at increasing students' knowledge of Medicare Part D, improving their ability to apply the online Medicare Prescription Drug Plan Finder tool to a patient case, and improving their attitudes toward patient advocacy for Medicare beneficiaries. Methods A survey instrument and a case-based online Medicare Prescription Drug Plan Finder tool exercise were administered to a single group (n = 120) of second-year pharmacy graduate students prior to and following completion of a course on health policy. Three domains (knowledge, skill mastery and attitudes) were measured before and after two 90-minute lectures on Medicare Part D. Results The online Medicare Prescription Drug Plan Finder exercise and Medicare Part D didactic lectures had positive effects on students' knowledge of Part D, attitudes toward patient advocacy, and ability to accurately use the Medicare Prescription Drug Plan Finder tool. Conclusions The success of these didactic and problem-based curricular innovations in improving pharmacy students' knowledge, skills, and attitudes regarding Part D warrants further evaluation to determine their portability to clinical settings and other pharmacy schools. PMID:18698399

High-Cost Patients Had Substantial Rates Of Leaving Medicare Advantage And Joining Traditional Medicare

PubMed Central

Rahman, Momotazur; Keohane, Laura; Trivedi, Amal N.; Mor, Vincent

2015-01-01

Medicare Advantage payment regulations include risk-adjusted capitated reimbursement, which was implemented to discourage favorable risk selection and encourage the retention of members who incur high costs. However, the extent to which risk-adjusted capitation has succeeded is not clear, especially for members using high-cost services not previously considered in assessments of risk selection. We examined the rates at which participants who used three high-cost services switched between Medicare Advantage and traditional Medicare. We found that the switching rate from 2010 to 2011 away from Medicare Advantage and to traditional Medicare exceeded the switching rate in the opposite direction for participants who used long-term nursing home care (17 percent versus 3 percent), short-term nursing home care (9 percent versus 4 percent), and home health care (8 percent versus 3 percent). These results were magnified among people who were enrolled in both Medicare and Medicaid. Our findings raise questions about the role of Medicare Advantage plans in serving high-cost patients with complex care needs, who account for a disproportionately high amount of total health care spending. PMID:26438743

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...

42 CFR 417.454 - Charges to Medicare enrollees.

Code of Federal Regulations, 2010 CFR

2010-10-01

... (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Enrollment, Entitlement, and Disenrollment under Medicare Contract § 417.454 Charges to... of the contract period, all premiums, enrollment fees, and other charges collected from its Medicare...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-05-05

... furnished to Medicare beneficiaries). A dentist furnishes many services that are not covered by Medicare and, as a result, most dentists are not enrolled in Medicare. However, a dentist may order services for...

Access to Care for Medicare-Medicaid Dually Eligible Beneficiaries: The Role of State Medicaid Payment Policies.

PubMed

Zheng, Nan Tracy; Haber, Susan; Hoover, Sonja; Feng, Zhanlian

2017-12-01

Medicaid programs are not required to pay the full Medicare coinsurance and deductibles for Medicare-Medicaid dually eligible beneficiaries. We examined the association between the percentage of Medicare cost sharing paid by Medicaid and the likelihood that a dually eligible beneficiary used evaluation and management (E&M) services and safety net provider services. Medicare and Medicaid Analytic eXtract enrollment and claims data for 2009. Multivariate analyses used fee-for-service dually eligible and Medicare-only beneficiaries in 20 states. A comparison group of Medicare-only beneficiaries controlled for state factors that might influence utilization. Paying 100 percent of the Medicare cost sharing compared to 20 percent increased the likelihood (relative to Medicare-only) that a dually eligible beneficiary had any E&M visit by 6.4 percent. This difference in the percentage of cost sharing paid decreased the likelihood of using safety net providers, by 37.7 percent for federally qualified health centers and rural health centers, and by 19.8 percent for hospital outpatient departments. Reimbursing the full Medicare cost-sharing amount would improve access for dually eligible beneficiaries, although the magnitude of the effect will vary by state and type of service. © Health Research and Educational Trust.

Preparing PharmD Students to Participate in Medicare Part D Education and Enrollment

PubMed Central

Zagar, Michelle

2007-01-01

Objective To create and implement a teaching module that prepares students to assist Medicare beneficiaries in evaluating and enrolling in Medicare Part D plans. Design A 6-hour module entitled “Medicare 2006: This Year, It's Different!”1 was developed and first presented to students in February 2006. Material describing provisions of Medicare Part D was included as well as instructions on using the plan selection tools available on the Medicare web site. Learning activities developed included listing the top 10 things a Medicare beneficiary should know about Medicare Part D, participating in a mock patient counseling activity, selecting an appropriate Medicare prescription drug plan for a given list of drugs, and writing a paper explaining features of the plan they selected and justifying their selection. Assessment Assessment of the 64 students who completed the module was based on completion of individual Top 10 lists, participation in mock counseling sessions, and appropriate drug plan recommendations in plan selection assignments. Overall student response to the series was overwhelmingly positive. Conclusion Given opportunities to apply Medicare Part D knowledge in the classroom setting, PharmD students were able to empathize with the plight of elderly patients and took the initiative to participate in Part D education and enrollment efforts in their communities. PMID:17786265

Cost of schizophrenia in the Medicare program.

PubMed

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

2014-06-01

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

How does beneficiary knowledge of the Medicare program vary by type of insurance?

PubMed

McCormack, Lauren A; Uhrig, Jennifer D

2003-08-01

Prior research found that Medicare beneficiaries' knowledge of the Medicare program varied by the type of supplemental insurance they had. However, none of these studies used both multivariate methods and nationally representative data to examine the issue. OBJECTIVES To measure beneficiary knowledge of the Medicare program and to evaluate how knowledge varies by type of supplemental insurance. A mail survey with telephone follow-up to a nationally representative random sample of Medicare beneficiaries, which had a 76% response rate. The purpose of the study was to evaluate the effects of providing the Medicare & You handbook on beneficiary knowledge, information needs, and health plan decision making. A total of 3738 Medicare beneficiaries who completed the survey. A psychometrically validated 22-item index that reflects Medicare-related knowledge in seven different content areas. RESULTS Overall, beneficiaries with a Medicare HMO or non-employer-sponsored supplemental insurance were more knowledgeable about Medicare than those who had Medicare only. In general, beneficiaries tended to be more knowledgeable about issues related to the type of insurance they had (fee-for-service or managed care) than other types of insurance. Higher levels of knowledge about one's own type of insurance may suggest that beneficiaries learn by experience or they learn more about that type of insurance before enrollment. Further research is needed to better understand how and when beneficiaries learn about insurance and what educational strategies are more effective at increasing knowledge.

78 FR 71468 - Rules Relating to Additional Medicare Tax

Federal Register 2010, 2011, 2012, 2013, 2014

2013-11-29

... Rules Relating to Additional Medicare Tax AGENCY: Internal Revenue Service (IRS), Treasury. ACTION... Insurance Tax on income above threshold amounts (``Additional Medicare Tax''), as added by the Affordable... to the implementation of Additional Medicare Tax, including the requirement to withhold Additional...

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...

Hospitals need to help Medicare HMOs.

PubMed

Johnson, D E

1998-09-01

Many of the health maintenance organizations that rushed to create Medicare products are bailing out of their Medicare contracts. Donald E.L. Johnson writes that Medicare HMOs face market and government challenges, and hospitals should try to anticipate HMOs' next moves and have responses ready.

42 CFR 411.351 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Financial Relationships Between Physicians and... and that is used exclusively by the group practice. Space in a building or a mobile vehicle, van, or...

Centers for Medicare & Medicaid Services

MedlinePlus

... sites Expand Expand Home - Opens in a new window About CMS Newsroom Archive - Opens in a new window Tools dropdown menu to share, print or email ... the medicare.gov website - Opens in a new window MyMedicare.gov Link to the MyMedicare.gov website - ...

42 CFR 422.524 - Special rules for RFB societies.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Application Procedures and Contracts for Medicare Advantage Organizations § 422.524 Special rules for RFB societies. In order to participate as an... affiliated, but who are not entitled to receive benefits from the Medicare program. ...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-11-21

... percent reserve has been the normal target used to calculate the Part B premium. In view of the strong... 0938-AR16 Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual...

The Relationship between Commercial Health Care Prices and Medicare Spending and Utilization.

PubMed

Romley, John A; Axeen, Sarah; Lakdawalla, Darius N; Chernew, Michael E; Bhattacharya, Jay; Goldman, Dana P

2015-06-01

To explore the relationship between commercial health care prices and Medicare spending/utilization across U.S. regions. Claims from large employers and Medicare Parts A/B/D over 2007-2009. We compared prices paid by commercial health plans to Medicare spending and utilization, adjusted for beneficiary health and the cost of care, across 301 hospital referral regions. A 10 percent lower commercial price (around the average level) is associated with 3.0 percent higher Medicare spending per member per year, and 4.3 percent more specialist visits (p < .01). Commercial health care prices are negatively associated with Medicare spending across regions. Providers may respond to low commercial prices by shifting service volume into Medicare. Further investigation is needed to establish causality. © Health Research and Educational Trust.

Inpatient Utilization and Costs for Medicare Fee-for-Service Beneficiaries with Heart Failure

PubMed Central

Fitch, Kathryn; Pelizzari, Pamela M.; Pyenson, Bruce

2016-01-01

Background Although the medical and economic burden of heart failure in the United States is already substantial, it will likely grow as the population ages and life expectancy increases. Not surprisingly, most of the heart failure burden is borne by individuals aged ≥65 years, many of whom are in the Medicare population. The population-based utilization and costs of inpatient care for Medicare beneficiaries with heart failure are not well understood by payers and providers. Objective To create a real-world view of utilization and costs associated with inpatient admissions, readmissions, and admissions to skilled nursing facilities among Medicare fee-for-service (FFS) beneficiaries with heart failure. Methods The study used the 2011 and 2012 Medicare 5% sample limited data set to perform a retrospective analysis of claims data. The look-back year that was used to identify certain patient characteristics was 2011, and 2012 was the analysis period for the study. Beneficiaries with heart failure were defined as those who had ≥1 acute inpatient, emergency department, nonacute inpatient, or outpatient claims in 2012 containing an International Classification of Diseases, Ninth Revision code for heart failure. To be included in the study, beneficiaries with heart failure had to have eligibility for ≥1 months in 2012 and in all 2011 months, with Part A and Part B eligibility in all the study months, and no enrollment in an HMO (Medicare Advantage plan). Utilization of inpatient admissions, inpatient readmissions, and skilled nursing facility admissions in 2012 were reported for Medicare FFS beneficiaries with heart failure and for all Medicare FFS beneficiaries. The costs for key metrics included all allowed Medicare payments in 2012 US dollars. Results The 2012 Medicare FFS population for this study consisted of 1,461,935 patients (1,301,545 without heart failure; 160,390 with heart failure); the heart failure prevalence was 11%. The Medicare-allowed cost per member per month (PMPM) was $3395 for a patient with heart failure, whereas the allowed cost for the total Medicare population was $1045 PMPM. The Medicare–allowed amounts for the population with heart failure accounted for 34% of the total annual Medicare FFS population–allowed amounts. The heart failure population constituted 41.5%, 55.3%, and 49.5% of total Medicare FFS inpatient admissions, readmissions, and admissions to skilled nursing facilities, respectively. The costs of inpatient admissions, readmissions, and admissions to skilled nursing facilities among the heart failure population contributed $182 PMPM (17.5%), $58 PMPM (5.6%), and $46 PMPM (4.4%), respectively, to the total Medicare FFS population–allowed cost of $1045 PMPM. Conclusions Medicare FFS beneficiaries with heart failure have high inpatient admission and readmission rates and generate substantial costs. Because a substantial portion of all inpatient admissions are for Medicare beneficiaries with heart failure, it is reasonable for hospitals in Medicare accountable care organizations to focus on more aggressive post–acute care management, including a focus on reducing readmissions for the population with heart failure. Our study findings highlight areas of high service utilization and cost for Medicare patients with heart failure that can be of value to Medicare, Medicare Advantage plans, and providers. PMID:27182428

Changes in initial expenditures for benign prostatic hyperplasia evaluation in the Medicare population: a comparison to overall Medicare inflation.

PubMed

Bellinger, Adam S; Elliott, Sean P; Yang, Liu; Wei, John T; Saigal, Christopher S; Smith, Alexandria; Wilt, Timothy J; Strope, Seth A

2012-05-01

Benign prostatic hyperplasia creates significant expenses for the Medicare program. We determined expenditure trends for benign prostatic hyperplasia evaluative testing after urologist consultation and placed these trends in the context of overall Medicare expenditures. Using a 5% national sample of Medicare beneficiaries from 2000 to 2007 we developed a cohort of 40,253 with claims for new visits to urologists for diagnoses consistent with symptomatic benign prostatic hyperplasia. We assessed trends in initial inflation and geography adjusted expenditures within 12 months of diagnosis by evaluative test categories derived from the 2003 American Urological Association guideline on the management of benign prostatic hyperplasia. Using governmental reports on Medicare expenditure trends for benign prostatic hyperplasia we compared expenditures to overall and imaging specific Medicare expenditures. Comparisons were assessed by the Z-test and regression analysis for linear trends, as appropriate. Between 2000 and 2007 inflation adjusted total Medicare expenditures per patient for the initial evaluation of patients with benign prostatic hyperplasia seen by urologists increased from $255.44 to $343.98 (p <0.0001). Benign prostatic hyperplasia related imaging increases were significantly less than overall Medicare imaging expenditure increases (55% vs 104%, p <0.001). The increase in per patient expenditures for benign prostatic hyperplasia was significantly lower than the increase in overall Medicare expenditures per enrollee (35% vs 45%, p = 0.0015). From 2000 to 2007 inflation adjusted expenditures increased for benign prostatic hyperplasia related evaluations. This growth was slower than the overall growth in Medicare expenditures. The increase in BPH related imaging expenditures was restrained compared to that of the Medicare program as a whole. Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Cancer Stage at Diagnosis and Survival among Persons with Social Security Disability Insurance on Medicare

PubMed Central

McCarthy, Ellen P; Ngo, Long H; Chirikos, Thomas N; Roetzheim, Richard G; Li, Donglin; Drews, Reed E; Iezzoni, Lisa I

2007-01-01

Objective To examine stage at diagnosis and survival for disabled Medicare beneficiaries diagnosed with cancer under age 65 and compare their experiences with those of other persons diagnosed under age 65. Data Sources Surveillance, Epidemiology, and End Results (SEER) Program data and SEER-Medicare linked data for 1988–1999. SEER-11 Program includes 11 population-based tumor registries collecting information on all incident cancers in catchment areas. Tumor registry and Medicare data are linked for persons enrolled in Medicare. Study Design 307,595 incident cases of non-small cell lung (51,963), colorectal (52,092), breast (142,281), and prostate (61,259) cancer diagnosed in persons under age 65 from 1988 to 1999. Persons who qualified for Social Security Disability Insurance and had Medicare (SSDI/Medicare) were identified from Medicare enrollment files. Ordinal polychotomous logistic regression and Cox proportional hazards regression were used to estimate adjusted associations between disability status and later-stage diagnoses and mortality (all-cause and cancer-specific). Principal Findings Persons with SSDI/Medicare had lower rates of Stages III/IV diagnoses than others for lung (63.3 versus 69.5 percent) and prostate (25.5 versus 30.8 percent) cancers, but not for breast or colorectal cancers. After adjustment, they remained less likely to be diagnosed at later stages for lung and prostate cancers. Nevertheless, persons with SSDI/Medicare experienced higher all-cause mortality for each cancer. Cancer-specific mortality was higher among persons with SSDI/Medicare for breast and colorectal cancer patients. Conclusions Disabled Medicare beneficiaries are diagnosed with cancer at similar or earlier stages than others. However, they experience higher rates of cancer-related mortality when diagnosed at the same stage of breast and colorectal cancer. PMID:17362209

Health Insurance Knowledge Among Medicare Beneficiaries

PubMed Central

McCormack, Lauren A; Garfinkel, Steven A; Hibbard, Judith H; Keller, Susan D; Kilpatrick, Kerry E; Kosiak, Beth

2002-01-01

Objective To assess the effect of new consumer information materials about the Medicare program on beneficiary knowledge of their health care coverage under the Medicare system. Data Source A telephone survey of 2,107 Medicare beneficiaries in the 10-county Kansas City metropolitan statistical area. Study Design Beneficiaries were randomly assigned to a control group and three treatment groups each receiving a different set of Medicare informational materials. The “handbook-only” group received the Health Care Financing Administration's new Medicare & You 1999 handbook. The “bulletin” group received an abbreviated version of the handbook, and the “handbook + CAHPS” group received the Medicare & You handbook plus the Consumer Assessment of Health Plans (CAHPS)® survey report comparing the quality of health care provided by Medicare HMOs. Beneficiaries interested in receiving information were oversampled. Data Collection Methods Data were collected during two separate telephone surveys of Medicare beneficiaries: one survey of new beneficiaries and another survey of experienced beneficiaries. The intervention materials were mailed to sample members in advance of the interviews. Knowledge for the treatment groups was measured shortly after beneficiaries received the intervention materials. Principal Findings Respondents' knowledge was measured using a psychometrically valid and reliable 15-item measure. Beneficiaries who received the intervention materials answered significantly more questions correctly than control group members. The effect on beneficiary knowledge of providing the information was modest for all intervention groups but varied for experienced beneficiaries only, depending on the intervention they received. Conclusions The findings suggest that all of the new materials had a positive effect on beneficiary knowledge about Medicare and the Medicare + Choice program. While the absolute gain in knowledge was modest, it was greater than increases in knowledge associated with traditional Medicare information sources.

Trends in Medicare Part D Medication Therapy Management Eligibility Criteria

PubMed Central

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

2015-01-01

Background To increase the enrollment rate of medication therapy management (MTM) programs in Medicare Part D plans, the US Centers for Medicare & Medicaid Services (CMS) lowered the allowable eligibility thresholds based on the number of chronic diseases and Part D drugs for Medicare Part D plans for 2010 and after. However, an increase in MTM enrollment rates has not been realized. Objectives To describe trends in MTM eligibility thresholds used by Medicare Part D plans and to identify patterns that may hinder enrollment in MTM programs. Methods This study analyzed data extracted from the Medicare Part D MTM Programs Fact Sheets (2008–2014). The annual percentages of utilizing each threshold value of the number of chronic diseases and Part D drugs, as well as other aspects of MTM enrollment practices, were analyzed among Medicare MTM programs that were established by Medicare Part D plans. Results For 2010 and after, increased proportions of Medicare Part D plans set their eligibility thresholds at the maximum numbers allowable. For example, in 2008, 48.7% of Medicare Part D plans (N = 347:712) opened MTM enrollment to Medicare beneficiaries with only 2 chronic disease states (specific diseases varied between plans), whereas the other half restricted enrollment to patients with a minimum of 3 to 5 chronic disease states. After 2010, only approximately 20% of plans opened their MTM enrollment to patients with 2 chronic disease states, with the remaining 80% restricting enrollment to patients with 3 or more chronic diseases. Conclusion The policy change by CMS for 2010 and after is associated with increased proportions of plans setting their MTM eligibility thresholds at the maximum numbers allowable. Changes to the eligibility thresholds by Medicare Part D plans might have acted as a barrier for increased MTM enrollment. Thus, CMS may need to identify alternative strategies to increase MTM enrollment in Medicare plans. PMID:26380030

County-Level Population Economic Status and Medicare Imaging Resource Consumption.

PubMed

Rosenkrantz, Andrew B; Hughes, Danny R; Prabhakar, Anand M; Duszak, Richard

2017-06-01

The aim of this study was to assess relationships between county-level variation in Medicare beneficiary imaging resource consumption and measures of population economic status. The 2013 CMS Geographic Variation Public Use File was used to identify county-level per capita Medicare fee-for-service imaging utilization and nationally standardized costs to the Medicare program. The County Health Rankings public data set was used to identify county-level measures of population economic status. Regional variation was assessed, and multivariate regressions were performed. Imaging events per 1,000 Medicare beneficiaries varied 1.8-fold (range, 2,723-4,843) at the state level and 5.3-fold (range, 1,228-6,455) at the county level. Per capita nationally standardized imaging costs to Medicare varied 4.2-fold (range, $84-$353) at the state level and 14.1-fold (range, $33-$471) at the county level. Within individual states, county-level utilization varied on average 2.0-fold (range, 1.1- to 3.1-fold), and costs varied 2.8-fold (range, 1.1- to 6.4-fold). For both large urban populations and small rural states, Medicare imaging resource consumption was heterogeneously variable at the county level. Adjusting for county-level gender, ethnicity, rural status, and population density, countywide unemployment rates showed strong independent positive associations with Medicare imaging events (β = 26.96) and costs (β = 4.37), whereas uninsured rates showed strong independent positive associations with Medicare imaging costs (β = 2.68). Medicare imaging utilization and costs both vary far more at the county than at the state level. Unfavorable measures of county-level population economic status in the non-Medicare population are independently associated with greater Medicare imaging resource consumption. Future efforts to optimize Medicare imaging use should consider the influence of local indigenous socioeconomic factors outside the scope of traditional beneficiary-focused policy initiatives. Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.

77 FR 43289 - Agency Information Collection Activities: Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2012-07-24

... (OCN: 0938-1115); Frequency: Reporting-- Annually; Affected Public: Private sector--Business or other... Centers for Medicare and Medicaid Services (CMS) established reporting requirements for Medicare Part C... these reporting requirements, each sponsoring organization must submit Medicare Part C, Medicare Part D...

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...

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 422.108 - Medicare secondary payer (MSP) procedures.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Benefits and Beneficiary Protections § 422...; (2) Identify the amounts payable by those payers; and (3) Coordinate its benefits to Medicare enrollees with the benefits of the primary payers, including reporting, on an ongoing basis, information...

Medicare home health care patient case-mix before and after the Balanced Budget Act of 1997: effect on dual eligible beneficiaries.

PubMed

Shih, Huai-Che; Temkin-Greener, Helena; Votava, Kathryn; Friedman, Bruce

2014-01-01

The Balanced Budget Act (BBA) of 1997 changed the payment system for Medicare home health care (HHC) from cost-based to prospective reimbursement. We used Medical Expenditure Panel Survey data to assess the impact of the BBA on Medicare HHC patient case-mix measured by the Centers for Medicare and Medicaid Services Hierarchical Condition Categories (CMS-HCC) model. There was a significant increase in Medicare HHC patient case-mix between the pre-BBA and Prospective Payment System (PPS) periods. The increase in the standardized-predicted risk score from the Interim Payment System period to PPS was nearly 4 times greater for the dual eligibles (Medicare-Medicaid) than for the Medicare-only population. This significantly greater rise in the HHC resources required by dual eligibles as compared to nonduals could be due to a shift in HHC payers from Medicare only to Medicaid rather than be an actual increase in case-mix per se.

Medicare covers the majority of FDA-approved devices and Part B drugs, but restrictions and discrepancies remain.

PubMed

Chambers, James D; May, Katherine E; Neumann, Peter J

2013-06-01

The Food and Drug Administration (FDA) and Medicare use different standards to determine, first, whether a new drug or medical device can be marketed to the public and, second, if the federal health insurance program will pay for use of the drug or device. This discrepancy creates hurdles and uncertainty for drug and device manufacturers. We analyzed discrepancies between FDA approval and Medicare national coverage determinations for sixty-nine devices and Part B drugs approved during 1999-2011. We found that Medicare covered FDA-approved drugs or devices 80 percent of the time. However, Medicare often added conditions beyond FDA approval, particularly for devices and most often restricting coverage to patients with the most severe disease. In some instances, Medicare was less restrictive than the FDA. Our findings highlight the importance for drug and device makers of anticipating Medicare's needs when conducting clinical studies to support their products. Our findings also provide important insights for the FDA's and Medicare's pilot parallel review program.

Medicare Advantage Enrollees More Likely To Enter Lower-Quality Nursing Homes Compared To Fee-For-Service Enrollees

PubMed Central

Meyers, David J.; Mor, Vincent; Rahman, Momotazur

2018-01-01

Unlike fee-for-service (FFS) Medicare, most Medicare Advantage (MA) plans have a preferred network of care providers that serve most of a plan’s enrollees. Little is known about how the quality of care MA enrollees receive differs from that of FFS Medicare enrollees. This article evaluates the differences in the quality of skilled nursing facilities (SNFs) that Medicare Advantage and FFS beneficiaries entered in the period 2012–14. After we controlled for patients’ clinical, demographic, and residential neighborhood effects, we found that FFS Medicare patients have substantially higher probabilities of entering higher-quality SNFs (those rated four or five stars by Nursing Home Compare) and those with lower readmission rates, compared to MA enrollees. The difference between MA and FFS Medicare SNF selections was less for enrollees in higher-quality MA plans than those in lower-quality plans, but Medicare Advantage still guided patients to lower-quality facilities. PMID:29309215

Voluntary partial capitation: the Community Nursing Organization Medicare demonstration.

PubMed

Frakt, Austin B; Pizer, Steven D; Schmitz, Robert J; Mattke, Soeren

2005-01-01

In a recently concluded Medicare demonstration, Community Nursing Organizations (CNOs) received capitated payment to provide a subset of Medicare services through a nursing case management delivery system. Demonstration participation was voluntary, both for CNOs and recruited beneficiaries, raising several challenging issues associated with selection. We investigate provider and beneficiary selection, as well as Medicare costs, using multiple evaluation methodologies. We find that CNO enrollment is associated with increased payment by Medicare for CNO-covered services. Results showing CNO enrollees to be more costly to Medicare for non-CNO services are consistent with cost shifting, but could also be accounted for by biased provider selection into the demonstration.

Prices Don't Drive Regional Medicare Spending Variations

PubMed Central

Gottlieb, Daniel J.; Zhou, Weiping; Song, Yunjie; Andrews, Kathryn Gilman; Skinner, Jonathan S.; Sutherland, Jason M.

2010-01-01

Per capita Medicare spending is more than twice as high in New York City and Miami than in places like Salem, Oregon. How much of these differences can be explained by Medicare's paying more to compensate for the higher cost of goods and services in such areas? To answer this question, we analyzed Medicare spending after adjusting for local price differences in 306 Hospital Referral Regions. The price-adjustment analysis resulted in less variation in what Medicare pays regionally, but not much. The findings suggest that utilization—not local price differences—drives Medicare regional payment variations, along with special payments for medical education and care for the poor. PMID:20110290

Growth in HMO share of the Medicare market, 1989-1994.

PubMed

Welch, W P

1996-01-01

Between 1989 and 1994 the health maintenance organization (HMO) share of the Medicare market grew rapidly. It is still heavily concentrated geographically, however. The most influential factor in this growth is HMO penetration into an area's general health care market. Medicare payment rates and prior Medicare HMO penetration also have an impact, but their effects are much weaker. Thus, payment rate reform is likely to have only a modest impact on Medicare HMO growth in the short term. In the longer term, the HMO share of the Medicare market will continue to grow, because HMO penetration in the general health care market is growing rapidly.

Medicare spending by state: the border-crossing adjustment.

PubMed

Basu, J; Lazenby, H C; Levit, K R

1995-01-01

As the first step in a pioneering effort by the Health Care Financing Administration (HCFA) to measure interstate border crossing for services used by both Medicare and non-Medicare beneficiaries, the authors study the spending behavior of Medicare beneficiaries for 10 Medicare-covered services. Based on interstate flow-of-expenditure data developed for calendar year 1991, the authors analyze the spending patterns of State residents by studying the inflow and outflow rates and the netflow ratios of expenditures incurred by Medicare patients. The report also provides per capita expenditure estimates with residence-based adjustments and evaluates the impact of the border-crossing adjustment for individual services and States.

Understanding Trends in Medicare Spending, 2007-2014.

PubMed

Keohane, Laura M; Gambrel, Robert J; Freed, Salama S; Stevenson, David; Buntin, Melinda B

2018-03-06

To analyze the sources of per-beneficiary Medicare spending growth between 2007 and 2014, including the role of demographic characteristics, attributes of Medicare coverage, and chronic conditions. Individual-level Medicare spending and enrollment data. Using an Oaxaca-Blinder decomposition model, we analyzed whether changes in price-standardized, per-beneficiary Medicare Part A and B spending reflected changes in the composition of the Medicare population or changes in relative spending levels per person. We identified a 5 percent sample of fee-for-service Medicare beneficiaries age 65 and above from years 2007 to 2014. Mean payment-adjusted Medicare per-beneficiary spending decreased by $180 between the 2007-2010 and 2011-2014 time periods. This decline was almost entirely attributable to lower spending levels for beneficiaries. Notably, declines in marginal spending levels for beneficiaries with chronic conditions were associated with a $175 reduction in per-beneficiary spending. The decline was partially offset by the increasing prevalence of certain chronic diseases. Still, we are unable to attribute a large share of the decline in spending levels to observable beneficiary characteristics or chronic conditions. Declines in spending levels for Medicare beneficiaries with chronic conditions suggest that changing patterns of care use may be moderating spending growth. © Health Research and Educational Trust.

High-Cost Patients Had Substantial Rates Of Leaving Medicare Advantage And Joining Traditional Medicare.

PubMed

Rahman, Momotazur; Keohane, Laura; Trivedi, Amal N; Mor, Vincent

2015-10-01

Medicare Advantage payment regulations include risk-adjusted capitated reimbursement, which was implemented to discourage favorable risk selection and encourage the retention of members who incur high costs. However, the extent to which risk-adjusted capitation has succeeded is not clear, especially for members using high-cost services not previously considered in assessments of risk selection. We examined the rates at which participants who used three high-cost services switched between Medicare Advantage and traditional Medicare. We found that the switching rate from 2010 to 2011 away from Medicare Advantage and to traditional Medicare exceeded the switching rate in the opposite direction for participants who used long-term nursing home care (17 percent versus 3 percent), short-term nursing home care (9 percent versus 4 percent), and home health care (8 percent versus 3 percent). These results were magnified among people who were enrolled in both Medicare and Medicaid. Our findings raise questions about the role of Medicare Advantage plans in serving high-cost patients with complex care needs, who account for a disproportionately high amount of total health care spending. Project HOPE—The People-to-People Health Foundation, Inc.

Disease prevention policy under Medicare: a historical and political analysis.

PubMed

Schauffler, H H

1993-01-01

I review the history and politics of Medicare disease prevention policy and identify factors associated with the success or failure of legislative initiatives to add preventive services benefits to Medicare. Between 1965 and 1990, 453 bills for Medicare preventive services were introduced in the U.S. Congress, but not until 1980, after 350 bills had failed, was the first preventive service added to the Medicare program. Medicare currently pays for only four of the 44 preventive services recommended for the elderly by the U.S. Preventive Services Task Force (pneumococcal and hepatitis B vaccinations, Pap smears, and mammography). In addition, Congress has funded demonstration programs for the influenza vaccine and comprehensive preventive services. The preventive services added to Medicare reflect the bias of the biomedical model toward screening and immunizations. Counseling services have received the least legislative attention. Factors associated with successful enactment include single-benefit bills, incorporation into budget-deficit reduction legislation, documented evidence of cost-effectiveness, public hearings, sponsorship by chairs of key congressional committees, and persistent congressional leadership. Factors associated with failure include lack of support from Medicare beneficiaries, lack of professional support, impact on total Medicare expenditures, disagreement over or failure to address payment and financing mechanisms, and competing congressional priorities.

High Variation of Intravitreal Injection Rates and Medicare Anti-Vascular Endothelial Growth Factor Payments per Injection in the United States.

PubMed

Erie, Jay C; Barkmeier, Andrew J; Hodge, David O; Mahr, Michael A

2016-06-01

To estimate geographic variation of intravitreal injection rates and Medicare anti-vascular endothelial growth factor (VEGF) drug costs per injection in aging Americans. Observational cohort study using 2013 Medicare claims database. United States fee-for-service (FFS) Part B Medicare beneficiaries and their providers. Medicare Provider Utilization and Payment Data furnished by the Centers for Medicare and Medicaid Services was used to identify all intravitreal injection claims and anti-VEGF drug claims among FFS Medicare beneficiaries in all 50 states and the District of Columbia in 2013. The rate of FFS Medicare beneficiaries receiving intravitreal injections and the mean Medicare-allowed drug payment per anti-VEGF injection was calculated nationally and for each state. Geographic variations were evaluated by using extremal quotient, coefficient of variation, and systematic component of variance (SCV). Rate of FFS Medicare Part B beneficiaries receiving intravitreal injections (Current Procedural Terminology [CPT] code, 67028), nationally and by state; mean Medicare-allowed drug payment per anti-VEGF injection (CPT code, 67028; and treatment-specific J-codes, J0178, J2778, J9035, J3490, and J3590) nationally and by state. In 2013, the rate of FFS Medicare beneficiaries receiving intravitreal injections varied widely by 7-fold across states (range by state, 4 per 1000 [Wyoming]-28 per 1000 [Utah]), averaging 19 per 1000 beneficiaries. The mean SCV was 8.5, confirming high nonrandom geographic variation. There were more than 2.1 million anti-VEGF drug claims, totaling more than $2.3 billion in Medicare payments for anti-VEGF agents in 2013. The mean national Medicare drug payment per anti-VEGF injection varied widely by 6.2-fold across states (range by state, $242 [South Carolina]-$1509 [Maine]), averaging $1078 per injection. Nationally, 94% of injections were office based and 6% were facility based. High variation was observed in intravitreal injection rates and in Medicare drug payments per anti-VEGF injection across the United States in 2013. Identifying factors that contribute to high variation may help the ophthalmology community to optimize further the delivery and use of anti-VEGF agents. Copyright © 2016 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.

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 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 412.110 - Total Medicare payment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Payments to Hospitals Under the Prospective Payment Systems § 412.110 Total Medicare payment. Under the prospective payment systems, Medicare... 42 Public Health 2 2010-10-01 2010-10-01 false Total Medicare payment. 412.110 Section 412.110...

42 CFR 422.311 - RADV audit dispute and appeal processes.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false RADV audit dispute and appeal processes. 422.311 Section 422.311 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Payments to Medicare Advantage...

Effect of medicare payment on rural health care systems.

PubMed

McBride, Timothy D; Mueller, Keith J

2002-01-01

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

Did recent changes in Medicare reimbursement hit teaching hospitals harder?

PubMed

Konetzka, R Tamara; Zhu, Jingsan; Volpp, Kevin G

2005-11-01

To inform the policy debate on Medicare reimbursement by examining the financial effects of the Balanced Budget Act of 1997 (BBA) and subsequent adjustments on major academic medical centers, minor teaching hospitals, and nonteaching hospitals. The authors simulated the impacts of BBA and subsequent BBA adjustments to predict the independent effects of changes in Medicare reimbursement on hospital revenues using 1997-2001 Medicare Cost Reports for all short-term acute-care hospitals in the United States. The authors also calculated actual (nonsimulated) operating and total margins among major teaching, minor teaching, and nonteaching hospitals to account for hospital response to the changes. The BBA and subsequent refinements reduced Medicare revenues to a greater degree in major teaching hospitals, but the fact that such hospitals had a smaller proportion of Medicare patients meant that the BBA reduced overall revenues by similar percentages across major, minor, and nonteaching hospitals. Consistently lower margins may have made teaching hospitals more vulnerable to cuts in Medicare support. Recent Medicare changes affected revenues at teaching and nonteaching hospitals more similarly than is commonly believed. However, the Medicare cuts under the BBA probably exacerbated preexisting financial strain on major teaching hospitals, and increased Medicare funding may not suffice to eliminate the strain. This report's findings are consistent with recent calls to support needed services of teaching hospitals through all-payer or general funds.

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.

Savings estimate for a Medicare insured group

PubMed Central

Birnbaum, Howard; Holland, Stephen K.; Lenhart, Gregory; Reilly, Helena L.; Hoffman, Kevin; Pardo, Dennis P.

1991-01-01

Estimates of the savings potential of a managed-care program for a Medicare retiree population in Michigan under a hypothetical Medicare insured group (MIG) are presented in this article. In return for receiving an experience-rated capitation payment, a MIG would administer all Medicare and employer complementary benefits for its enrollees. A study of the financial and operational feasibility of implementing a MIG for retirees of a national corporation involving an analysis of 1986 claims data finds that selected managed-care initiatives implemented by a MIG would generate an annual savings of 3.8 percent of total (Medicare plus complementary) expenditures. Although savings are less than the 5 percent to be retained by Medicare, this finding illustrates the potential for savings from managed-care initiatives to Medicare generally and to MIGs elsewhere, where savings may be greater if constraints are less restrictive. PMID:10113700

Medicare expenditures among nursing home residents with advanced dementia.

PubMed

Goldfeld, Keith S; Stevenson, David G; Hamel, Mary Beth; Mitchell, Susan L

2011-05-09

Nursing home residents with advanced dementia commonly experience burdensome and costly interventions (eg, tube feeding) that may be of limited clinical benefit. To our knowledge, Medicare expenditures have not been extensively described in this population. Nursing home residents with advanced dementia in 22 facilities (N = 323) were followed up for 18 months. Clinical and health services use data were collected every 90 days. Medicare expenditures were described. Multivariate analysis was used to identify factors associated with total 90-day expenditures for (1) all Medicare services and (2) all Medicare services excluding hospice. Over an 18-month period, total mean Medicare expenditures were $2303 per 90 days but were highly skewed; expenditures were less than $500 for 77.1% of the 90-day assessment periods and more than $12,000 for 5.5% of these periods. The largest proportion of Medicare expenditures were for hospitalizations (30.2%) and hospice (45.6%). Among decedents (n = 177), mean Medicare expenditures increased by 65% in each of the last 4 quarters before death owing to an increase in both acute care and hospice. After multivariable adjustment, not living in a special care dementia unit was a modifiable factor associated with higher total expenditures for all Medicare services. Lack of a do-not-hospitalize order, tube feeding, and not living in a special care unit were associated with higher nonhospice Medicare expenditures. Medicare expenditures among nursing home residents with advanced dementia vary substantially. Hospitalizations and hospice account for most spending. Strategies that promote high-quality palliative care may shift expenditures away from aggressive treatments for these patients at the end of life.

Cost-Savings to Medicare From Pre-Medicare Colorectal Cancer Screening.

PubMed

Goede, Simon L; Kuntz, Karen M; van Ballegooijen, Marjolein; Knudsen, Amy B; Lansdorp-Vogelaar, Iris; Tangka, Florence K; Howard, David H; Chin, Joseph; Zauber, Ann G; Seeff, Laura C

2015-07-01

Many individuals have not received recommended colorectal cancer (CRC) screening before they become Medicare eligible at the age of 65. We aimed to estimate the long-term implications of increased CRC screening in the pre-Medicare population (50-64 y) on costs in the pre-Medicare and Medicare populations (65+ y). We used 2 independently developed microsimulation models [Microsimulation Screening Analysis Colon (MISCAN) and Simulation Model of CRC (SimCRC)] to project CRC screening and treatment costs under 2 scenarios, starting in 2010: "current trends" (60% of the population up-to-date with screening recommendations) and "enhanced participation" (70% up-to-date). The population was scaled to the projected US population for each year between 2010 and 2060. Costs per year were derived by age group (50-64 and 65+ y). By 2060, the discounted cumulative total costs in the pre-Medicare population were $35.7 and $28.1 billion higher with enhanced screening participation, than in the current trends scenario ($252.1 billion with MISCAN and $239.5 billion with SimCRC, respectively). Because of CRC treatment savings with enhanced participation, cumulative costs in the Medicare population were $18.3 and $32.7 billion lower (current trends: $423.5 billion with MISCAN and $372.8 billion with SimCRC). Over the 50-year time horizon an estimated 60% (MISCAN) and 89% (SimCRC) of the increased screening costs could be offset by savings in Medicare CRC treatment costs. Increased CRC screening participation in the pre-Medicare population could reduce CRC incidence and mortality, whereas the additional screening costs can be largely offset by long-term Medicare treatment savings.

Roles of prices, poverty, and health in Medicare and private spending in Texas.

PubMed

White, Chapin; Taychakhoonavudh, Suthira; Parikh, Rohan; Franzini, Luisa

2015-05-01

To investigate the roles of prices, poverty, and health in divergences between Medicare and private spending in Texas. Retrospective observational design using 2011 Blue Cross Blue Shield of Texas claims data and publicly available Medicare data. We measured market-level spending per enrollee among the privately insured. Variation in Medicare and private spending per person are decomposed into prices and quantities, and their associations with poverty are measured. Markets are divided into 4 groups and are compared based on the ratio of Medicare to private spending: "high-private," "proportional," "high-Medicare," and "extremely high-Medicare." Among the privately insured, poverty appears to have large spillover effects; it is strongly associated with lower prices, quantities, and spending. Among Medicare beneficiaries, health status is a key driver of spending variation. The 2 markets with extremely high Medicare-to-private spending ratios (Harlingen and McAllen) are predominantly Hispanic communities with markedly higher rates of poverty and lack of insurance and also extremely low physician supply. The markets with relatively high private spending stand out for having good health-system performance and health outcomes, and higher than average hospital prices. Variation in private spending appears to reflect the ability of the local population to pay for healthcare, whereas variation in Medicare is more heavily driven by health status, and presumably, by clinical need. These findings highlight the inadvisability of using Medicare spending as a proxy for systemwide spending, and the need for comprehensive market-level spending data that allow comparisons among populations with different sources of insurance coverage.

42 CFR 411.108 - Taking into account entitlement to Medicare.

Code of Federal Regulations, 2012 CFR

2012-10-01

...) Terminating coverage because the individual has become entitled to Medicare, except as permitted under COBRA..., instructions to bill Medicare first for services furnished to Medicare beneficiaries without stipulating that... employment status, the GHP coverage is by virtue of the COBRA law rather than by virtue of the current...

42 CFR 411.108 - Taking into account entitlement to Medicare.

Code of Federal Regulations, 2013 CFR

2013-10-01

...) Terminating coverage because the individual has become entitled to Medicare, except as permitted under COBRA..., instructions to bill Medicare first for services furnished to Medicare beneficiaries without stipulating that... employment status, the GHP coverage is by virtue of the COBRA law rather than by virtue of the current...

42 CFR 411.108 - Taking into account entitlement to Medicare.

Code of Federal Regulations, 2014 CFR

2014-10-01

...) Terminating coverage because the individual has become entitled to Medicare, except as permitted under COBRA..., instructions to bill Medicare first for services furnished to Medicare beneficiaries without stipulating that... employment status, the GHP coverage is by virtue of the COBRA law rather than by virtue of the current...

42 CFR 411.108 - Taking into account entitlement to Medicare.

Code of Federal Regulations, 2011 CFR

2011-10-01

...) Terminating coverage because the individual has become entitled to Medicare, except as permitted under COBRA..., instructions to bill Medicare first for services furnished to Medicare beneficiaries without stipulating that... employment status, the GHP coverage is by virtue of the COBRA law rather than by virtue of the current...

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...

42 CFR 405.410 - Conditions for properly opting-out of Medicare.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Conditions for properly opting-out of Medicare. 405.410 Section 405.410 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED Private Contracts...

42 CFR 405.455 - Application to Medicare+Choice contracts.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Application to Medicare+Choice contracts. 405.455 Section 405.455 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED Private Contracts § 405.455...

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

Code of Federal Regulations, 2010 CFR

2010-10-01

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

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

Code of Federal Regulations, 2011 CFR

2011-10-01

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

42 CFR 447.30 - Withholding the Federal share of payments to Medicaid providers to recover Medicare overpayments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Medicaid providers to recover Medicare overpayments. 447.30 Section 447.30 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE... payments to Medicaid providers to recover Medicare overpayments. (a) Basis and purpose. This section...

42 CFR 447.31 - Withholding Medicare payments to recover Medicaid overpayments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Withholding Medicare payments to recover Medicaid overpayments. 447.31 Section 447.31 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Provisions § 447.31 Withholding Medicare payments to recover Medicaid overpayments. (a) Basis and purpose...

Use of Medicare's Diabetes Self-Management Training Benefit

ERIC Educational Resources Information Center

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

2015-01-01

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

42 CFR 435.1007 - Categorically needy, medically needy, and qualified Medicare beneficiaries.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Categorically needy, medically needy, and qualified Medicare beneficiaries. 435.1007 Section 435.1007 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES... Limitations on Ffp § 435.1007 Categorically needy, medically needy, and qualified Medicare beneficiaries. (a...

75 FR 21295 - Agency Information Collection Activities: Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2010-04-23

... Medicare Advantage Quality Improvement Project; Use: The Social Security Act, section 1852 e(1), (2) and (3)(a)(i), and CFR 42, 422.152 describe CMS' regulatory authority to require each Medicare Advantage...; Title of Information Collection: Medicare Prescription Drug Plan (PDP) and Medicare Advantage...

75 FR 30756 - Medicare Program; Supplemental Proposed Changes to the Hospital Inpatient Prospective Payment...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-06-02

.... 93.773, Medicare--Hospital Insurance; and Program No. 93.774, Medicare-- Supplementary Medical... technical errors that appeared in the supplementary proposed rule entitled ``Medicare Program; Supplemental... Doc. 2010-12567 filed May 21, 2010, there are technical and typographical errors that are identified...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-09

... returned to Medicare by the hospice. CMS' contractors calculate each hospice's aggregate cap every year... Medicare contractor recalculate the hospice's aggregate cap using longer timeframes. Option 2: In this... individual hospices to request the Medicare contractor to apply a patient-by-patient proportional methodology...

Opening a dialog: communicating with retirees about Medicare+Choice.

PubMed

Maeyer, M M; Marlowe, J F

1999-01-01

In October 1998, the Health Care Financing Administration sent information to 38 million Medicare beneficiaries in five pilot states, consisting of a comprehensive handbook entitled Medicare and You. The purpose of the handbook is to clarify new options under Medicare+Choice to participants. Such clarification is bound to initiate contact by Medicare beneficiaries to former employers/unions. This article addresses employers' need to develop a communication strategy for beneficiaries and suggests a methodology and possible questions that may arise.

Beneficiaries' perceptions of new Medicare health plan choice print materials.

PubMed

Harris-Kojetin, L D; McCormack, L A; Jaël, E M; Lissy, K S

2001-01-01

This article presents findings from a study involving seven focus groups with aged and disabled Medicare beneficiaries in the Kansas City area regarding their impressions of a pilot version of the Medicare & You 1999 handbook and the Medicare Consumer Assessment of Health Plans Study (CAHPS) survey report. Beneficiaries generally had positive reactions to both booklets and viewed the handbook as an important reference tool. Based on the findings, we present policy recommendations for the development and dissemination of Medicare health plan information to beneficiaries.

Medicare prescription drug discount cards.

PubMed

Bryant, Natasha

2004-01-01

With the passage of the Medicare Prescription Drug Improvement and Modernization Act of 2003 came the creation of a Part D drug benefit through Medicare. Until that benefit is implemented, Medicare has established a drug discount card program to help your clients save money on their outpatient prescription drug expenses. In this brief, we discuss the Medicare-approved discount cards--who is eligible, how they work, how your clients can best make important decisions about them, and what help is out there for people with low incomes.

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-12-27

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

Eliminating cost-sharing requirements for colon cancer screening in Medicare.

PubMed

Howard, David H; Guy, Gery P; Ekwueme, Donatus U

2014-12-15

Medicare beneficiaries do not have to pay for screening colonoscopies but must pay coinsurance if a polyp is removed via polypectomy. Likewise, beneficiaries do not have to pay for fecal occult blood tests but are liable for cost-sharing for diagnostic colonoscopies after a positive test. Legislative and regulatory requirements related to colorectal cancer screening are described, and on the basis of Medicare claims, it is estimated that Medicare spending would increase by $48 million annually if Medicare were to waive cost-sharing requirements for these services. The economic impact on Medicare if beneficiaries were not responsible for any cost-sharing requirements related to colorectal cancer screening services is described. © 2014 American Cancer Society.

DataView: Medicare Spending by State: The Border-Crossing Adjustment

PubMed Central

Basu, Joy; Lazenby, Helen C.; Levit, Katharine R.

1995-01-01

As the first step in a pioneering effort by the Health Care Financing Administration (HCFA) to measure interstate border crossing for services used by both Medicare and non-Medicare beneficiaries, the authors study the spending behavior of Medicare beneficiaries for 10 Medicare-covered services. Based on interstate flow-of-expenditure data developed for calendar year 1991, the authors analyze the spending patterns of State residents by studying the inflow and outflow rates and the net flow ratios of expenditures incurred by Medicare patients. The report also provides per capita expenditure estimates with residence-based adjustments and evaluates the impact of the border-crossing adjustment for individual services and States. PMID:10157375

The Affordable Care Act versus Medicare for All.

PubMed

Seidman, Laurence

2015-08-01

Many problems facing the Affordable Care Act would disappear if the nation were instead implementing Medicare for All - the extension of Medicare to every age group. Every American would be automatically covered for life. Premiums would be replaced with a set of Medicare taxes. There would be no patient cost sharing. Individuals would have free choice of doctors. Medicare's single-payer bargaining power would slow price increases and reduce medical cost as a percentage of gross domestic product (GDP). Taxes as a percentage of GDP would rise from below average to average for economically advanced nations. Medicare for All would be phased in by age. Copyright © 2015 by Duke University Press.

Subacute care, Medicare benefits, and nursing home behavior.

PubMed

Aaronson, W E; Zinn, J S; Rosko, M D

1995-09-01

Two policy changes in 1988, one administrative and one legislative, allowed greater Medicare coverage of subacute care in skilled nursing facilities (SNFs). The Medicare Catastrophic Coverage Act (MCCA) of 1988, in conjunction with an administrative directive, or transmittal, from the Health Care Financing Administration (HCFA), changed the Medicare SNF benefit structure substantially. In this study, we specified a simultaneous equation system to explain the effects of the benefit changes on Medicare use. The results suggest that the two policy changes increased Medicare use in Pennsylvania SNFs substantially; however, the increase was associated with facility and case mix characteristics, which suggest that the increase was largely attributable to reclassification of current patients from other payer categories, Medicaid and self-pay, rather than new admissions. The effects of the MCCA and the HCFA transmittal on increased Medicare use were unanticipated and have important implications for the way in which subacute care is defined and financed in future benefit discussions.

Favorable Risk Selection in Medicare Advantage: Trends in Mortality and Plan Exits Among Nursing Home Beneficiaries

PubMed Central

Goldberg, Elizabeth M.; Trivedi, Amal N.; Mor, Vincent; Jung, Hye-Young; Rahman, Momotazur

2016-01-01

The 2003 Medicare Modernization Act (MMA) increased payments to Medicare Advantage plans and instituted a new risk-adjustment payment model to reduce plans' incentives to enroll healthier Medicare beneficiaries and avoid those with higher costs. Whether the MMA reduced risk selection remains debatable. This study uses mortality differences, nursing home utilization, and switch rates to assess whether the MMA successfully decreased risk selection from 2000 to 2012. We found no decrease in the mortality difference or adjusted difference in nursing home use between plan beneficiaries pre- and post the MMA. Among beneficiaries with nursing home use, disenrollment from Medicare Advantage plans declined from 20% to 12%, but it remained 6 times higher than the switch rate from traditional Medicare to Medicare Advantage. These findings suggest that the MMA was not associated with reductions in favorable risk selection, as measured by mortality, nursing home use, and switch rates. PMID:27516452

Having it all: national benefit equity and local payment parity in Medicare.

PubMed

Dowd, Bryan; Feldman, Roger

2002-01-01

The Medicare Payment Advisory Commission (MedPAC) has identified two important problems with the Medicare+Choice (M+C) program: nationwide geographic inequity in government-financed benefits, and unequal government payments for M+C plans versus fee-for-service (FFS) Medicare in the same market area. MedPAC concludes that both problems cannot be solved simultaneously. We argue that both problems could be solved if Congress discontinued its policy of underwriting the cost of FFS Medicare. Instead, Congress should define a national entitlement benefit package and have all health plans submit bids on the package in each market area. The government's premium contribution should be equal to the lowest bid submitted by a qualified health plan in each market area. The contribution could be adjusted for health risk, the special obligations of FFS Medicare, and welfare enhancements associated with FFS Medicare that are valued by both beneficiaries and taxpayers but unrelated to beneficiaries' health status.

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-27

... sources and types of other data that these organizations might match to Medicare claims; challenges in... and Affordable Care Act, Availability of Medicare Data for Performance Measurement DATE: September 20... 1874 of the Social Security Act: Availability of Medicare Data for Performance Measurement. The purpose...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-17

... collections of information in CMS regulations and a list of Medicare- approved carotid stent facilities.... Questions concerning Medicare-approved carotid stent facilities in Addendum VIII may be addressed to Sarah J... 20 of the CFR. Addendum VIII includes listings of Medicare-approved carotid stent facilities. All...

42 CFR 431.625 - Coordination of Medicaid with Medicare part B.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Coordination of Medicaid with Medicare part B. 431.625 Section 431.625 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND... available in State expenditures for Medicare Part B premiums for Medicaid recipients unless the recipients...

42 CFR 431.625 - Coordination of Medicaid with Medicare part B.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Coordination of Medicaid with Medicare part B. 431.625 Section 431.625 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND... available in State expenditures for Medicare Part B premiums for Medicaid recipients unless the recipients...

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

Code of Federal Regulations, 2010 CFR

2010-10-01

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

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...

75 FR 70274 - Statement of Organization, Functions, and Delegations of Authority

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-17

... establishment of a new Center for Medicare and Medicaid Innovation and to update the organization for CMS, as... Medicare and Medicaid Innovation (FCP).'' (2.) Under Part F, CMS, FC. 20 Functions, insert the following after the description of the Center for Medicare (FCH): Center for Medicare and Medicaid Innovation (FCP...

42 CFR 424.350 - Replacement of checks that are lost, stolen, defaced, mutilated, destroyed, or paid on forged...

Code of Federal Regulations, 2010 CFR

2010-10-01

... CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Replacement and Reclamation of Medicare Payments § 424.350... investigation and settlement of claims in connection with Treasury checks issued on behalf of CMS. (2) Action by...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-22

... and the Medicare Prescription Drug Benefit Programs for Contract Year 2012 and Other Proposed Changes... for Contract Year 2012 and Other Proposed Changes'' which was filed for public inspection on November 10, 2010. FOR FURTHER INFORMATION CONTACT: Sabrina Ahmed, (410) 786-7499. SUPPLEMENTARY INFORMATION...

76 FR 65196 - Privacy Act of 1974; Report of a New Routine Use for Selected CMS System of Records

Federal Register 2010, 2011, 2012, 2013, 2014

2011-10-20

... Medicare beneficiaries. This system utilizes data extraction tools to support accessing data by chronic... system is to collect and maintain billing and utilization data on Medicare beneficiaries enrolled in... Medicare program. 2. ``Medicare Drug Data Processing System (DDPS),'' System No. 09- 70-0553, last...

42 CFR 411.204 - Medicare benefits secondary to LGHP benefits.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 2 2011-10-01 2011-10-01 false Medicare benefits secondary to LGHP benefits. 411... benefits secondary to LGHP benefits. (a) Medicare benefits are secondary to benefits payable by an LGHP for services furnished during any month in which the individual— (1) Is entitled to Medicare Part A benefits...

42 CFR 411.204 - Medicare benefits secondary to LGHP benefits.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 2 2012-10-01 2012-10-01 false Medicare benefits secondary to LGHP benefits. 411... benefits secondary to LGHP benefits. (a) Medicare benefits are secondary to benefits payable by an LGHP for services furnished during any month in which the individual— (1) Is entitled to Medicare Part A benefits...

42 CFR 411.204 - Medicare benefits secondary to LGHP benefits.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Medicare benefits secondary to LGHP benefits. 411... benefits secondary to LGHP benefits. (a) Medicare benefits are secondary to benefits payable by an LGHP for services furnished during any month in which the individual— (1) Is entitled to Medicare Part A benefits...

42 CFR 411.204 - Medicare benefits secondary to LGHP benefits.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 2 2013-10-01 2013-10-01 false Medicare benefits secondary to LGHP benefits. 411... benefits secondary to LGHP benefits. (a) Medicare benefits are secondary to benefits payable by an LGHP for services furnished during any month in which the individual— (1) Is entitled to Medicare Part A benefits...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-12-11

... [CMS-6061-ANPRM] RIN 0938-AR88 Medicare Program; Medicare Secondary Payer and Certain Civil Money... practices for which civil money penalties (CMPs) may or may not be imposed for failure to comply with...-3951. I. Background A. Imposition of Civil Money Penalties (CMPs) In 1981, the Congress added section...

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

Code of Federal Regulations, 2010 CFR

2010-10-01

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

Understanding the Impacts of the Medicare Modernization Act: Concerns of Congressional Staff

ERIC Educational Resources Information Center

Mueller, Keith J.; Coburn, Andrew F.; MacKinney, Clinton; McBride, Timothy D.; Slifkin, Rebecca T.; Wakefield, Mary K.

2005-01-01

Sweeping changes to the Medicare program embodied in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), including a new prescription drug benefit, changes in payment policies, and reform of the Medicare managed-care program, have major implications for rural health care. The most efficient mechanism for research to…

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-14

....773, Medicare--Hospital Insurance; and Program No. 93.774, Medicare-- Supplementary Medical Insurance... errors in the proposed rule entitled ``Medicare Program; Proposed Changes to the Hospital Inpatient...-9644 of May 5, 2011 (76 FR 25788), there were a number of technical and typographical errors that are...

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...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-09

... 0938-AP81 Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual... (SMI) program beginning January 1, 2011. In addition, this notice announces the monthly premium for... beneficiaries with modified adjusted gross income above certain threshold amounts. The monthly actuarial rates...

76 FR 67572 - Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual Deductible...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-11-01

... 0938-AQ16 Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual... (SMI) program beginning January 1, 2012. In addition, this notice announces the monthly premium for... beneficiaries with modified adjusted gross income above certain threshold amounts. The monthly actuarial rates...

78 FR 64943 - Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual Deductible...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-10-30

... 0938-AR58 Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual... (SMI) program beginning January 1, 2014. In addition, this notice announces the monthly premium for... beneficiaries with modified adjusted gross income above certain threshold amounts. The monthly actuarial rates...

Straight chiropractic philosophy as a barrier to Medicare compliance: a discussion of 5 incongruent issues

PubMed Central

Seaman, David R.; Soltys, Jonathan R.

2013-01-01

Objective The purpose of this commentary is to discuss potential 5 factors within straight chiropractic philosophy and practice that may prevent Medicare compliance. Discussion The national Medicare Benefit Policy Manual and the Florida Local Coverage Determination were reviewed to identify documentation and conceptual issues regarding chiropractic practice. Five Medicare positions were contrasted with tenets of straight chiropractic philosophy. Based on Medicare’s documentation requirements, Medicare defines subluxation and chiropractic practice from the perspective of treating spinal pain and related functional disability. In contrast, traditional straight chiropractic philosophy is not based on the treatment of spinal pain and disability or other symptomatic presentations. In this context, 5 potential areas of conflict are discussed. Conclusion The Medicare version of chiropractic practice is not consistent with traditional straight chiropractic philosophy, which may play a role in preventing Medicare compliance. The chiropractic profession may need to consider the fashion in which “philosophy” as it relates to technique and practice is presented to students and doctors to facilitate compliance with the documentation requirements of Medicare. PMID:25067928

The Evolution of Private Plans in Medicare.

PubMed

Patel, Yash M; Guterman, Stuart

2017-12-01

Since the 1980s, private plans have played an increasingly important role in the Medicare program. While initially created with the goals of reducing costs, improving choice, and enhancing quality, risk-based plans--now known as Medicare Advantage plans--have undergone significant policy changes since their inception; these changes have not always aligned with the original policy objectives. To examine major policy changes to Medicare risk plans and the effects of these policies on plan participation, enrollment, average premiums and cost-sharing, total costs to Medicare, and quality of care. Review of key policy documents, reports, position statements, and academic studies. Private plans have changed considerably since their introduction into Medicare. Enrollment has risen to 33 percent of all Medicare beneficiaries; 99 percent of beneficiaries have access to private plans in 2017. Recent policies have improved risk-adjustment methods, rewarded plans’ performance on quality of care, and reduced average payments to private plans to 100 percent of traditional Medicare spending. As enrollment in private plans continues to grow and as health care costs rise, policymakers should enhance incentives for private plans to meet intended goals for higher-quality care at lower cost.

Competitive bidding in Medicare: who benefits from competition?

PubMed

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

2012-09-01

To conduct the first empirical study of competitive bidding in Medicare. We analyzed 2006-2010 Medicare Advantage data from the Centers for Medicare and Medicaid Services using longitudinal models adjusted for market and plan characteristics. A $1 increase in Medicare's payment to health maintenance organization (HMO) plans led to a $0.49 (P <.001) increase in plan bids, with $0.34 (P <.001) going to beneficiaries in the form of extra benefits or lower cost sharing. With preferred provider organization and private fee-for-service plans included, higher Medicare payments increased bids less ($0.33 per dollar), suggesting more competition among these latter plans. As a market-based alternative to cost control through administrative pricing, competitive bidding relies on private insurance plans proposing prices they are willing to accept for insuring a beneficiary. However, competition is imperfect in the Medicare bidding market. As much as half of every dollar in increased plan payment went to higher bids rather than to beneficiaries. While having more insurers in a market lowered bids, the design of any bidding system for Medicare should recognize this shortcoming of competition.

Recent proposals to limit Medigap coverage and modify Medicare cost sharing.

PubMed

Linehan, Kathryn

2012-02-24

As policymakers look for savings from the Medicare program, some have proposed eliminating or discouraging "first-dollar coverage" available through privately purchased Medigap policies. Medigap coverage, which beneficiaries obtain to protect themselves from Medicare's cost-sharing requirements and its lack of a cap on out-of-pocket spending, may discourage the judicious use of medical services by reducing or eliminating beneficiary cost sharing. It is estimated that eliminating such coverage, which has been shown to be associated with higher Medicare spending, and requiring some cost sharing would encourage beneficiaries to reduce their service use and thus reduce pro­gram spending. However, eliminating first-dollar coverage could cause some beneficiaries to incur higher spending or forego necessary services. Some policy proposals to eliminate first-dollar coverage would also modify Medicare's cost sharing and add an out-of-pocket spending cap for fee-for-service Medicare. This paper discusses Medicare's current cost-sharing requirements, Medigap insurance, and proposals to modify Medicare's cost sharing and eliminate first-dollar coverage in Medigap plans. It reviews the evidence on the effects of first-dollar coverage on spending, some objections to eliminating first-dollar coverage, and results of research that has modeled the impact of eliminating first-dollar coverage, modifying Medicare's cost-sharing requirements, and adding an out-of-pocket limit on beneficiaries' spending.

Variation in Payment Rates under Medicare's Inpatient Prospective Payment System.

PubMed

Krinsky, Sam; Ryan, Andrew M; Mijanovich, Tod; Blustein, Jan

2017-04-01

To measure variation in payment rates under Medicare's Inpatient Prospective Payment System (IPPS) and identify the main payment adjustments that drive variation. Medicare cost reports for all Medicare-certified hospitals, 1987-2013, and Dartmouth Atlas geographic files. We measure the Medicare payment rate as a hospital's total acute inpatient Medicare Part A payment, divided by the standard IPPS payment for its geographic area. We assess variation using several measures, both within local markets and nationally. We perform a factor decomposition to identify the share of variation attributable to specific adjustments. We also describe the characteristics of hospitals receiving different payment rates and evaluate changes in the magnitude of the main adjustments over time. Data downloaded from the Centers for Medicare and Medicaid Services, the National Bureau of Economic Research, and the Dartmouth Atlas. In 2013, Medicare paid for acute inpatient discharges at a rate 31 percent above the IPPS base. For the top 10 percent of discharges, the mean rate was double the IPPS base. Variations were driven by adjustments for medical education and care to low-income populations. The magnitude of variation has increased over time. Adjustments are a large and growing share of Medicare hospital payments, and they create significant variation in payment rates. © Health Research and Educational Trust.

Medicare coverage for patients with diabetes. A national plan with individual consequences.

PubMed

Ashkenazy, R; Abrahamson, M J

2006-04-01

The prevalence of diabetes in the U.S. Medicare population is growing at an alarming rate. From 1980 to 2004, the number of people aged 65 or older with diagnosed diabetes increased from 2.3 million to 5.8 million. According to the Centers for Medicare and Medicaid (CMS), 32% of Medicare spending is attributed to the diabetes population. Since its inception, Medicare has expanded medical coverage of monitoring devices, screening tests and visits, educational efforts, and preventive medical services for its diabetic enrollees. However, oral antidiabetic agents and insulin were excluded from reimbursement. In 2003, Congress passed the Medicare Modernization Act that includes a drug benefit to be administered either through Medicare Advantage drug plans or privately sponsored prescription drug plans for implementation in January 2006. In this article we highlight key patient and drug plan characteristics and resources that providers may focus upon to assist their patients choose a coverage plan. Using a case example, we illustrate the variable financial impact the adoption of Medicare part D may have on beneficiaries with diabetes due to their economic status. We further discuss the potential consequences the legislation will have on diabetic patients enrolled in Medicare, their providers, prescribing strategies, and the diabetes market.

Medicaid Bed-Hold Policy and Medicare Skilled Nursing Facility Rehospitalizations

PubMed Central

Grabowski, David C; Feng, Zhanlian; Intrator, Orna; Mor, Vincent

2010-01-01

Objective To analyze the effect of states' Medicaid bed-hold policies on the 30-day rehospitalization of Medicare postacute skilled nursing facility (SNF) residents. Data Sources Minimum data set assessments were merged with Medicare claims and eligibility files for all first-time SNF admissions (N = 3,322,088) over the period 2000 through 2005; states' Medicaid bed-hold policies were obtained via survey. Study Design Regression specification incorporating facility fixed effects to examine changes in Medicaid bed-hold policies on the likelihood of a 30-day SNF rehospitalization. Principal Findings Using a continuous measure of bed-hold generosity, state Medicaid bed-hold was positively related to Medicare SNF rehospitalization. Specifically, the introduction of a bed-hold policy with average generosity increases Medicare rehospitalizations by 1.8 percent, representing roughly 12,000 SNF rehospitalizations at a cost to Medicare of approximately U.S.$100 million over our study period. Conclusions Although facilities do not receive a Medicaid bed-hold payment for Medicare SNF stays, we found that the adoption of more generous policies led to greater SNF rehospitalizations. This type of spillover is largely ignored in current discussions of Medicare payment reforms such as bundled payment. Neither Medicare nor Medicaid has an incentive to internalize the risks and benefits of its actions as they affect the other. PMID:20403059

No association between Centers for Medicare and Medicaid services payments and volume of Medicare beneficiaries or per-capita health care costs for each state.

PubMed

Harewood, Gavin C; Alsaffar, Omar

2015-03-01

The Centers for Medicare and Medicaid Services recently published data on Medicare payments to physicians for 2012. We investigated regional variations in payments to gastroenterologists and evaluated whether payments correlated with the number of Medicare patients in each state. We found that the mean payment per gastroenterologist in each state ranged from $35,293 in Minnesota to $175,028 in Mississippi. Adjusted per-physician payments ranged from $11 per patient in Hawaii to $62 per patient in Washington, DC. There was no correlation between the mean per-physician payment and the mean number of Medicare patients per physician (r = 0.09), there also was no correlation between the mean per-physician payment and the overall mean per-capita health care costs for each state (r = -0.22). There was a 5.6-fold difference between the states with the lowest and highest adjusted Medicare payments to gastroenterologists. Therefore, the Centers for Medicare and Medicaid Services payments do not appear to be associated with the volume of Medicare beneficiaries or overall per-capita health care costs for each state. Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.

Medicare long-term CPAP coverage policy: a cost-utility analysis.

PubMed

Billings, Martha E; Kapur, Vishesh K

2013-10-15

CPAP is an effective treatment for OSA that may reduce health care utilization and costs. Medicare currently reimburses the costs of long-term CPAP therapy only if the patient is adherent during a 90-day trial. If not, Medicare requires a repeat polysomnogram (PSG) and another trial which seems empirically not cost-effective. We modeled the cost-effectiveness of current Medicare policy compared to an alternative policy (clinic-only) without the adherence criterion and repeat PSG. Cost-utility and cost-effectiveness analysis. U.S. Medicare Population. N/A. N/A. We created a decision tree modeling (1) clinic only follow-up vs. (2) current Medicare policy. Costs were assigned based on Medicare reimbursement rates in 2012. Sensitivity analyses were conducted to test our assumptions. We estimated cumulative costs, overall adherence, and QALY gained for a 5-year time horizon from the perspective of Medicare as the payer. Current Medicare policy is more costly than the clinic-only policy but has higher net adherence and improved utility. Current Medicare policy compared to clinic-only policy costs $30,544 more per QALY. Current CMS policy promotes early identification of those more likely to adhere to CPAP therapy by requiring strict adherence standards. The policy effect is to deny coverage to those unlikely to use CPAP long-term and prevent wasted resources. Future studies are needed to measure long-term adherence in an elderly population with and without current adherence requirements to verify the cost-effectiveness of a policy change.

Use of VA and Medicare Services By Dually Eligible Veterans with Psychiatric Problems

PubMed Central

Carey, Kathleen; Montez-Rath, Maria E; Rosen, Amy K; Christiansen, Cindy L; Loveland, Susan; Ettner, Susan L

2008-01-01

Objective To examine how service accessibility measured by geographic distance affects service sector choices for veterans who are dually eligible for veterans affairs (VA) and Medicare services and who are diagnosed with mental health and/or substance abuse (MH/SA) disorders. Data Sources Primary VA data sources were the Patient Treatment (acute care), Extended Care (long-term care), and Outpatient Clinic files. VA cost data were obtained from (1) inpatient and outpatient cost files developed by the VA Health Economics and Resource Center and (2) outpatient VA Decision Support System files. Medicare data sources were the denominator, Medicare Provider Analysis Review (MEDPAR), Provider-of-Service, Outpatient Standard Analytic and Physician/Supplier Standard Analytic files. Additional sources included the Area Resource File and Census Bureau data. Study Design We identified dually eligible veterans who had either an inpatient or outpatient MH/SA diagnosis in the VA system during fiscal year (FY)'99. We then estimated one- and two-part regression models to explain the effects of geographic distance on both VA and Medicare total and MH/SA costs. Principal Findings Results provide evidence for substitution between the VA and Medicare, demonstrating that poorer geographic access to VA inpatient and outpatient clinics decreased VA expenditures but increased Medicare expenditures, while poorer access to Medicare-certified general and psychiatric hospitals decreased Medicare expenditures but increased VA expenditures. Conclusions As geographic distance to VA medical facility increases, Medicare plays an increasingly important role in providing mental health services to veterans. PMID:18355256

Market and beneficiary characteristics associated with enrollment in Medicare managed care plans and fee-for-service.

PubMed

Shimada, Stephanie L; Zaslavsky, Alan M; Zaborski, Lawrence B; O'Malley, A James; Heller, Amy; Cleary, Paul D

2009-05-01

Risk selection in the Medicare managed care program ("Medicare Advantage") is an important policy concern. Past research has shown that Medicare managed care plans tend to attract healthier beneficiaries and that market characteristics such as managed care penetration may also affect risk selection. To assess whether patient enrollment in Medicare managed care (MMC) or traditional fee-for-service (FFS) Medicare is related to beneficiary and market characteristics and provide a baseline for understanding how changes in Medicare policy affect MMC enrollment over time. Data sources were the 2004 Medicare MMC and FFS CAHPS surveys, the Social Security Administration's Master Beneficiary Record, MMC Market Penetration Files, and 2000 Census data. We estimated logistic regression models to assess what beneficiary characteristics predict enrollment in MMC and the moderating effects of market characteristics. Enrollees in MMC plans tend to have better health than those in FFS. This effect is weaker in areas with more competition. Latinos and beneficiaries with less education and lower income, as indicated by earnings history or local-area median income, are more likely to enroll in MMC. Enrollment in MMC is related to beneficiary characteristics, including health status and socioeconomic status, and is modified by MMC presence in the local market. Because vulnerable subgroups are more likely to enroll in MMC plans, the Centers for Medicare & Medicaid Services should monitor how changes to Medicare Advantage policies and payment methods may affect beneficiaries in those groups.

An Analysis of Medicare Reimbursement to Ophthalmologists: Years 2012 to 2013.

PubMed

Han, Everett; Baisiwala, Shivani; Jain, Atul; Bundorf, M Kate; Pershing, Suzann

2017-10-01

To analyze trends in utilization and payment of ophthalmic services in the Medicare population for years 2012 and 2013. Retrospective, cross-sectional study. A retrospective cross-sectional observational analysis was performed using publicly available Medicare Physician and Other Supplier aggregate file and the Physician and Other Supplier Public Use File. Variables analyzed included aggregate beneficiary demographics, Medicare payments to ophthalmologists, ophthalmic medical services provided, and the most common Medicare-reimbursed ophthalmic services. In 2013, total Medicare Part B reimbursement for ophthalmology was $5.8 billion, an increase of 3.6% from the previous year. From 2012 to 2013, the total number of ophthalmology services rendered increased by 2.2%, while average dollar amount reimbursed per ophthalmic service decreased by 5.4%. The top 5 highest reimbursed services accounted for 85% of total ophthalmic Medicare payments in 2013, an 11% increase from 2012. During 2013, drug reimbursement represented 32.8% of the total Medicare payments to ophthalmologists. Ranibizumab and aflibercept alone accounted for 95% of the entire $1.9 billion in drug reimbursements ophthalmologists in 2013. Medicare Part B reimbursement for ophthalmologists was primarily driven by use of anti-vascular endothelial growth factor (anti-VEGF) injections from 2012 to 2013. Of the total drug payments to ophthalmologists, biologic anti-VEGF agents ranibizumab and aflibercept accounted for 95% of all drug reimbursement. This is in contrast to other specialties, in which drug reimbursement represented only a small portion of Medicare reimbursement. Published by Elsevier Inc.

Legal Briefing: Medicare Coverage of Advance Care Planning.

PubMed

Pope, Thaddeus Mason

2015-01-01

This issue's "Legal Briefing" column covers the recent decision by the Centers for Medicare and Medicaid Services (CMS) to expand Medicare coverage of advance care planning, beginning 1 January 2016. Since 2009, most "Legal Briefings" in this journal have covered a wide gamut of judicial, legislative, and regulatory developments concerning a particular topic in clinical ethics. In contrast, this "Legal Briefing" is more narrowly focused on one single legal development. This concentration on Medicare coverage of advance care planning seems warranted. Advance care planning is a frequent subject of articles in JCE. After all, it has long been seen as an important, albeit only partial, solution to a significant range of big problems in clinical ethics. These problems range from medical futility disputes to decision making for incapacitated patients who have no available legally authorized surrogate. Consequently, expanded Medicare coverage of advance care planning is a potentially seismic development. It may materially reduce both the frequency and severity of key problems in clinical ethics. Since the sociological, medical, and ethical literature on advance care planning is voluminous, I will not even summarize it here. Instead, I focus on Medicare coverage. I proceed, chronologically, in six stages: 1. Prior Medicare Coverage of Advance Care Planning 2. Proposed Expanded Medicare Coverage in 2015 3. Proposed Expanded Medicare Coverage in 2016 4. The Final Rule Expanding Medicare Coverage in 2016 5. Remaining Issues for CMS to Address in 2017 6. Pending Federal Legislation. Copyright 2015 The Journal of Clinical Ethics. All rights reserved.

Medicare Long-Term CPAP Coverage Policy: A Cost-Utility Analysis

PubMed Central

Billings, Martha E.; Kapur, Vishesh K.

2013-01-01

Study Objectives: CPAP is an effective treatment for OSA that may reduce health care utilization and costs. Medicare currently reimburses the costs of long-term CPAP therapy only if the patient is adherent during a 90-day trial. If not, Medicare requires a repeat polysomnogram (PSG) and another trial which seems empirically not cost-effective. We modeled the cost-effectiveness of current Medicare policy compared to an alternative policy (clinic-only) without the adherence criterion and repeat PSG. Design: Cost-utility and cost-effectiveness analysis. Setting: U.S. Medicare Population. Patients or Participants: N/A. Interventions: N/A. Measurements and Results: We created a decision tree modeling (1) clinic only follow-up vs. (2) current Medicare policy. Costs were assigned based on Medicare reimbursement rates in 2012. Sensitivity analyses were conducted to test our assumptions. We estimated cumulative costs, overall adherence, and QALY gained for a 5-year time horizon from the perspective of Medicare as the payer. Current Medicare policy is more costly than the clinic-only policy but has higher net adherence and improved utility. Current Medicare policy compared to clinic-only policy costs $30,544 more per QALY. Conclusions: Current CMS policy promotes early identification of those more likely to adhere to CPAP therapy by requiring strict adherence standards. The policy effect is to deny coverage to those unlikely to use CPAP long-term and prevent wasted resources. Future studies are needed to measure long-term adherence in an elderly population with and without current adherence requirements to verify the cost-effectiveness of a policy change. Citation: Billings ME; Kapur VK. Medicare long-term CPAP coverage policy: a cost-utility analysis. J Clin Sleep Med 2013;9(10):1023-1029. PMID:24127146

Current operator volumes of invasive coronary procedures in Medicare patients: implications for future manpower needs in the catheterization laboratory.

PubMed

Maroney, Justin; Khan, Saba; Powell, Wayne; Klein, Lloyd W

2013-01-01

We seek to assess the per-operator volume of diagnostic catheterizations and percutaneous coronary interventions (PCI) among US cardiologists, and its implication for future manpower needs in the catheterization laboratory. The number of annual Medicare PCIs peaked in 2004 and has trended downward since, however the total number of catheterization laboratories nationwide has increased. It is unknown whether these trends have resulted in a dilution of per-operator volumes, and whether the current supply of interventional cardiologists is appropriate to meet future needs. We analyzed the Centers for Medicare and Medicaid Services 2008 Medicare 5% sample file, and extracted the total number of Medicare fee-for-service (Medicare FFS) diagnostic catheterizations and PCIs performed in 2008. We then determined per-physician procedure volumes using National Provider Identifier numbers. There were 1,198,610 Medicare FFS diagnostic catheterizations performed by 11,029 diagnostic cardiologists, and there were 378,372 Medicare FFS PCIs performed by 6,443 interventional cardiologists in 2008. The data reveal a marked difference in the 2008 distribution of diagnostic catheterizations and PCIs among operators. Just over 10% of diagnostic catheterizations were performed by operators performing 40 or fewer Medicare FFS diagnostic catheterizations, contrasted with almost 30% of PCIs performed by operators with 40 of fewer Medicare FFS PCIs. A significant majority of interventional cardiologists (61%) performed 40 or fewer Medicare FFS PCIs in 2008. There is a high percentage of low-volume operators performing PCI, raising questions regarding annual volume recommendations for procedural skill maintenance, and the future manpower requirements in the catheterization laboratory. Copyright © 2012 Wiley Periodicals, Inc.

State Policies Influence Medicare Telemedicine Utilization.

PubMed

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

2016-01-01

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

Impact of Medicare Part D on out-of-pocket drug costs and medical use for patients with cancer.

PubMed

Kircher, Sheetal M; Johansen, Michael E; Nimeiri, Halla S; Richardson, Caroline R; Davis, Matthew M

2014-11-01

Medicare Part D was designed to reduce out-of-pocket (OOP) costs for Medicare beneficiaries, but to the authors' knowledge the extent to which this occurred for patients with cancer has not been measured to date. The objective of the current study was to examine the impact of Medicare Part D eligibility on OOP cost for prescription drugs and use of medical services among patients with cancer. Using the Medical Expenditure Panel Survey (MEPS) for the years 2002 through 2010, a differences-in-differences analysis estimated the effects of Medicare Part D eligibility on OOP pharmaceutical costs and medical use. The authors compared per capita OOP cost and use between Medicare beneficiaries (aged ≥65 years) with cancer to near-elderly patients aged 55 years to 64 years with cancer. Statistical weights were used to generate nationally representative estimates. A total of 1878 near-elderly and 4729 individuals with Medicare were included (total of 6607 individuals). The mean OOP pharmaceutical cost for Medicare beneficiaries before the enactment of Part D was $1158 (standard error, ±$52) and decreased to $501 (standard error, ±$30), a decline of 43%. Compared with changes in OOP pharmaceutical costs for nonelderly patients with cancer over the same period, the implementation of Medicare Part D was associated with a further reduction of $356 per person. Medicare Part D appeared to have no significant impact on the use of medications, hospitalizations, or emergency department visits, but was associated with a reduction of 1.55 in outpatient visits. Medicare D has reduced OOP prescription drug costs and outpatient visits for seniors with cancer beyond trends observed for younger patients, with no major impact on the use of other medical services noted. © 2014 American Cancer Society.

Meaningful Use of Electronic Health Records and Medicare Expenditures: Evidence from a Panel Data Analysis of U.S. Health Care Markets, 2010-2013.

PubMed

Lammers, Eric J; McLaughlin, Catherine G

2017-08-01

To determine if recent growth in hospital and physician electronic health record (EHR) adoption and use is correlated with decreases in expenditures for elderly Medicare beneficiaries. American Hospital Association (AHA) General Survey and Information Technology Supplement, Health Information Management Systems Society (HIMSS) Analytics survey, SK&A Information Services, and the Centers for Medicare & Medicaid Services (CMS) Chronic Conditions Data Warehouse Geographic Variation Database for 2010 through 2013. Fixed effects model comparing associations between hospital referral region (HRR) level measures of hospital and physician EHR penetration and annual Medicare expenditures for beneficiaries with one of four chronic conditions. Calculated hospital penetration rates as the percentage of Medicare discharges from hospitals that satisfied criteria analogous to Meaningful Use (MU) Stage 1 requirements and physician rates as the percentage of physicians using ambulatory care EHRs. An increase in the hospital penetration rate was associated with a small but statistically significant decrease in total Medicare and Medicare Part A acute care expenditures per beneficiary. An increase in physician EHR penetration was also associated with a significant decrease in total Medicare and Medicare Part A acute care expenditures per beneficiary as well as a decrease in Medicare Part B expenditures per beneficiary. For the study population, we estimate approximately $3.8 billion in savings related to hospital and physician EHR adoption during 2010-2013. We also found that an increase in physician EHR penetration was associated with an increase in lab test expenses. Health care markets that had steeper increases in EHR penetration during 2010-2013 also had steeper decreases in total Medicare and acute care expenditures per beneficiary. Markets with greater increases in physician EHR had greater declines in Medicare Part B expenditures per beneficiary. © Health Research and Educational Trust.

Offering lung cancer screening to high-risk medicare beneficiaries saves lives and is cost-effective: an actuarial analysis.

PubMed

Pyenson, Bruce S; Henschke, Claudia I; Yankelevitz, David F; Yip, Rowena; Dec, Ellynne

2014-08-01

By a wide margin, lung cancer is the most significant cause of cancer death in the United States and worldwide. The incidence of lung cancer increases with age, and Medicare beneficiaries are often at increased risk. Because of its demonstrated effectiveness in reducing mortality, lung cancer screening with low-dose computed tomography (LDCT) imaging will be covered without cost-sharing starting January 1, 2015, by nongrandfathered commercial plans. Medicare is considering coverage for lung cancer screening. To estimate the cost and cost-effectiveness (ie, cost per life-year saved) of LDCT lung cancer screening of the Medicare population at high risk for lung cancer. Medicare costs, enrollment, and demographics were used for this study; they were derived from the 2012 Centers for Medicare & Medicaid Services (CMS) beneficiary files and were forecast to 2014 based on CMS and US Census Bureau projections. Standard life and health actuarial techniques were used to calculate the cost and cost-effectiveness of lung cancer screening. The cost, incidence rates, mortality rates, and other parameters chosen by the authors were taken from actual Medicare data, and the modeled screenings are consistent with Medicare processes and procedures. Approximately 4.9 million high-risk Medicare beneficiaries would meet criteria for lung cancer screening in 2014. Without screening, Medicare patients newly diagnosed with lung cancer have an average life expectancy of approximately 3 years. Based on our analysis, the average annual cost of LDCT lung cancer screening in Medicare is estimated to be $241 per person screened. LDCT screening for lung cancer in Medicare beneficiaries aged 55 to 80 years with a history of ≥30 pack-years of smoking and who had smoked within 15 years is low cost, at approximately $1 per member per month. This assumes that 50% of these patients were screened. Such screening is also highly cost-effective, at <$19,000 per life-year saved. If all eligible Medicare beneficiaries had been screened and treated consistently from age 55 years, approximately 358,134 additional individuals with current or past lung cancer would be alive in 2014. LDCT screening is a low-cost and cost-effective strategy that fits well within the standard Medicare benefit, including its claims payment and quality monitoring.

Offering Lung Cancer Screening to High-Risk Medicare Beneficiaries Saves Lives and Is Cost-Effective: An Actuarial Analysis

PubMed Central

Pyenson, Bruce S.; Henschke, Claudia I.; Yankelevitz, David F.; Yip, Rowena; Dec, Ellynne

2014-01-01

Background By a wide margin, lung cancer is the most significant cause of cancer death in the United States and worldwide. The incidence of lung cancer increases with age, and Medicare beneficiaries are often at increased risk. Because of its demonstrated effectiveness in reducing mortality, lung cancer screening with low-dose computed tomography (LDCT) imaging will be covered without cost-sharing starting January 1, 2015, by nongrandfathered commercial plans. Medicare is considering coverage for lung cancer screening. Objective To estimate the cost and cost-effectiveness (ie, cost per life-year saved) of LDCT lung cancer screening of the Medicare population at high risk for lung cancer. Methods Medicare costs, enrollment, and demographics were used for this study; they were derived from the 2012 Centers for Medicare & Medicaid Services (CMS) beneficiary files and were forecast to 2014 based on CMS and US Census Bureau projections. Standard life and health actuarial techniques were used to calculate the cost and cost-effectiveness of lung cancer screening. The cost, incidence rates, mortality rates, and other parameters chosen by the authors were taken from actual Medicare data, and the modeled screenings are consistent with Medicare processes and procedures. Results Approximately 4.9 million high-risk Medicare beneficiaries would meet criteria for lung cancer screening in 2014. Without screening, Medicare patients newly diagnosed with lung cancer have an average life expectancy of approximately 3 years. Based on our analysis, the average annual cost of LDCT lung cancer screening in Medicare is estimated to be $241 per person screened. LDCT screening for lung cancer in Medicare beneficiaries aged 55 to 80 years with a history of ≥30 pack-years of smoking and who had smoked within 15 years is low cost, at approximately $1 per member per month. This assumes that 50% of these patients were screened. Such screening is also highly cost-effective, at <$19,000 per life-year saved. Conclusion If all eligible Medicare beneficiaries had been screened and treated consistently from age 55 years, approximately 358,134 additional individuals with current or past lung cancer would be alive in 2014. LDCT screening is a low-cost and cost-effective strategy that fits well within the standard Medicare benefit, including its claims payment and quality monitoring. PMID:25237423

The Experience of Rural Independent Pharmacies with Medicare Part D: Reports from the Field

ERIC Educational Resources Information Center

Radford, Andrea; Slifkin, Rebecca; Fraser, Roslyn; Mason, Michelle; Mueller, Keith

2007-01-01

Context: The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) created prescription drug coverage for Medicare beneficiaries through a new Part D program, the single largest addition to Medicare since its creation in 1965. Prior to program implementation in January 2006, concerns had been voiced as to how independent…

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

Code of Federal Regulations, 2010 CFR

2010-10-01

... application applicable for its provider or supplier type, and has not submitted a plan of corrective action as... supplier is no longer operational to furnish Medicare covered items or services, or is not meeting Medicare... A provider is no longer operational to furnish Medicare covered items or services, or the provider...

42 CFR 423.908. - Phased-down State contribution to drug benefit costs assumed by Medicare.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Phased-down State contribution to drug benefit costs assumed by Medicare. 423.908. Section 423.908. Public Health CENTERS FOR MEDICARE & MEDICAID... Provisions § 423.908. Phased-down State contribution to drug benefit costs assumed by Medicare. This subpart...

42 CFR 405.371 - Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services. 405.371 Section 405.371 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR...

42 CFR 405.371 - Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 2 2011-10-01 2011-10-01 false Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services. 405.371 Section 405.371 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR...

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...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-08

... Evaluation; Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports AGENCY... announces a public meeting of the Technical Advisory Panel on Medicare Trustee Reports (Panel). Notice of... long run. The Panel's discussion is expected to be very technical in nature and will focus on the...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-22

... offered in a service area by identifying for non-renewal plans with sustained low enrollment. In our April... seeking to expand their service areas may continue to offer DE SNPs through the 2012 contract. For... Part II Department of Health and Human Services Centers for Medicare & Medicaid Services 42 CFR...

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...

Choice of Personal Assistance Services Providers by Medicare Beneficiaries Using a Consumer-Directed Benefit: Rural-Urban Differences

ERIC Educational Resources Information Center

Meng, Hongdao; Friedman, Bruce; Wamsley, Brenda R.; Van Nostrand, Joan F.; Eggert, Gerald M.

2010-01-01

Purpose: To examine the impact of an experimental consumer-choice voucher benefit on the selection of independent and agency personal assistance services (PAS) providers among rural and urban Medicare beneficiaries with disabilities. Methods: The Medicare Primary and Consumer-Directed Care Demonstration enrolled 1,605 Medicare beneficiaries in 19…

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

PubMed

1995-06-27

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

Medicare payment transparency

PubMed Central

Jones, Lyell K.; Craft, Karolina; Fritz, Joseph V.

2016-01-01

Abstract In 2014, the Centers for Medicare and Medicaid Services began a now annual process of releasing payment data made to physicians and other providers from Medicare Part B. The unprecedented availability of detailed payment information has generated considerable interest among policymakers, the public, and the media, and raised concerns from a number of physician groups. In the current climate of financial transparency, publication of Medicare payment data will likely continue. In an effort to prepare neurologists for future releases of payment data, we review the background, limitations, potential benefits, and appropriate responses to Medicare payment data releases. PMID:29443257

Medicare payment changes and nursing home quality: effects on long-stay residents.

PubMed

Konetzka, R Tamara; Norton, Edward C; Stearns, Sally C

2006-09-01

The Balanced Budget Act of 1997 dramatically changed the way that Medicare pays skilled nursing facilities, providing a natural experiment in nursing home behavior. Medicare payment policy (directed at short-stay residents) may have affected outcomes for long-stay, chronic-care residents if services for these residents were subsidized through cost-shifting prior to implementation of Medicare prospective payment for nursing homes. We link changes in both the form and level of Medicare payment at the facility level with changes in resident-level quality, as represented by pressure sores and urinary tract infections in Minimum Data Set (MDS) assessments. Results show that long-stay residents experienced increased adverse outcomes with the elimination of Medicare cost reimbursement.

How do Medicare Physician Fees Compare With Private Payers?

PubMed Central

Miller, Mark E.; Zuckerman, Stephen; Gates, Michael

1993-01-01

Under the new fee schedule, Medicare physician fees are 76 percent of private fees. Consistent with the intent of payment reform, Medicare physician fees more closely approximate private fees for visits (93 percent) than for surgery (51 percent) and in rural areas as compared with large metropolitan areas. Variation in private fees across the country is considerably greater than it is for Medicare fees. Consequently, Medicare fees are most generous in areas that compare least favorably with the private market because private fees in these areas are well above average. These results shed light on the impact of the fee schedule and on the implications of using Medicare payment methods as part of a broad-based health reform. PMID:10130578

42 CFR 417.452 - Liability of Medicare enrollees.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Enrollment, Entitlement, and Disenrollment under Medicare Contract § 417.452...

42 CFR 422.502 - Evaluation and determination procedures.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Application Procedures and Contracts for Medicare Advantage Organizations § 422.502 Evaluation and determination procedures. (a) Basis for...

42 CFR 423.156 - Consumer satisfaction surveys.

Code of Federal Regulations, 2013 CFR

2013-10-01

... (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Cost Control and... Healthcare Providers and Systems (CAHPS) survey vendors to conduct the Medicare CAHPS satisfaction survey of...

42 CFR 422.2262 - Review and distribution of marketing materials.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Medicare Advantage Marketing... model materials. (d) Ad hoc enrollee communication materials. Ad hoc enrollee communication materials...

Paying Medicare Advantage Plans: To Level or Tilt the Playing Field

PubMed Central

Glazer, Jacob; McGuire, Thomas G.

2017-01-01

Medicare beneficiaries are eligible for health insurance through the public option of traditional Medicare (TM) or may join a private Medicare Advantage (MA) plan. Both are highly subsidized but in different ways. Medicare pays for most of costs directly in TM, and makes a subsidy payment to an MA plan based on a “benchmark” for each beneficiary choosing a private plan. The level of this benchmark is arguably the most important policy decision Medicare makes about the MA program. Presently, about 30% of beneficiaries are in MA, and Medicare subsidizes MA plans more on average than TM. Many analysts recommend equalizing Medicare’s subsidy across the options – referred to in policy circles as a “level playing field.” This paper studies the normative question of how to set the level of the benchmark, applying the versatile model of plan choice developed by Einav and Finkelstein (EF) to Medicare. The EF framework implies unequal subsidies to counteract risk selection across plan types. We also study other reasons to tilt the field: the relative efficiency of MA vs. TM, market power of MA plans, and institutional features of the way Medicare determines subsidies and premiums. After review of the empirical and policy literature, we conclude that in areas where the MA market is competitive, the benchmark should be set below average costs in TM, but in areas characterized by imperfect competition in MA, it should be raised in order to offset output (enrollment) restrictions by plans with market power. We also recommend specific modifications of Medicare rules to make demand for MA more price elastic. PMID:28318667

Direct Cost Analysis of Outpatient Arthroscopic Rotator Cuff Repair in Medicare and Non-Medicare Populations.

PubMed

Narvy, Steven J; Didinger, Tracey C; Lehoang, David; Vangsness, C Thomas; Tibone, James E; Hatch, George F Rick; Omid, Reza; Osorno, Felipe; Gamradt, Seth C

2016-10-01

Providing high-quality care while also containing cost is a paramount goal in orthopaedic surgery. Increasingly, insurance providers in the United States, including government payers, are requiring financial and performance accountability for episodes of care, including a push toward bundled payments. The direct cost of outpatient arthroscopic rotator cuff repair was assessed to determine whether, due to an older population, rotator cuff surgery was more costly in Medicare-insured patients than in patients covered by other insurers. We hypothesized that operative time, implant cost, and overall higher cost would be observed in Medicare patients. Cohort study; Level of evidence, 3. Billing and operative reports from 184 outpatient arthroscopic rotator cuff repairs performed by 5 fellowship-trained arthroscopic surgeons were reviewed. Operative time, number and cost of implants, hospital reimbursement, surgeon reimbursement, and insurance type were determined from billing records and operative reports. Patients were stratified by payer (Medicare vs non-Medicare), and these variables were compared. There were no statistically significant differences in the number of suture anchors used, implant cost, surgical duration, or overall cost of arthroscopic rotator cuff repair between Medicare and other insurers. Reimbursement was significantly higher for other payers when compared with Medicare, resulting in a mean per case deficit of $263.54 between billing and reimbursement for Medicare patients. Operating room time, implant cost, and total procedural cost was the same for Medicare patients as for patients with private payers. Further research needs to be conducted to understand the patient-specific factors that affect the cost of an episode of care for rotator cuff surgery.

Legal and Regulatory Challenges Currently Facing Diabetes Treatment Providers and Related Durable Medical Equipment Suppliers

PubMed Central

Liles, Robert

2013-01-01

It has been estimated that 24 million Americans have diabetes, many of whom are Medicare beneficiaries. These individuals carefully monitor their blood glucose levels primarily through the use of in-home blood glucose testing kits. Although the test is relatively simple, the cumulative expense of providing glucose test strips and lancets to patients is ever increasing, both to the Medicare program and to uninsured individuals who must pay out-of-pocket for these testing supplies. This article discusses the diabetes durable medical equipment (DME) coverage under Part B Medicare, the establishment and role of DME Medicare administrative contractors, and national and local coverage requirements for diabetes DME suppliers. This article also discusses the federal government’s ongoing concerns regarding the improper billing of diabetes testing supplies. To protect the Medicare Trust Fund, the federal government has contracted with multiple private entities to conduct reviews and audits of questionable Medicare claims. These private sector contractors have conducted unannounced site visits of DME supplier offices, interviewed patients and their families, placed suppliers on prepayment review, and conducted extensive postpayment audits of prior paid Medicare claims. In more egregious administrative cases, Medicare contractors have recommended that problematic providers and/or DME suppliers have their Medicare numbers suspended or, in some instances, revoked. More serious infractions can lead to civil or criminal liability. In the final part of this article, we will examine the future of enforcement efforts by law enforcement and Medicare contractors and the importance of understanding and complying with federal laws when ordering and supplying diabetes testing strips and lancets. PMID:23566989

Trends in Medicare Service Volume for Cataract Surgery and the Impact of the Medicare Physician Fee Schedule.

PubMed

Gong, Dan; Jun, Lin; Tsai, James C

2017-08-01

To calculate the associations between Medicare payment and service volume for complex and noncomplex cataract surgeries. The 2005-2009 CMS Part B National Summary Data Files, CMS Part B Carrier Summary Data Files, and the Medicare Physician Fee Schedule. Conducting a retrospective, longitudinal analysis using a fixed-effects model of Medicare Part B carriers representing all 50 states and the District of Columbia from 2005 to 2009, we calculated the Medicare payment-service volume elasticities for noncomplex (CPT 66984) and complex (CPT 66982) cataract surgeries. Service volume data were extracted from the CMS Part B National Summary and Carrier Summary Data Files. Payment data were extracted from the Medicare Physician Fee Schedule. From 2005 to 2009, the proportion of total cataract services billed as complex increased from 3.2 to 6.7 percent. Every 1 percent decrease in Medicare payment was associated with a nonsignificant change in noncomplex cataract service volume (elasticity = 0.15, 95 percent CI [-0.09, 0.38]) but a statistically significant increase in complex cataract service volume (elasticity = -1.12, 95 percent CI [-1.60, -0.63]). Reduced Medicare payment was associated with a significant increase in complex cataract service volume but not in noncomplex cataract service volume, resulting in a shift toward performing a greater proportion of complex cataract surgeries from 2005 to 2009. © Health Research and Educational Trust.

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

PubMed

McCall, Nancy; Cromwell, Jerry

2011-11-03

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

42 CFR 423.156 - Consumer satisfaction surveys.

Code of Federal Regulations, 2011 CFR

2011-10-01

... (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Cost Control and Quality... as of July of the prior year must contract with approved Medicare Consumer Assessment of Healthcare...

Medicare

Cancer.gov

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

42 CFR 422.2276 - Employer group retiree marketing.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Medicare Advantage Marketing Requirements... for members of an employer group who are eligible for employer-sponsored benefits through the MA...

The first 3 years of Medicare prospective payment: An overview

PubMed Central

Guterman, Stuart; Eggers, Paul W.; Riley, Gerald; Greene, Timothy F.; Terrell, Sherry A.

1988-01-01

This article provides a synopsis of the available evidence on the impact of the Medicare prospective payment system (PPS) for hospitals over the first 3 years of its implementation. The impact of PPS on hospitals, Medicare beneficiaries, post-hospital care, other payers for inpatient hospital services, other health care providers, and Medicare program operations and expenditures is examined. PMID:10312519

Improving Medicare coverage of psychological services for older Americans.

PubMed

Karlin, Bradley E; Humphreys, Keith

2007-10-01

Professional psychology's ability to meet older Americans' psychological needs and to simultaneously thrive as a profession will be closely tied to the federal Medicare program over the coming decades. Despite legislative changes in the 1980s providing professional autonomy to psychologists and expanding coverage for mental health services, Medicare coverage policies, reimbursement mechanisms, and organizational traditions continue to limit older Americans' access to psychological services. This article describes how psychologists can influence Medicare coverage policy. Specifically, the authors examine widely unrecognized policy processes and recent political developments and analyze the recent creation of a new Medicare counseling benefit, applying J. W. Kingdon's (1995) well-known model of policy change. These recent developments offer new opportunities for expanding Medicare coverage of psychological services, particularly in the areas of prevention, screening, and early intervention. The article provides an analysis to guide psychologists in engaging in strategic advocacy and incorporating psychological prevention and early intervention services into Medicare. As Medicare policy entrepreneurs, psychologists can improve the well-being of millions of Americans who rely on the national health insurance program and, in so doing, can help shape the future practice of psychology. Copyright 2007 APA, all rights reserved.

Medicare essential: an option to promote better care and curb spending growth.

PubMed

Davis, Karen; Schoen, Cathy; Guterman, Stuart

2013-05-01

Medicare's core benefit design reflects private insurance as of 1965, with separate coverage for hospital and physician services (and now prescription drugs) and no protection against catastrophic costs. Modernizing Medicare's benefit design to offer comprehensive benefits, financial protection, and incentives to choose high-value care could improve coverage and lower beneficiary costs. We describe a new option we call Medicare Essential, which would combine Medicare's hospital, physician, and prescription drug coverage into an integrated benefit with an annual limit on out-of-pocket expenses for covered benefits. Cost sharing would be reduced for enrollees who seek care from high-quality low-cost providers. Out-of-pocket savings from lower premiums and health care costs for a Medicare Essential enrollee could be $173 per month, compared to what an enrollee would pay with traditional Medicare, prescription drug and private supplemental coverage. Financed by a budget-neutral premium, we estimate that this new plan choice could reduce total health spending relative to current projections by $180 billion and reduce employer retiree spending by $90 billion during 2014-23. Given its potential, such an alternative should be a part of the debate over the future of Medicare.

Competitive Bidding in Medicare: Who Benefits From Competition?

PubMed Central

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

2012-01-01

Objectives To conduct the first empirical study of competitive bidding in Medicare. Study Design and Methods We analyzed 2006–2010 Medicare Advantage data from the Centers for Medicare & Medicaid Services using longitudinal models adjusted for market and plan characteristics. Results A $1 increase in Medicare's payment to health maintenance organization (HMO) plans led to a $0.49 (P <.001) increase in plan bids, with $0.34 (P <.001) going to beneficiaries in the form of extra benefits or lower cost sharing. With preferred provider organization and private fee-for-service plans included, higher Medicare payments increased bids less ($0.33 per dollar), suggesting more competition among these latter plans. Conclusions As a market-based alternative to cost control through administrative pricing, competitive bidding relies on private insurance plans proposing prices they are willing to accept for insuring a beneficiary. However, competition is imperfect in the Medicare bidding market. As much as half of every dollar in increased plan payment went to higher bids rather than to beneficiaries. While having more insurers in a market lowered bids, the design of any bidding system for Medicare should recognize this shortcoming of competition. PMID:23009305

Assessing Measurement Error in Medicare Coverage From the National Health Interview Survey

PubMed Central

Gindi, Renee; Cohen, Robin A.

2012-01-01

Objectives Using linked administrative data, to validate Medicare coverage estimates among adults aged 65 or older from the National Health Interview Survey (NHIS), and to assess the impact of a recently added Medicare probe question on the validity of these estimates. Data sources Linked 2005 NHIS and Master Beneficiary Record and Payment History Update System files from the Social Security Administration (SSA). Study design We compared Medicare coverage reported on NHIS with “benchmark” benefit records from SSA. Principal findings With the addition of the probe question, more reports of coverage were captured, and the agreement between the NHIS-reported coverage and SSA records increased from 88% to 95%. Few additional overreports were observed. Conclusions Increased accuracy of the Medicare coverage status of NHIS participants was achieved with the Medicare probe question. Though some misclassification remains, data users interested in Medicare coverage as an outcome or correlate can use this survey measure with confidence. PMID:24800138

A Political History of Medicare and Prescription Drug Coverage

PubMed Central

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

2004-01-01

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

42 CFR 423.664 - Authority of hearing officer.

Code of Federal Regulations, 2010 CFR

2010-10-01

... (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Medicare Contract Determinations and Appeals § 423.664 Authority of hearing officer. In exercising his or her authority, the hearing...

Medicare Prescription Drug Coverage

MedlinePlus

Part D is the name of Medicare's prescription drug coverage. It's insurance that helps people pay for prescription drugs. It is available to everyone who has Medicare. It provides protection if you ...

42 CFR 422.527 - Agreements with Federally qualified health centers.

Code of Federal Regulations, 2010 CFR

2010-10-01

... AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Application Procedures and Contracts for Medicare Advantage Organizations § 422.527 Agreements with Federally qualified health centers...

42 CFR 422.506 - Nonrenewal of contract.

Code of Federal Regulations, 2010 CFR

2010-10-01

... (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Application Procedures and Contracts for Medicare Advantage Organizations § 422.506 Nonrenewal of contract. (a) Nonrenewal by an MA organization. (1) An MA...

MIPPA: First Broad Changes to Medicare Part D Plan Operations.

PubMed

LeMasurier, Jean D; Edgar, Babette

2009-04-01

In July 2008, as part of broad Medicare reform, Congress passed the first major legislative changes to Medicare Part D since its enactment in 2003-the Medicare Improvements for Patients and Providers Act. This new legislation has significant implications for how Part D plans can market and enroll Medicare beneficiaries. The new legislation also strengthened beneficiary protections, expanded the low-income subsidy provisions originally included in Part D, and expanded Part D coverage. These changes have significant implications for the operation of Part D plans and can affect those involved in benefit design, including specialty pharmacy coverage. This article discusses the major changes that took effect on January 1, 2009, and have immediate implications for Part D plan sponsors, including Medicare Advantage plans and stand-alone prescription drug plans.

Puzzling out the new Medicare. How plan sponsors can understand and use Medicare+Choice to benefit their members and themselves.

PubMed

Parahus, S

1999-01-01

This article will discuss issues confronting plan sponsors in light of new Medicare+Choice options, and ways of responding to those issues. It will include a section with highlights of the "new" Medicare, including a brief description of new terminology and general descriptions of the different types of "coordinated care plans" and other options, e.g., POS, PPO, HMO, FFS, PSO and MSA. Its principal focus, however, will be on ways that plan sponsors can respond to--and capitalize on--the changes in Medicare and offer retirees a broader array of benefits while at the same time increasing their control over plan costs. The article will introduce the idea of plan sponsors constructing a retiree "flexible benefits" program comprising Medicare+Choice options.

Medicare Managed Care Spillovers and Treatment Intensity.

PubMed

Callison, Kevin

2016-07-01

Evidence suggests that the share of Medicare managed care enrollees in a region affects the costs of treating traditional fee-for-service (FFS) Medicare beneficiaries; however, little is known about the mechanisms through which these 'spillover effects' operate. This paper examines the relationship between Medicare managed care penetration and treatment intensity for FFS enrollees hospitalized with a primary diagnosis of AMI. I find that increased Medicare managed care penetration is associated with a reduction in both the costs and the treatment intensity of FFS AMI patients. Specifically, as Medicare managed care penetration increases, FFS AMI patients are less likely to receive surgical reperfusion and mechanical ventilation and to experience an overall reduction in the number of inpatient procedures. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

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.

MIPPA: First Broad Changes to Medicare Part D Plan Operations

PubMed Central

LeMasurier, Jean D.; Edgar, Babette

2009-01-01

In July 2008, as part of broad Medicare reform, Congress passed the first major legislative changes to Medicare Part D since its enactment in 2003—the Medicare Improvements for Patients and Providers Act. This new legislation has significant implications for how Part D plans can market and enroll Medicare beneficiaries. The new legislation also strengthened beneficiary protections, expanded the low-income subsidy provisions originally included in Part D, and expanded Part D coverage. These changes have significant implications for the operation of Part D plans and can affect those involved in benefit design, including specialty pharmacy coverage. This article discusses the major changes that took effect on January 1, 2009, and have immediate implications for Part D plan sponsors, including Medicare Advantage plans and stand-alone prescription drug plans. PMID:25126279

Lessons learned from the National Medicare & You Education Program.

PubMed

Goldstein, E; Teichman, L; Crawley, B; Gaumer, G; Joseph, C; Reardon, L

2001-01-01

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

Health care use by Medicare's disabled enrollees

PubMed Central

Lubitz, James; Pine, Penelope

1986-01-01

Three million persons under age 65 are entitled to Medicare because of disability. This study examines their Medicare use and mortality. Disabled enrollees had higher health care use and mortality than comparison groups of Medicare's aged enrollees or of the general population under age 65. One type of disabled enrollee, adults disabled as children (over one-half of whom are mentally retarded) show lower use rates than the other types of enrollees—workers and widows. High mortality of the disabled during the 2-year waiting period for Medicare suggests the need to investigate how they pay for care during this period. PMID:10317775

Special Medicare reimbursement and fraud and abuse considerations for management services organizations, medical foundations, and integrated delivery systems.

PubMed

DeMuro, P R; Owens, J F

1994-01-01

This chapter discusses certain Medicare reimbursement and fraud and abuse considerations for management services organizations (MSOs), medical foundations, and integrated delivery systems. It stresses the necessity of a business plan, the sources of capitalization that might be used in creating an integrated delivery system, and their effect on Medicare reimbursement. It also discusses related party principles and considerations and the Medicare "incident to" regulations. Furthermore, it discusses the application of certain Medicare safe harbor regulations on MSOs' structures and services, and those of medical foundations and integrated delivery systems.

Medicare's Drug Discount Card Program: Beneficiaries' Experience with Choice

PubMed Central

Hassol, Andrea; Wrobel, Marian V.; Doksum, Teresa

2007-01-01

This article describes Medicare beneficiaries' experience with the choice among Medicare drug discount cards and is based primarily on surveys and focus groups with beneficiaries as well as interviews with other stakeholders. Although competition and choice have the potential to reduce cost and enhance quality in the Medicare Program, our findings highlight some of the challenges involved in making choice work in practice. Despite the unique and temporary nature of the drug discount card program, these findings have considerable relevance to the Part D drug benefit and to other Medicare initiatives that rely on choice. PMID:17722747

Lessons Learned from the National Medicare & You Education Program

PubMed Central

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

2001-01-01

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

Making It Safe to Grow Old: A Financial Simulation Model for Launching MediCaring Communities for Frail Elderly Medicare Beneficiaries

PubMed Central

BERNHARDT, ANTONIA K.; BERGER, GREGORY; LEE, JAMES A.; REUTER, KEVIN; DAVANZO, JOAN; MONTGOMERY, ANNE; DOBSON, ALLEN

2016-01-01

Policy Points: At age 65, the average man and woman can respectively expect 1.5 years and 2.5 years of requiring daily help with “activities of daily living.” Available services fail to match frail elders’ needs, thereby routinely generating errors, unreliability, unwanted services, unmet needs, and high costs.The number of elderly Medicare beneficiaries likely to be frail will triple between 2000 and 2050. Low retirement savings, rising medical and long‐term care costs, and declining family caregiver availability portend gaps in badly needed services.The financial simulation reported here for 4 diverse MediCaring Communities shows lower per capita costs. Program savings are substantial and can improve coverage and function of local supportive services within current overall Medicare spending levels. Context The Altarum Institute Center for Elder Care and Advanced Illness has developed a reform model, MediCaring Communities, to improve services for frail elderly Medicare beneficiaries through longitudinal care planning, better‐coordinated and more desirable medical and social services, and local monitoring and management of a community's quality and supply of services. This study uses financial simulation to determine whether communities could implement the model within current Medicare and Medicaid spending levels, an important consideration to enable development and broad implementation. Methods The financial simulation for MediCaring Communities uses 4 diverse communities chosen for adequate size, varying health care delivery systems, and ability to implement reforms and generate data rapidly: Akron, Ohio; Milwaukie, Oregon; northeastern Queens, New York; and Williamsburg, Virginia. For each community, leaders contributed baseline population and program effect estimates that reflected projections from reported research to build the model. Findings The simulation projected third‐year savings between $269 and $537 per beneficiary per month and cumulative returns on investment between 75% and 165%. Conclusions The MediCaring Communities financial simulation demonstrates that better care at lower cost for frail elderly Medicare beneficiaries is possible within current financing levels. Long‐term success of the initiative will require reinvestment of Medicare savings to bolster nonmedical supportive services in the community. Successful implementation will necessitate waiving certain regulations and developing new infrastructure in pilot communities. This financial simulation methodology will help leadership in other communities to project fiscal performance. Since the MediCaring Communities model also achieves the Centers for Medicare and Medicaid Services' vision for care for frail elders (better care, healthier people, smarter spending) and since these reforms can proceed with limited waivers from Medicare, willing communities should explore implementation and share best practices about how to achieve fundamental service delivery changes that can meet the challenges of a much older population in the 21st century. PMID:27378581

Making It Safe to Grow Old: A Financial Simulation Model for Launching MediCaring Communities for Frail Elderly Medicare Beneficiaries.

PubMed

Bernhardt, Antonia K; Lynn, Joanne; Berger, Gregory; Lee, James A; Reuter, Kevin; Davanzo, Joan; Montgomery, Anne; Dobson, Allen

2016-09-01

At age 65, the average man and woman can respectively expect 1.5 years and 2.5 years of requiring daily help with "activities of daily living." Available services fail to match frail elders' needs, thereby routinely generating errors, unreliability, unwanted services, unmet needs, and high costs. The number of elderly Medicare beneficiaries likely to be frail will triple between 2000 and 2050. Low retirement savings, rising medical and long-term care costs, and declining family caregiver availability portend gaps in badly needed services. The financial simulation reported here for 4 diverse MediCaring Communities shows lower per capita costs. Program savings are substantial and can improve coverage and function of local supportive services within current overall Medicare spending levels. The Altarum Institute Center for Elder Care and Advanced Illness has developed a reform model, MediCaring Communities, to improve services for frail elderly Medicare beneficiaries through longitudinal care planning, better-coordinated and more desirable medical and social services, and local monitoring and management of a community's quality and supply of services. This study uses financial simulation to determine whether communities could implement the model within current Medicare and Medicaid spending levels, an important consideration to enable development and broad implementation. The financial simulation for MediCaring Communities uses 4 diverse communities chosen for adequate size, varying health care delivery systems, and ability to implement reforms and generate data rapidly: Akron, Ohio; Milwaukie, Oregon; northeastern Queens, New York; and Williamsburg, Virginia. For each community, leaders contributed baseline population and program effect estimates that reflected projections from reported research to build the model. The simulation projected third-year savings between $269 and $537 per beneficiary per month and cumulative returns on investment between 75% and 165%. The MediCaring Communities financial simulation demonstrates that better care at lower cost for frail elderly Medicare beneficiaries is possible within current financing levels. Long-term success of the initiative will require reinvestment of Medicare savings to bolster nonmedical supportive services in the community. Successful implementation will necessitate waiving certain regulations and developing new infrastructure in pilot communities. This financial simulation methodology will help leadership in other communities to project fiscal performance. Since the MediCaring Communities model also achieves the Centers for Medicare and Medicaid Services' vision for care for frail elders (better care, healthier people, smarter spending) and since these reforms can proceed with limited waivers from Medicare, willing communities should explore implementation and share best practices about how to achieve fundamental service delivery changes that can meet the challenges of a much older population in the 21st century. © 2016 Milbank Memorial Fund. Published by Wiley Periodicals Inc.

42 CFR 422.521 - Effective date of new significant regulatory requirements.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Application Procedures and Contracts for Medicare Advantage Organizations § 422.521 Effective date of new significant...

Medicare

MedlinePlus

... for receiving health services If you have other health insurance Contacting Social Security 1 1 3 7 8 ... 2048 What is Medicare? Medicare is our country’s health insurance program for people age 65 or older. People ...

42 CFR 422.505 - Effective date and term of contract.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Application Procedures and Contracts for Medicare Advantage Organizations § 422.505 Effective date and term of contract. (a) Effective date. The...

42 CFR 422.2272 - Licensing of marketing representatives and confirmation of marketing resources.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Medicare Advantage Marketing Requirements § 422.2272 Licensing of marketing representatives and...

42 CFR 422.508 - Modification or termination of contract by mutual consent.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Application Procedures and Contracts for Medicare Advantage Organizations § 422.508 Modification or termination of contract...

42 CFR 412.79 - Determination of the hospital-specific rate for inpatient operating costs for Medicare-dependent...

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 2 2011-10-01 2011-10-01 false Determination of the hospital-specific rate for inpatient operating costs for Medicare-dependent, small rural hospitals based on a Federal fiscal year 2002 base period. 412.79 Section 412.79 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE...

42 CFR 412.79 - Determination of the hospital-specific rate for inpatient operating costs for Medicare-dependent...

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 2 2014-10-01 2014-10-01 false Determination of the hospital-specific rate for inpatient operating costs for Medicare-dependent, small rural hospitals based on a Federal fiscal year 2002 base period. 412.79 Section 412.79 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE...

42 CFR 412.79 - Determination of the hospital-specific rate for inpatient operating costs for Medicare-dependent...

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 2 2013-10-01 2013-10-01 false Determination of the hospital-specific rate for inpatient operating costs for Medicare-dependent, small rural hospitals based on a Federal fiscal year 2002 base period. 412.79 Section 412.79 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE...

42 CFR 412.79 - Determination of the hospital-specific rate for inpatient operating costs for Medicare-dependent...

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 2 2012-10-01 2012-10-01 false Determination of the hospital-specific rate for inpatient operating costs for Medicare-dependent, small rural hospitals based on a Federal fiscal year 2002 base period. 412.79 Section 412.79 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE...

How Successful Is Medicare Advantage?

PubMed Central

Newhouse, Joseph P; McGuire, Thomas G

2014-01-01

Context Medicare Part C, or Medicare Advantage (MA), now almost 30 years old, has generally been viewed as a policy disappointment. Enrollment has vacillated but has never come close to the penetration of managed care plans in the commercial insurance market or in Medicaid, and because of payment policy decisions and selection, the MA program is viewed as having added to cost rather than saving funds for the Medicare program. Recent changes in Medicare policy, including improved risk adjustment, however, may have changed this picture. Methods This article summarizes findings from our group's work evaluating MA's recent performance and investigating payment options for improving its performance even more. We studied the behavior of both beneficiaries and plans, as well as the effects of Medicare policy. Findings Beneficiaries make “mistakes” in their choice of MA plan options that can be explained by behavioral economics. Few beneficiaries make an active choice after they enroll in Medicare. The high prevalence of “zero-premium” plans signals inefficiency in plan design and in the market's functioning. That is, Medicare premium policies interfere with economically efficient choices. The adverse selection problem, in which healthier, lower-cost beneficiaries tend to join MA, appears much diminished. The available measures, while limited, suggest that, on average, MA plans offer care of equal or higher quality and for less cost than traditional Medicare (TM). In counties, greater MA penetration appears to improve TM's performance. Conclusions Medicare policies regarding lock-in provisions and risk adjustment that were adopted in the mid-2000s have mitigated the adverse selection problem previously plaguing MA. On average, MA plans appear to offer higher value than TM, and positive spillovers from MA into TM imply that reimbursement should not necessarily be neutral. Policy changes in Medicare that reform the way that beneficiaries are charged for MA plan membership are warranted to move more beneficiaries into MA. PMID:24890251

How successful is Medicare Advantage?

PubMed

Newhouse, Joseph P; McGuire, Thomas G

2014-06-01

Medicare Part C, or Medicare Advantage (MA), now almost 30 years old, has generally been viewed as a policy disappointment. Enrollment has vacillated but has never come close to the penetration of managed care plans in the commercial insurance market or in Medicaid, and because of payment policy decisions and selection, the MA program is viewed as having added to cost rather than saving funds for the Medicare program. Recent changes in Medicare policy, including improved risk adjustment, however, may have changed this picture. This article summarizes findings from our group's work evaluating MA's recent performance and investigating payment options for improving its performance even more. We studied the behavior of both beneficiaries and plans, as well as the effects of Medicare policy. Beneficiaries make "mistakes" in their choice of MA plan options that can be explained by behavioral economics. Few beneficiaries make an active choice after they enroll in Medicare. The high prevalence of "zero-premium" plans signals inefficiency in plan design and in the market's functioning. That is, Medicare premium policies interfere with economically efficient choices. The adverse selection problem, in which healthier, lower-cost beneficiaries tend to join MA, appears much diminished. The available measures, while limited, suggest that, on average, MA plans offer care of equal or higher quality and for less cost than traditional Medicare (TM). In counties, greater MA penetration appears to improve TM's performance. Medicare policies regarding lock-in provisions and risk adjustment that were adopted in the mid-2000s have mitigated the adverse selection problem previously plaguing MA. On average, MA plans appear to offer higher value than TM, and positive spillovers from MA into TM imply that reimbursement should not necessarily be neutral. Policy changes in Medicare that reform the way that beneficiaries are charged for MA plan membership are warranted to move more beneficiaries into MA. © 2014 Milbank Memorial Fund.

Medicare Special Needs Plan (SNP)

MedlinePlus

... of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific ... work Health Maintenance Organization (HMO) Preferred Provider Organization (PPO) Private Fee-for-Service (PFFS) Find someone to ...

42 CFR 422.510 - Termination of contract by CMS.

Code of Federal Regulations, 2010 CFR

2010-10-01

... (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Application Procedures and Contracts for Medicare Advantage Organizations § 422.510 Termination of contract by CMS. (a) Termination by CMS. CMS may at any...

The Impact of Medicare Part D on the Proportion of Out-of-Pocket Prescription Drug Costs Among Older Adults With Diabetes.

PubMed

Choi, Yoon Jeong; Jia, Haomiao; Gross, Tal; Weinger, Katie; Stone, Patricia W; Smaldone, Arlene M

2017-04-01

The purpose of this study was to evaluate the impact of Medicare Part D on reducing the financial burden of prescription drugs in older adults with diabetes. Using Medical Expenditure Panel Survey data (2000-2011), interrupted time series and difference-in-difference analyses were used to examine out-of-pocket costs for prescription drugs in 4,664 Medicare beneficiaries (≥65 years of age) compared with 2,938 younger, non-Medicare adults (50-60 years) with diabetes and to estimate the causal effects of Medicare Part D. Part D enrollment of Medicare beneficiaries with diabetes gradually increased from 45.7% (2006) to 52.4% (2011). Compared with years 2000-2005, out-of-pocket pharmacy costs decreased by 13.5% (SE 2.1) for all Medicare beneficiaries with diabetes following Part D implementation; on average, Part D beneficiaries had 5.3% (0.8) lower costs compared with those without Part D. Compared with a younger group with diabetes, out-of-pocket pharmacy costs decreased by 19.4% (1.7) for Medicare beneficiaries after Part D. Part D beneficiaries with diabetes who experienced the coverage gap decreased from 60.1% (2006) to 40.9% (2011) over this period. These findings demonstrate that although Medicare Part D has been effective in reducing the out-of-pocket cost burden of prescription drugs, approximately two out of five Part D beneficiaries with diabetes experienced the coverage gap in 2011. Future research is needed to examine the impact of Affordable Care Act provisions to close the coverage gap on the cost burden of prescription drugs for Medicare beneficiaries with diabetes. © 2017 by the American Diabetes Association.

The burden of hepatitis C to the United States Medicare system in 2009: Descriptive and economic characteristics.

PubMed

Rein, David B; Borton, Joshua; Liffmann, Danielle K; Wittenborn, John S

2016-04-01

The aim of this work was to estimate and describe the Medicare beneficiaries diagnosed with hepatitis C virus (HCV) in 2009, incremental annual costs by disease stage, incremental total Medicare HCV payments in 2009 using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data covering the years 2002 to 2009. We weighted the 2009 SEER-Medicare data to create estimates of the number of patients with an HCV diagnosis, used an inverse probability-weighted two-part, probit, and generalized linear model to estimate incremental per patient per month costs, and used simulation to estimate annual 2009 Medicare burden, presented in 2014 dollars. We summarized patient characteristics, diagnoses, and costs from SEER-Medicare files into a person-year panel data set. We estimated there were 407,786 patients with diagnosed HCV in 2009, of whom 61.4% had one or more comorbidities defined by the study. In 2009, 68% of patients were diagnosed with chronic HCV only, 9% with cirrhosis, 12% with decompensated cirrhosis (DCC), 2% with liver cancer, 2% with a history of transplant, and 8% who died. Annual costs for patients with chronic infection only and DCC were higher than the values used in many previous cost-effectiveness studies, and treatment of DCC accounted for 63.9% of total Medicare's HCV expenditures. Medicare paid $2.7 billion (credible interval: $0.7-$4.6 billion) in incremental costs for HCV in 2009. The costs of HCV to Medicare in 2009 were substantial and expected to increase over the next decade. Annual costs for patients with chronic infection only and DCC were higher than values used in many cost-effectiveness analyses. © 2015 by the American Association for the Study of Liver Diseases.

Factors associated with independent pharmacy owners' satisfaction with Medicare Part D contracts.

PubMed

Zhang, Su; Doucette, William R; Urmie, Julie M; Xie, Yang; Brooks, John M

2010-06-01

As Medicare Part D contracts apply pressure on the profitability of independent pharmacies, there is concern about their owners' willingness to sign such contracts. Identifying factors affecting independent pharmacy owners' satisfaction with Medicare Part D contracts could inform policy makers in managing Medicare Part D. (1) To identify influences on independent pharmacy owners' satisfaction with Medicare Part D contracts and (2) to characterize comments made by independent pharmacy owners about Medicare Part D. This cross-sectional study used a mail survey of independent pharmacy owners in 15 states comprising 6 Medicare regions to collect information on their most- and least-favorable Medicare Part D contracts, including satisfaction, contract management activities, market position, pharmacy operation, and specific payment levels on brand and generic drugs. Of the 1649 surveys mailed, 296 surveys were analyzed. The regression models for satisfaction with both the least and the most-favorable Part D contracts were significant (P<0.05). A different set of significant influences on satisfaction was identified for each regression model. For the most-favorable contract, influences were contending and equity. For the least-favorable contract, influences were negotiation, equity, generic rate bonus, and medication therapy management (MTM) payment. About one-third of the survey respondents made at least 1 comment. The most frequent themes in the comments were that Medicare Part D reimbursement rate is too low (28%) and that contracts are offered without negotiation in a "take it or leave it" manner (20%). Equity, contending, negotiation, generic rate bonus, and MTM payments were identified as the influences of independent pharmacy owners' satisfaction toward Medicare Part D contracts. Generic rate bonus and MTM payment provide additional financial incentives to less financially favorable contracts and, in turn, contribute to independent pharmacy owner's satisfaction toward these contracts. Copyright 2010 Elsevier Inc. All rights reserved.

Linkage of a Population-Based Cohort With Primary Data Collection to Medicare Claims: The Reasons for Geographic and Racial Differences in Stroke Study.

PubMed

Xie, Fenglong; Colantonio, Lisandro D; Curtis, Jeffrey R; Safford, Monika M; Levitan, Emily B; Howard, George; Muntner, Paul

2016-10-01

We described the linkage of primary data with administrative claims using the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study and Medicare. REGARDS study data were linked with Medicare claims by use of Social Security numbers. We compared REGARDS participants by Medicare linkage status, having fee-for-service (FFS) coverage or not, and with a 5% sample of Medicare beneficiaries who had FFS coverage in 2005, overall, by age (45-64 and ≥65 years), and by race. Among REGARDS participants who were ≥65 years of age, 80% had data linked to Medicare on their study-visit date (64% with FFS coverage). No differences except race and sex were present between REGARDS participants without Medicare linkage and those with data linked to Medicare with and without FFS coverage. After the age-sex-race adjustment, comorbid conditions and health-care utilization were similar for those with FFS coverage in the REGARDS study and the 5% sample of Medicare beneficiaries. Among REGARDS participants aged 45-64 years, 11% had FFS coverage on their study-visit date. In this age group, differences were present between participants with and without FFS coverage and the Medicare 5% sample with FFS coverage. In conclusion, REGARDS participants aged ≥65 years with FFS coverage are representative of the study cohort and the US population aged ≥65 years with FFS coverage. © The Author 2016. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Feasibility of Economic Analysis of Radiation Therapy Oncology Group (RTOG) 91-11 Using Medicare Data

DOE Office of Scientific and Technical Information (OSTI.GOV)

Konski, Andre, E-mail: akonski@med.wayne.ed; Bhargavan, Mythreyi; Owen, Jean

Purpose: The specific aim of this analysis was to evaluate the feasibility of performing a cost-effectiveness analysis using Medicare data from patients treated on a randomized Phase III clinical trial. Methods and Materials: Cost data included Medicare Part A and Part B costs from all providers-inpatient, outpatient, skilled nursing facility, home health, hospice, and physicians-and were obtained from the Centers for Medicare and Medicaid Services for patients eligible for Medicare, treated on Radiation Therapy Oncology Group (RTOG) 9111 between 1992 and 1996. The 47-month expected discounted (annual discount rate of 3%) cost for each arm of the trial was calculatedmore » in 1996 dollars, with Kaplan-Meier sampling average estimates of survival probabilities for each month and mean monthly costs. Overall and disease-free survival was also discounted 3%/year. The analysis was performed from a payer's perspective. Incremental cost-effectiveness ratios were calculated comparing the chemotherapy arms to the radiation alone arm. Results: Of the 547 patients entered, Medicare cost data and clinical outcomes were available for 66 patients. Reasons for exclusion included no RTOG follow-up, Medicare HMO enrollment, no Medicare claims since trial entry, and trial entry after 1996. Differences existed between groups in tumor characteristics, toxicity, and survival, all which could affect resource utilization. Conclusions: Although we were able to test the methodology of economic analysis alongside a clinical trial using Medicare data, the results may be difficult to translate to the entire trial population because of non-random missing data. Methods to improve Medicare data capture and matching to clinical trial samples are required.« less

42 CFR 422.320 - Special rules for hospice care.

Code of Federal Regulations, 2010 CFR

2010-10-01

... (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Payments to Medicare Advantage Organizations § 422... her enrollment in the MA plan and is entitled to receive, through the MA plan, any benefits other than...

42 CFR 422.304 - Monthly payments.

Code of Federal Regulations, 2010 CFR

2010-10-01

...) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Payments to Medicare Advantage Organizations § 422.304 Monthly... original fee-for-service benefits for an individual in an MA payment area for a month. (1) Payment of bid...

Medicare Financial Status, Budget Impact, and Sustainability—Which Concept is Which?

PubMed Central

Foster, Richard S.; Clemens, M. Kent

2005-01-01

Medicare is continually undergoing change, as it must in order to reflect advances in medical technology, new health care delivery systems, financial pressures, and other developments. Modifications to the program are debated by policymakers in Congress and the administration, together with academic experts and others. These debates would be improved if policymakers and the public had a clearer understanding of Medicare and certain commonly cited views of the program's overall status. Three such concepts—the financial status of the Medicare trust funds, the impact of Medicare on the Federal budget, and the long-run sustainability of Medicare—are often confused with each other and are sometimes used interchangeably. Each concept is important but needs to be used for its own purpose. This article clarifies the differences among these three views of Medicare and provides examples of each. PMID:17290643

Medicare Financial Status, Budget Impact, and Sustainability—Which Concept is Which?

PubMed Central

Foster, Richard S.; Clemens, M. Kent

2009-01-01

Medicare is continually undergoing change, as it must in order to reflect advances in medical technology, new health care delivery systems, financial pressures, and other developments. Modifications to the program are debated by policymakers in Congress and the administration, together with academic experts and others. These debates would be improved if policymakers and the public had a clearer understanding of Medicare and certain commonly cited views of the program's overall status. Three such concepts—the financial status of the Medicare trust funds, the impact of Medicare on the Federal budget, and the long-run sustainability of Medicare—are often confused with each other and are sometimes used interchangeably. Each concept is important but needs to be used for its own purpose. This article clarifies the differences among these three views of Medicare and provides examples of each. PMID:19544937

Geographic variation in Medicare and the military healthcare system.

PubMed

Adesoye, Taiwo; Kimsey, Linda G; Lipsitz, Stuart R; Nguyen, Louis L; Goodney, Philip; Olaiya, Samuel; Weissman, Joel S

2017-08-01

To compare geographic variation in healthcare spending and utilization between the Military Health System (MHS) and Medicare across hospital referral regions (HRRs). Retrospective analysis. Data on age-, sex-, and race-adjusted Medicare per capita expenditure and utilization measures by HRR were obtained from the Dartmouth Atlas for 2007 to 2010. Similarly, adjusted data from 2007 and 2010 were obtained from the MHS Data Repository and patients assigned to HRRs. We compared high- and low-spending regions, and computed coefficient of variation (CoV) and correlation coefficients for healthcare spending, hospital inpatient days, hip surgery, and back surgery between MHS and Medicare patients. We found significant variation in spending and utilization across HRRs in both the MHS and Medicare. CoV for spending was higher in the MHS compared with Medicare, (0.24 vs 0.15, respectively) and CoV for inpatient days was 0.36 in the MHS versus 0.19 in Medicare. The CoV for back surgery was also greater in the MHS compared with Medicare (0.47 vs 0.29, respectively). Per capita Medicare spending per HRR was significantly correlated to adjusted MHS spending (r = 0.3; P <.0001). Correlation in inpatient days (r = 0.29; P <.0001) and back surgery (r = 0.52; P <.0001) was also significant. Higher spending markets in both systems were not comparable; lower spending markets were located mostly in the Midwest. In comparing 2 systems with similar pricing schemes, differences in spending likely reflect variation in utilization and the influence of local provider culture.

The Impact of Hospital Pay-for-Performance on Hospital and Medicare Costs

PubMed Central

Kruse, Gregory B; Polsky, Daniel; Stuart, Elizabeth A; Werner, Rachel M

2012-01-01

Objective To evaluate the effects of Medicare's hospital pay-for-performance demonstration project on hospital revenues, costs, and margins and on Medicare costs. Data Sources/Study Setting All health care utilization for Medicare beneficiaries hospitalized for acute myocardial infarction (AMI; ICD-9-CM code 410.x1) in fiscal years 2002–2005 from Medicare claims, containing 420,211 admissions with AMI. Study Design We test for changes in hospital costs and revenues and Medicare payments among 260 hospitals participating in the Medicare hospital pay-for-performance demonstration project and a group of 780 propensity-score-matched comparison hospitals. Effects were estimated using a difference-in-difference model with hospital fixed effects, testing for changes in costs among pay-for-performance hospitals above and beyond changes in comparison hospitals. Principal Findings We found no significant effect of pay-for-performance on hospital financials (revenues, costs, and margins) or Medicare payments (index hospitalization and 1 year after admission) for AMI patients. Conclusions Pay-for-performance in the CMS hospital demonstration project had minimal impact on hospital financials and Medicare payments to providers. As P4P extends to all hospitals under the Affordable Care Act, these results provide some estimates of the impact of P4P and emphasize our need for a better understanding of the financial implications of P4P on providers and payers if we want to create sustainable and effective programs to improve health care value. PMID:23088391

Financial and quality impacts of the Medicare physician group practice demonstration.

PubMed

Pope, Gregory; Kautter, John; Leung, Musetta; Trisolini, Michael; Adamache, Walter; Smith, Kevin

2014-01-01

To examine the impact of the Medicare Physician Group Practice (PGP) demonstration on expenditure, utilization, and quality outcomes. Secondary data analysis of 2001-2010 Medicare claims for 1,776,387 person years assigned to the ten participating provider organizations and 1,579,080 person years in the corresponding local comparison groups. We used a pre-post comparison group observational design consisting of four pre-demonstration years (1/01-12/04) and five demonstration years (4/05-3/10). We employed a propensity-weighted difference-in-differences regression model to estimate demonstration effects, adjusting for demographics, health status, geographic area, and secular trends. The ten demonstration sites combined saved $171 (2.0%) per assigned beneficiary person year (p<0.001) during the five-year demonstration period. Medicare paid performance bonuses to the participating PGPs that averaged $102 per person year. The net savings to the Medicare program were $69 (0.8%) per person year. Demonstration savings were achieved primarily from the inpatient setting. The demonstration improved quality of care as measured by six of seven claims-based process quality indicators. The PGP demonstration, which used a payment model similar to the Medicare Accountable Care Organization (ACO) program, resulted in small reductions in Medicare expenditures and inpatient utilization, and improvements in process quality indicators. Judging from this demonstration experience, it is unlikely that Medicare ACOs will initially achieve large savings. Nevertheless, ACOs paid through shared savings may be an important first step toward greater efficiency and quality in the Medicare fee-for-service program.

The impact of hospital pay-for-performance on hospital and Medicare costs.

PubMed

Kruse, Gregory B; Polsky, Daniel; Stuart, Elizabeth A; Werner, Rachel M

2012-12-01

To evaluate the effects of Medicare's hospital pay-for-performance demonstration project on hospital revenues, costs, and margins and on Medicare costs. All health care utilization for Medicare beneficiaries hospitalized for acute myocardial infarction (AMI; ICD-9-CM code 410.x1) in fiscal years 2002-2005 from Medicare claims, containing 420,211 admissions with AMI. We test for changes in hospital costs and revenues and Medicare payments among 260 hospitals participating in the Medicare hospital pay-for-performance demonstration project and a group of 780 propensity-score-matched comparison hospitals. Effects were estimated using a difference-in-difference model with hospital fixed effects, testing for changes in costs among pay-for-performance hospitals above and beyond changes in comparison hospitals. We found no significant effect of pay-for-performance on hospital financials (revenues, costs, and margins) or Medicare payments (index hospitalization and 1 year after admission) for AMI patients. Pay-for-performance in the CMS hospital demonstration project had minimal impact on hospital financials and Medicare payments to providers. As P4P extends to all hospitals under the Affordable Care Act, these results provide some estimates of the impact of P4P and emphasize our need for a better understanding of the financial implications of P4P on providers and payers if we want to create sustainable and effective programs to improve health care value. © Health Research and Educational Trust.

Inflation in DoD Medical Care.

DTIC Science & Technology

1997-07-01

cataract surgery , to the outpatient setting); • 1.4%, trends in medical practice in place prior to PPS; • 0.0%, aging of the Medicare population...HFCA’s Medicare Economic Index.17 The MEI is used to update payments for physician services under Medicare Part B. The MEI is oriented toward care... physician services industry.l% [emphasis added] Table III-3. Medicare Economic Index: Expense Categories, Expenditure Weights, and Price Proxies

HMOs must submit Medicare HEDIS.

PubMed

Grimaldi, P L

1997-03-01

Health maintenance organizations (HMOs) are now required to submit the Health Plan Employer Data and Information Set (HEDIS) for Medicare members to the federal government. The information will be used to assess an HMO's stability and performance in meeting its contractual obligations, including providing Medicare members with timely access to quality care. It also may be used to develop explanatory materials for Medicare beneficiaries trying to decide which health plan to join.

Medicare Hospital Charges in the Last Year of Life: Distribution by Quarter for Rural and Urban Nursing Home Decedents with Cognitive Impairment

ERIC Educational Resources Information Center

Gessert, Charles E.; Haller, Irina V.

2008-01-01

Background: Medicare beneficiaries incur 27%-30% of lifetime charges in the last year of life; most charges occur in the last quarter. Factors associated with high end-of-life Medicare charges include less advanced age, non-white race, absence of advance directive, and urban residence. Methods: We analyzed Medicare hospital charges in the last…

20 CFR 418.1355 - What are the rules for reopening a decision by an administrative law judge of the Office of...

Code of Federal Regulations, 2010 CFR

2010-04-01

... 20 Employees' Benefits 2 2010-04-01 2010-04-01 false What are the rules for reopening a decision by an administrative law judge of the Office of Medicare Hearings and Appeals (OMHA) or by the Medicare Appeals Council (MAC)? 418.1355 Section 418.1355 Employees' Benefits SOCIAL SECURITY ADMINISTRATION MEDICARE SUBSIDIES Medicare Part B...

Identifying the Transgender Population in the Medicare Program

PubMed Central

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

2016-01-01

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

Boutique to Booming: Medicare Managed Care and the Private Path to Policy Change.

PubMed

Kelly, Andrew S

2016-06-01

In 2014, Medicare Advantage (MA) enrollment surpassed 30 percent of eligible beneficiaries. Twenty-five years earlier, enrollment hovered at just 3 percent. The expansion of private Medicare plans presents a puzzling instance of policy change within Medicare-a program long held to be a quintessential case of policy stasis. This article investigates the policy features that made Medicare susceptible to this dramatic policy shift, as well as the processes by which the initial policy change remade the politics of Medicare and solidified the MA program. The first enrollment surge occurred in the absence of a proximate legislative or administrative change. Instead, increased spending and expanded benefits were the result of the interaction of new market dynamics with an existing legislative framework-demonstrating an expansionary form of policy drift. The 1982 Tax Equity and Fiscal Responsibility Act created a policy space that gave the new and lightly controlled managed care industry considerable operational discretion. As the interests of the government's private partners changed in response to new market dynamics, a change occurred in the output and performance of the Medicare managed care program. As enrollment and spending increased, Medicare's politics were remade by the political empowerment of the managed care industry and the creation of a new subconstituency of beneficiaries. Copyright © 2016 by Duke University Press.

A Review of the Use of Medicare Claims Data in Plastic Surgery Outcomes Research

PubMed Central

Mahmoudi, Elham; Kotsis, Sandra V.

2015-01-01

Summary: With a growing national emphasis in data transparency and reporting of public health data, it is essential for researchers to know more about Medicare claims data, the largest and most reliable source of health-care utilization and expenditure for individuals older than 65 years in the United States. This article provides an overview of Medicare claims data for plastic surgery outcomes research. We highlight essential information on various files included in Medicare claims data, strengths and limitations of the data, and ways to expand the use of existing data for research purposes. As of now, Medicare data are limited in providing adequate information regarding severity of diagnosed conditions, health status of individuals, and health outcomes after certain procedures. However, the data contain all health-care utilization and expenditures for services that are covered by Medicare Parts A, B, and D (inpatient, outpatient, ambulatory-based and physician-based services, and prescription drugs). Additionally, Medicare claims data can be used for longitudinal analysis of variations in utilization and cost of health-care services at the patient level and provider level. Linking Medicare claims data with other national databases and utilizing the ICD-10 coding system would further expand the use of these datasets in health services research. PMID:26579336

Public Health Spending and Medicare Resource Use: A Longitudinal Analysis of U.S. Communities.

PubMed

Mays, Glen P; Mamaril, Cezar B

2017-12-01

To examine whether local expenditures for public health activities influence area-level medical spending for Medicare beneficiaries. Six census surveys of the nation's 2,900 local public health agencies were conducted between 1993 and 2013, linked with contemporaneous information on population demographics, socioeconomic characteristics, and area-level Medicare spending estimates from the Dartmouth Atlas of Health Care. Measures derive from agency survey data and aggregated Medicare claims. A longitudinal cohort design follows the geographic areas served by local public health agencies. Multivariate, fixed-effects, and instrumental-variables regression models estimate how area-level Medicare spending changes in response to shifts in local public health spending, controlling for observed and unmeasured confounders. A 10 percent increase in local public health spending per capita was associated with 0.8 percent reduction in adjusted Medicare expenditures per person after 1 year (p < .01) and a 1.1 percent reduction after 5 years (p < .05). Estimated Medicare spending offsets were larger in communities with higher rates of poverty, lower health insurance coverage, and health professional shortages. Expanded financing for public health activities may provide an effective way of constraining Medicare spending, particularly in low-resource communities. © Health Research and Educational Trust.

Medicare claims data reliably identify treatments for basal cell carcinoma and squamous cell carcinoma: a prospective cohort study.

PubMed

Thompson, Bridie S; Olsen, Catherine M; Subramaniam, Padmini; Neale, Rachel E; Whiteman, David C

2016-04-01

To investigate the accuracy of Medical Benefit Schedule (MBS) item numbers to identify treatments for basal cell carcinomas (BCC) and squamous cell carcinomas (SCC). We linked records from QSkin Study participants (n=37,103) to Medicare. We measured the proportion of Medicare claims for primary excision of BCC/SCC that had corresponding claims for histopathology services. In subsets of participants, we estimated the sensitivity and external concordance of MBS item numbers for identifying BCC/SCC diagnoses by comparing against 'gold-standard' histopathology reports. A total of 2,821 (7.6%) participants had 4,830 separate Medicare claims for BCC/SCC excision; almost all (97%) had contemporaneous Medicare claims for histopathology services. Among participants with BCC/SCC confirmed by histology reports, 76% had a corresponding Medicare claim for primary surgical excision of BCC/SCC. External concordance for Medicare claims for primary BCC/SCC excision was 68%, increasing to 97% when diagnoses for intra-epidermal carcinomas and keratoacanthomas were included. MBS item numbers for primary excision of BCC/SCC are reasonably reliable for determining incident cases of keratinocyte skin cancers, but may underestimate incidence by up to 24%. Medicare claims data may have utility in monitoring trends in conditions for which there is no mandatory reporting. © 2015 Public Health Association of Australia.

Examining Measures of Income and Poverty in Medicare Administrative Data.

PubMed

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

2017-12-01

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

The Role of Medicare's Inpatient Cost-Sharing in Medicaid Entry.

PubMed

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

2018-04-01

To isolate the effect of greater inpatient cost-sharing on Medicaid entry among Medicare beneficiaries. Medicare administrative data (years 2007-2010) were linked to nursing home assessments and area-level socioeconomic indicators. Medicare beneficiaries who are readmitted to a hospital must pay an additional deductible ($1,100 in 2010) if their readmission occurs more than 59 days following discharge. In a regression discontinuity analysis, we take advantage of this Medicare benefit feature to test whether beneficiaries with greater cost-sharing have higher rates of Medicaid enrollment. We identified 221,248 Medicare beneficiaries with an initial hospital stay and a readmission 53-59 days later (no deductible) or 60-66 days later (charged a deductible). Among beneficiaries in low-socioeconomic areas with two hospitalizations, those readmitted 60-66 days after discharge were 21 percent more likely to join Medicaid compared with those readmitted 53-59 days following their initial hospitalization (absolute difference in adjusted risk of Medicaid entry: 3.7 percent vs. 3.1 percent, p = .01). Increasing Medicare cost-sharing requirements may promote Medicaid enrollment among low-income beneficiaries. Potential savings from an increased cost-sharing in the Medicare program may be offset by increased Medicaid participation. © Health Research and Educational Trust.

Contrary to cost-shift theory, lower Medicare hospital payment rates for inpatient care lead to lower private payment rates.

PubMed

White, Chapin

2013-05-01

Many policy makers believe that when Medicare constrains its payment rates for hospital inpatient care, private insurers end up paying higher rates as a result. I tested this "cost-shifting" theory using a unique new data set that combines MarketScan private claims data with Medicare hospital cost reports. Contrary to the theory, I found that hospital markets with relatively slow growth in Medicare inpatient hospital payment rates also had relatively slow growth in private hospital payment rates during 1995-2009. Using regression analyses, I found that a 10 percent reduction in Medicare payment rates led to an estimated reduction in private payment rates of 3 percent or 8 percent, depending on the statistical model used. These payment rate spillovers may reflect an effort by hospitals to rein in their operating costs in the face of lower Medicare payment rates. Alternatively, hospitals facing cuts in Medicare payment rates may also cut the payment rates they seek from private payers to attract more privately insured patients. My findings indicate that repealing cuts in Medicare payment rates would not slow the growth in spending on hospital care by private insurers and would in fact be likely to accelerate the growth in private insurers' costs and premiums.

Medicare privatization and the erosion of retirement security.

PubMed

Polivka, Larry; Kwak, Jung

2008-01-01

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

Market Size and Innovation: Effects of Medicare Part D on Pharmaceutical Research and Development

PubMed Central

Sood, Neeraj

2012-01-01

Recent evidence suggests that Medicare Part D increased prescription drug use among seniors, and increased pharmaceutical firms’ revenues from sales. Previous studies also indicate that increases in market size induce pharmaceutical innovation. This paper assesses the impact of the Medicare Part D legislation on pharmaceutical research and development (R&D), using time-series data on the number of drugs entering preclinical and clinical development by therapeutic class and phase. We find that the passage and implementation of Medicare Part D is associated with significant increases in pharmaceutical R&D for therapeutic classes with higher Medicare market share. PMID:23869113

From politics to policy: a new payment approach in Medicare Advantage.

PubMed

Berenson, Robert A

2008-01-01

While the Medicare Advantage program's future remains contentious politically, the Medicare Payment Advisory Commission's (MedPAC's) recommended policy of financial neutrality at the local level between private plans and traditional Medicare ignores local market dynamics in important ways. An analysis correlating plan bids against traditional Medicare's local spending levels likely would provide an alternative method of setting benchmarks, by producing a blend of local and national rates. A result would be that the rural and lower-cost urban "floor counties" would have benchmarks below currently inflated levels but above what financial neutrality at the local level--MedPAC's approach--would produce.

Your Medicare Benefits

MedlinePlus

... health plans include all Medicare Advantage Plans, Medicare Cost Plans, and Demonstration/Pilot Programs. PACE plans can be offered by public or private entities and provide Part D and other benefits in addition to Part A and Part B ...

42 CFR 422.316 - Special rules for payments to Federally qualified health centers.

Code of Federal Regulations, 2010 CFR

2010-10-01

..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Payments to Medicare Advantage Organizations § 422.316 Special rules for payments to Federally qualified health centers...

Cross-Sectional Analysis of Per Capita Supply of Doctors of Chiropractic and Opioid Use in Younger Medicare Beneficiaries.

PubMed

Weeks, William B; Goertz, Christine M

2016-05-01

The purpose of this study was to determine whether the per-capita supply of doctors of chiropractic (DCs) or Medicare spending on chiropractic care was associated with opioid use among younger, disabled Medicare beneficiaries. Using 2011 data, at the hospital referral region level, we correlated the per-capita supply of DCs and spending on chiropractic manipulative therapy (CMT) with several measures of per-capita opioid use by younger, disabled Medicare beneficiaries. Per-capita supply of DCs and spending on CMT were strongly inversely correlated with the percentage of younger Medicare beneficiaries who had at least 1, as well as with 6 or more, opioid prescription fills. Neither measure was correlated with mean daily morphine equivalents per opioid user or per chronic opioid user. A higher per-capita supply of DCs and Medicare spending on CMT were inversely associated with younger, disabled Medicare beneficiaries obtaining an opioid prescription. However, neither measure was associated with opioid dosage among patients who obtained opioid prescriptions. Copyright © 2016. Published by Elsevier Inc.

The Effect of Benefits, Premiums, and Health Risk on Health Plan Choice in the Medicare Program

PubMed Central

Atherly, Adam; Dowd, Bryan E; Feldman, Roger

2004-01-01

Objective To estimate the effect of Medicare+Choice (M+C) plan premiums and benefits and individual beneficiary characteristics on the probability of enrollment in a Medicare+Choice plan. Data Source Individual data from the Medicare Current Beneficiary Survey were combined with plan-level data from Medicare Compare. Study Design Health plan choices, including the Medicare+Choice/Fee-for-Service decision and the choice of plan within the M+C sector, were modeled using limited information maximum likelihood nested logit. Principal Findings Premiums have a significant effect on plan selection, with an estimated out-of-pocket premium elasticity of −0.134 and an insurer-perspective elasticity of −4.57. Beneficiaries are responsive to plan characteristics, with prescription drug benefits having the largest marginal effect. Sicker beneficiaries were more likely to choose plans with drug benefits and diabetics were more likely to pick plans with vision coverage. Conclusions Plan characteristics significantly impact beneficiaries' decisions to enroll in Medicare M+C plans and individuals sort themselves systematically into plans based on individual characteristics. PMID:15230931

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.

Supplemental Coverage Associated With More Rapid Spending Growth For Medicare Beneficiaries

PubMed Central

Golberstein, Ezra; Walsh, Kayo; He, Yulei; Chernew, Michael E.

2013-01-01

Lowering both Medicare spending and the rate of Medicare spending growth is important for the nation’s fiscal health. Policy makers in search of ways to achieve these reductions have looked at the role that supplemental coverage for Medicare beneficiaries plays in Medicare spending. Supplemental coverage makes health care more affordable for beneficiaries but also makes beneficiaries insensitive to the cost of their care, thereby increasing the demand for care. Ours is the first empirical study to investigate whether supplemental Medicare coverage is associated with higher rates of spending growth over time. We found that supplemental insurance coverage was associated with significantly higher rates of overall spending growth. Specifically, employer-sponsored and self-purchased supplemental coverage were associated with annual total spending growth rates of 7.17 percent and 7.18 percent, respectively, compared to 6.08 percent annual growth for beneficiaries without supplemental coverage. Results for Medicare program spending were more equivocal, however. Our results are consistent with the belief that current trends away from generous employer-sponsored supplemental coverage and efforts to restrict the generosity of supplemental coverage may slow spending growth. PMID:23650320

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

PubMed Central

Gailey, Adam; Lakdawalla, Darius; Sood, Neeraj

2013-01-01

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

The Balanced Budget Act of 1997 and U.S. hospital operations.

PubMed

Bazzoli, Gloria J; Lindrooth, Richard C; Hasnain-Wynia, Romana; Needleman, Jack

The Balanced Budget Act (BBA) of 1997 initiated several changes to Medicare payment policy in an effort to slow the growth of hospital Medicare payments and ensure the future of the Medicare Hospital Insurance Trust Fund. Although subsequent federal legislation relaxed some original proposals, restored funds were limited and directed to specific types of hospitals. In addition, these Medicare policy changes came at a time when hospitals faced private sector payment constraints. This paper assesses the short-term effects of the BBA on operations of nonprofit hospitals in the United States and compares these effects to those observed in the early 1980s during implementation of the Medicare prospective payment system (PPS). We found that some operational changes instituted by hospitals facing financial pressures from the BBA were similar to those observed for hospitals that faced pressure from Medicare PPS, including efforts to contain Medicare cost growth, to expand outpatient service provision, and to contain hospital staffing. However, during PPS implementation hospitals experienced declining inpatient use and growing profit margins, whereas post-BBA hospitals experienced growing inpatient use and declining margins.

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...

77 FR 29648 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-January Through March 2012

Federal Register 2010, 2011, 2012, 2013, 2014

2012-05-18

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

Medicare's post-acute care payment: a review of the issues and policy proposals.

PubMed

Linehan, Kathryn

2012-12-07

Medicare spending on post-acute care provided by skilled nursing facility providers, home health providers, inpatient rehabilitation facility providers, and long-term care hospitals has grown rapidly in the past several years. The Medicare Payment Advisory Commission and others have noted several long-standing problems with the payment systems for post-acute care and have suggested refinements to Medicare's post-acute care payment systems that are intended to encourage the delivery of appropriate care in the right setting for a patient's condition. The Patient Protection and Affordable Care Act of 2010 contained several provisions that affect the Medicare program's post-acute care payment systems and also includes broader payment reforms, such as bundled payment models. This issue brief describes Medicare's payment systems for post-acute care providers, evidence of problems that have been identified with the payment systems, and policies that have been proposed or enacted to remedy those problems.

COMPETITIVE BIDDING IN MEDICARE ADVANTAGE: EFFECT OF BENCHMARK CHANGES ON PLAN BIDS

PubMed Central

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

2013-01-01

Bidding has been proposed to replace or complement the administered prices in Medicare pays to hospitals and health plans. In 2006, the Medicare Advantage program implemented a competitive bidding system to determine plan payments. In perfectly competitive models, plans bid their costs and thus bids are insensitive to the benchmark. Under many other models of competition, bids respond to changes in the benchmark. We conceptualize the bidding system and use an instrumental variable approach to study the effect of benchmark changes on bids. We use 2006–2010 plan payment data from the Centers for Medicare and Medicaid Services, published county benchmarks, actual realized fee-for-service costs, and Medicare Advantage enrollment. We find that a $1 increase in the benchmark leads to about a $0.53 increase in bids, suggesting that plans in the Medicare Advantage market have meaningful market power. PMID:24308881

Paying Medicare Advantage plans by competitive bidding: how much competition is there?

PubMed

Biles, Brian; Pozen, Jonah; Guterman, Stuart

2009-08-01

Private health plans that enroll Medicare beneficiaries--known as Medicare Advantage (MA) plans--are being paid $11 billion more in 2009 than it would cost to cover these beneficiaries in regular fee-for-service Medicare. To generate Medicare savings for offsetting the costs of health reform, the Obama Administration has proposed eliminating these extra payments to private insurers and instituting a competitive bidding system that pays MA plans based on the bids they submit. This study examines the concentration of enrollment among MA plans and the degree to which firms offering MA plans actually face competition. The results show that in the large majority of U.S. counties, MA plan enrollment is highly concentrated in a small number of firms. Given the relative lack of competition in many markets as well as the potential impact on traditional Medicare, the authors call for careful consideration of a new system for setting MA plan payments.

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

PubMed

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

2013-12-01

Bidding has been proposed to replace or complement the administered prices that Medicare pays to hospitals and health plans. In 2006, the Medicare Advantage program implemented a competitive bidding system to determine plan payments. In perfectly competitive models, plans bid their costs and thus bids are insensitive to the benchmark. Under many other models of competition, bids respond to changes in the benchmark. We conceptualize the bidding system and use an instrumental variable approach to study the effect of benchmark changes on bids. We use 2006-2010 plan payment data from the Centers for Medicare and Medicaid Services, published county benchmarks, actual realized fee-for-service costs, and Medicare Advantage enrollment. We find that a $1 increase in the benchmark leads to about a $0.53 increase in bids, suggesting that plans in the Medicare Advantage market have meaningful market power. Copyright © 2013 Elsevier B.V. All rights reserved.

Capitation among Medicare beneficiaries.

PubMed

Bazos, D A; Fisher, E S

1999-01-01

The Medicare program has promoted capitation as a way to contain costs. About 15% of Medicare beneficiaries nationwide are currently under capitation, but tremendous regional variation exists. The proportion of Medicare beneficiaries who have enrolled in risk-contract plans in individual states and in the 25 largest metropolitan areas in the United States. Health Care Financing Administration data files. Medicare beneficiaries are most likely to be under capitation in Arizona (38%) and California (37%). Eight other states have capitation rates greater than 20%: Colorado, Florida, Rhode Island, Oregon, Washington, Pennsylvania, Massachusetts, and Nevada. Thirty states, largely in the Great Plains area and the southern United States, have capitation rates less than 10%. Four major metropolitan areas have market penetration rates greater than 40%: San Bernardino, California; San Diego, California; Phoenix, Arizona; and Miami, Florida. Little penetration exists outside of metropolitan areas. Capitation in Medicare is a regional and predominantly an urban phenomenon.

The fairness of the PPS reimbursement methodology.

PubMed Central

Gianfrancesco, F D

1990-01-01

In FY 1984 the Medicare program implemented a new method of reimbursing hospitals for inpatient services, the Prospective Payment System (PPS). Under this system, hospitals are paid a predetermined amount per Medicare discharge, which varies according to certain patient and hospital characteristics. This article investigates the presence of systematic biases and other potential imperfections in the PPS reimbursement methodology as revealed by its effects on Medicare operating ratios. The study covers the first three years of the PPS (approximately 1984-1986) and is based on hospital data from the Medicare cost reports and other related sources. Regression techniques were applied to these data to determine how Medicare operating ratios were affected by specific aspects of the reimbursement methodology. Several possible imbalances were detected. The potential undercompensation relating to these can be harmful to certain classes of hospitals and to the Medicare populations that they serve. PMID:2109738

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

PubMed

1983-08-18

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

Paying for the Medicare program.

PubMed

Munnell, A H

1985-01-01

Although the hospital insurance (HI) trust fund acted as a source of strength for the old-age, survivors, and disability insurance program during its recent financial crises, projections by HCFA and CBO reveal that the Medicare program will experience financing problems of its own within the next decade. No one would argue that Medicare's financing problems should be solved simply by raising more money. However, the prospect of insolvency in the HI trust fund and the increasing strain on general revenues from the Supplementary Medical Insurance trust fund require policymakers to survey the options for increasing Medicare revenues while cost-control devices are being developed. Indeed, even if cost-control efforts are completely successful, additional revenues may be needed in the future to finance new initiatives in the Medicare program. Therefore, this paper will look briefly at current efforts to regain control of soaring hospital and physician costs and then examine some of the more feasible options for increasing Medicare revenues.

The financial status of Medicare.

PubMed

Foster, R S

1998-01-01

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

Modernizing Medicare's Benefit Design and Low-Income Subsidies to Ensure Access and Affordability.

PubMed

Schoen, Cathy; Davis, Karen; Buttorff, Christine; Andersen, Martin

2015-07-01

Insurance coverage through the traditional Medicare program is complex, fragmented, and incomplete. Beneficiaries must purchase supplemental private insurance to fill in the gaps. While impoverished beneficiaries may receive supplemental coverage through Medicaid and subsidies for prescription drugs, help is limited for people with incomes above the poverty level. This patchwork quilt leads to confusion for beneficiaries and high administrative costs, while also undermining coverage and care coordination. Most important, Medicare's benefits fail to limit out-of-pocket costs or ensure adequate financial protection, especially for beneficiaries with low incomes and serious health problems. This brief, part of a series about Medicare's past, present, and future, presents options for an integrated benefit for enrollees in traditional Medicare. The new benefit would not only reduce cost burdens but also could potentially strengthen the Medicare program and enhance its role in stimulating and supporting innovations throughout the health care delivery system.

Impact of changes in Medicare payments on the financial condition of nonprofit hospitals.

PubMed

Das, Dhiman

2013-01-01

This article examines the implications of revenue changes on the financial condition of nonprofit hos pitals. I examine these implications empirically by studying the effect of changes in Medicare payments in the Balanced Budget Act of 1997. Using data from the Healthcare Cost Report Information System maintained by the Centers for Medicare & Medicaid Services between 1996 and 2004, I show that even though revenue fell significantly, resulting in a decline in profitability, hospitals did not significantly change their capital structure and use of capital. An important implication of this is a higher cost of borrowing for these hospitals, which can affect future capital accumulation and viability. Nonprofit hospitals are a very important part of the healthcare delivery system in the United States. Medicare patients constitute the single largest segment of their revenue sources. Understanding the consequences of the changes in Medicare reimbursement on hospital finances is useful in framing future revisions of Medicare payments.

The Effect of Medicare Eligibility on Spousal Insurance Coverage.

PubMed

Dillender, Marcus; Mulligan, Karen

2016-05-01

A majority of married couples in the USA take advantage of the fact that employers often provide health insurance coverage to spouses. When older spouses become eligible for Medicare, however, many of them can no longer provide their younger spouses with coverage. In this paper, we study how spousal eligibility for Medicare affects the health insurance and health care access of younger spouses. We find that spousal eligibility for Medicare results in younger spouses no longer having employers pay for their insurance and being less likely to have employer-sponsored coverage. Instead, younger spouses switch to privately purchased coverage, which tends to be worse than what they had before their spouses became eligible for Medicare. We also find suggestive evidence that younger spouses are less likely to use health care services after their older spouses become eligible for Medicare. Copyright © 2015 John Wiley & Sons, Ltd.

Competitive bidding for Medicare Part B clinical laboratory services.

PubMed

Kautter, John; Pope, Gregory C

2014-06-01

The traditional Medicare fee-for-service program may be able to purchase clinical laboratory test services at a lower cost through competitive bidding. Demonstrations of competitive bidding for clinical laboratory tests have been twice mandated or authorized by Congress but never implemented. This article provides a summary and review of the final design of the laboratory competitive bidding demonstration mandated by the Medicare Modernization Act of 2003. The design was analogous to a sealed bid (first price), clearing price auction. Design elements presented include covered laboratory tests and beneficiaries, laboratory bidding and payment status under the demonstration, composite bids, determining bidding winners and the demonstration fee schedule, and quality under the demonstration. Expanded use of competitive bidding in Medicare, including specifically for clinical laboratory tests, has been recommended in some proposals for Medicare reform. The presented design may be a useful point of departure if Medicare clinical laboratory competitive bidding is revived in the future.

The bribery statute: a new weapon against Medicare fraud.

PubMed

Cozort, L A

2001-03-01

A May 2000 U.S. Supreme Court decision determining when a Federal bribery statute can be used to fight Medicare fraud has ramifications for healthcare providers. In Fischer v. United States, the Court concluded that healthcare providers that participate in Medicare are considered to receive benefits as set forth in the bribery statute and thus can be prosecuted for fraudulent activities against the government under the statute. The statute mandates a fine, imprisonment for up to 10 years, or both for anyone convicted under it. Provider organizations that receive Medicare payments and business associates of such organizations should be aware that the government may step up its use of the bribery law in prosecuting fraudulent activity. In addition, although the case pertained specifically to healthcare providers that participate in Medicare, providers that do not participate in Medicare may wish to evaluate the advisability of accepting other Federal funding because of the possible reach of the bribery statute.

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

PubMed Central

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

2016-01-01

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

Medicare Part D is associated with reducing the financial burden of health care services in Medicare beneficiaries with diagnosed diabetes.

PubMed

Li, Rui; Gregg, Edward W; Barker, Lawrence E; Zhang, Ping; Zhang, Fang; Zhuo, Xiaohui; Williams, Desmond E; Soumerai, Steven B

2013-10-01

Medicare Part D, implemented in 2006, provided coverage for prescription drugs to all Medicare beneficiaries. To examine the effect of Part D on the financial burden of persons with diagnosed diabetes. We conducted an interrupted time-series analysis using data from the 1996 to 2008 Medical Expenditure Panel Survey (11,178 persons with diabetes who were covered by Medicare, and 8953 persons aged 45-64 y with diabetes who were not eligible for Medicare coverage). We then compared changes in 4 outcomes: (1) annual individual out-of-pocket expenditure (OOPE) for prescription drugs; (2) annual individual total OOPE for all health care services; (3) annual total family OOPE for all health care services; and (4) percentage of persons with high family financial burden (OOPE ≥10% of income). For Medicare beneficiaries with diabetes, Part D was associated with a 28% ($530) decrease in individual annual OOPE for prescription drugs, a 23% ($560) reduction in individual OOPE for all health care, a 23% ($863) reduction in family OOPE for all health care, and a 24% reduction in the percentage of families with high financial burden in 2006. There were similar reductions in 2007 and 2008. By 2008, the percentage of Medicare beneficiaries with diabetes living in high financial burden families was 37% lower than it would have been had Part D not been in place. Introduction of Part D coverage was associated with a substantial reduction in the financial burden of Medicare beneficiaries with diabetes and their families.

Area-level variations in cancer care and outcomes.

PubMed

Keating, Nancy L; Landrum, Mary Beth; Lamont, Elizabeth B; Bozeman, Samuel R; McNeil, Barbara J

2012-05-01

: Substantial regional variations in health-care spending exist across the United States; yet, care and outcomes are not better in higher-spending areas. Most studies have focused on care in fee-for-service Medicare; whether spillover effects exist in settings without financial incentives for more care is unknown. : We studied care for cancer patients in fee-for-service Medicare and the Veterans Health Administration (VA) to understand whether processes and outcomes of care vary with area-level Medicare spending. : An observational study using logistic regression to assess care by area-level measures of Medicare spending. : Patients with lung, colorectal, or prostate cancers diagnosed during 2001-2004 in Surveillance, Epidemiology, and End Results (SEER) areas or the VA. The SEER cohort included fee-for-service Medicare patients aged older than 65 years. : Recommended and preference-sensitive cancer care and mortality. : In fee-for-service Medicare, higher-spending areas had higher rates of recommended care (curative surgery and adjuvant chemotherapy for early-stage non-small-cell lung cancer and chemotherapy for stage III colon cancer) and preference-sensitive care (chemotherapy for stage IV lung and colon cancer and primary treatment of local/regional prostate cancer) and had lower lung cancer mortality. In the VA, we observed minimal variation in care by area-level Medicare spending. : Our findings suggest that intensity of care for Medicare beneficiaries is not driving variations in VA care, despite some overlap in physician networks. Although the Dartmouth Atlas work has been of unprecedented importance in demonstrating variations in Medicare spending, new measures may be needed to better understand variations in other populations.

Comparison of Medicare Claims vs. Physician Adjudication for Identifying Stroke Outcomes in the Women’s Health Initiative

PubMed Central

Lakshminarayan, Kamakshi; Larson, Joseph C.; Virnig, Beth; Fuller, Candace; Allen, Norrina Bai; Limacher, Marian; Winkelmayer, Wolfgang C.; Safford, Monika M.; Burwen, Dale R.

2014-01-01

Background and Purpose Many studies use medical record review for ascertaining outcomes. One large, longitudinal study, the Women’s Health Initiative (WHI) ascertains strokes using participant self-report and subsequent physician review of medical records. This is resource-intensive. Herein, we assess whether Medicare data can reliably assess stroke events in the WHI. Methods Subjects were WHI participants with fee-for-service Medicare. Four stroke definitions were created for Medicare data using discharge diagnoses in hospitalization claims. Definition 1: stroke codes in any position; Definition 2: primary position stroke codes; Definitions 3 & 4: hemorrhagic and ischemic stroke codes respectively. WHI data were randomly split into training (50%) and test sets. A concordance matrix was used to examine agreement between WHI and Medicare stroke diagnosis. A WHI stroke and a Medicare stroke were considered a match if they occurred within +/− 7 days of each other. Refined analyses excluded Medicare events where medical records were unavailable for comparison. Results Training data (n=24,428): There were 577 WHI strokes and 557 Medicare strokes using definition 1. Of these, 478 were a match. Algorithm performance: Specificity 99.7%; Negative Predictive Value 99.7%; Sensitivity 82.8%; Positive Predictive Value 85.8%; kappa 0.84. Performance was similar for test data. While specificity and negative predictive value exceeded 99%, sensitivity ranged from 75 to 88% and positive predictive value ranged from 80 to 90% across stroke definitions. Conclusion Medicare data appear useful for population-based stroke research; however the performance characteristics depend on the definition selected. PMID:24525955

What Is Medicare?

MedlinePlus

... Savings Account Plans These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules ... card . Check all other insurance cards that you use. Call the phone number ...

75 FR 58405 - Medicare Program; Meeting of the Advisory Panel on Medicare Education, October 13, 2010

Federal Register 2010, 2011, 2012, 2013, 2014

2010-09-24

... beneficiaries * * * on the coverage options provided under [Medicare Advantage] in order to promote an active... Area Agencies on Aging; David W. Roberts, M.P.A.,Vice President, Government Relations, Healthcare...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-11-09

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

42 CFR 422.501 - Application requirements.

Code of Federal Regulations, 2010 CFR

2010-10-01

... (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Application Procedures and Contracts for Medicare Advantage Organizations § 422.501 Application requirements. (a) Scope. This section sets forth application... offer health insurance or health benefits coverage that meets State-specified standards applicable to MA...

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

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.

Out-of-pocket health spending by poor and near-poor elderly Medicare beneficiaries.

PubMed

Gross, D J; Alecxih, L; Gibson, M J; Corea, J; Caplan, C; Brangan, N

1999-04-01

To estimate out-of-pocket health care spending by lower-income Medicare beneficiaries, and to examine spending variations between those who receive Medicaid assistance and those who do not receive such aid. DATA SOURCES AND COLLECTION: 1993 Medicare Current Beneficiary Survey (MCBS) Cost and Use files, supplemented with data from the Bureau of the Census (Current Population Survey); the Congressional Budget Office; the Health Care Financing Administration, Office of the Actuary (National Health Accounts); and the Social Security Administration. We analyzed out-of-pocket spending through a Medicare Benefits Simulation model, which projects out-of-pocket health care spending from the 1993 MCBS to 1997. Out-of-pocket health care spending is defined to include Medicare deductibles and coinsurance; premiums for private insurance, Medicare Part B, and Medicare HMOs; payments for non-covered goods and services; and balance billing by physicians. It excludes the costs of home care and nursing facility services, as well as indirect tax payments toward health care financing. Almost 60 percent of beneficiaries with incomes below the poverty level did not receive Medicaid assistance in 1997. We estimate that these beneficiaries spent, on average, about half their income out-of-pocket for health care, whether they were enrolled in a Medicare HMO or in the traditional fee-for-service program. The 75 percent of beneficiaries with incomes between 100 and 125 percent of the poverty level who were not enrolled in Medicaid spent an estimated 30 percent of their income out-of-pocket on health care if they were in the traditional program and about 23 percent of their income if they were enrolled in a Medicare HMO. Average out-of-pocket spending among fee-for-service beneficiaries varied depending on whether beneficiaries had Medigap policies, employer-provided supplemental insurance, or no supplemental coverage. Those without supplemental coverage spent more on health care goods and services, but spent less than the other groups on prescription drugs and dental care-services not covered by Medicare. While Medicaid provides substantial protection for some lower-income Medicare beneficiaries, out-of-pocket health care spending continues to be a substantial burden for most of this population. Medicare reform discussions that focus on shifting more costs to beneficiaries should take into account the dramatic costs of health care already faced by this vulnerable population.

Access to Medicaid and Medicare by the low-income disabled

PubMed Central

Ellwood, Marilyn Rymer; Burwell, Brian

1990-01-01

The most pervasive eligibility-related problems encountered by low-income disabled persons in gaining access to Medicaid and Medicare are reviewed in this article. A series of options for restructuring program eligibility requirements are presented, with particular attention to improving the plight of the low-income disabled worker during the 24-month waiting period for Medicare. Options for Medicaid involve nationwide income eligibility levels at 100 percent of poverty and mandatory buy-in provisions to Medicaid in all States. For Medicare, the reforms range from altering the waiting period for Medicare by the disabled who are expected to die within 24 months after benefit award to eliminating the waiting period altogether. PMID:10170682

The incentive effects of the Medicare indirect medical education policy.

PubMed

Nicholson, S; Song, D

2001-11-01

Medicare provided teaching hospitals with US$ 5.9 billion in supplemental graduate medical education (GME) payments in 1998. These payments distort input and output prices and provide teaching hospitals with incentives to hire residents, close beds, and admit more Medicare patients. The structure of the GME payment policy creates substantial variation in input and output prices between teaching hospitals. We examine the extent to which hospitals responded to these financial incentives using a panel data set of 3,900 hospitals, including over 900 teaching hospitals. We find that teaching hospitals did hire residents and close beds in response to the Medicare policy, but did not increase Medicare admissions or alter their use of registered nurses (RNs).

Premium Rebates and the Quiet Consensus on Market Reform for Medicare

PubMed Central

Feldman, Roger; Dowd, Bryan E.; Coulam, Robert; Nichols, Len; Mutti, Anne

2001-01-01

Premium rebates allow beneficiaries who choose more efficient Medicare options to receive cash rebates, rather than extra benefits. That simple idea has been controversial. Without fanfare, however, premium rebates have become a key area of agreement in the debate on Medicare reform. Moreover, in legislation in late 2000, it became official policy: Medicare+Choice (M+C) plans will be allowed to offer rebates beginning in 2003. This article explores the economic rationale for premium rebates, provides a historical perspective on the rebate debate, discusses some of the implementation issues that need to be addressed before 2003, and reviews the implications of premium rebates for current legislative proposals for Medicare reform. PMID:12500336

Payment Reduction and Medicare Private Fee-for-Service Plans

PubMed Central

Frakt, Austin B.; Pizer, Steven D.; Feldman, Roger

2009-01-01

Medicare private fee-for-service (PFFS) plans are paid like other Medicare Advantage (MA) plans but are exempt from many MA requirements. Recently, Congress set average payments well above the costs of traditional fee-for-service (FFS) Medicare, inducing dramatic increases in PFFS plan enrollment. This has significant implications for Medicare's budget, provoking calls for policy change. We predict the effect of proposals to cut PFFS payments on PFFS plan participation and enrollment. We find that small reductions in payment rates would reduce PFFS participation and enrollment; if Congress reduces payments to traditional FFS levels it would cause the vast majority (85 percent) of PFFS plans to exit the market. PMID:19544932

Multiple payers, commonality and free-riding in health care: Medicare and private payers.

PubMed

Glazer, Jacob; McGuire, Thomas G

2002-11-01

Managed health care plans and providers in the US and elsewhere sell their services to multiple payers. For example, the three largest groups of purchasers from health plans in the US are employers, Medicaid plans, and Medicare, with the first two accounting for over 90% of the total enrollees. In the case of hospitals, Medicare is the largest buyer, but it alone only accounts for 40% of the total payments. While payers have different objectives and use different contracting practices, the plans and providers set some elements of the quality in common for all payers. In this paper, we study the interactions between a public payer, modeled on Medicare, which sets a price and takes any willing provider, a private payer, which limits providers and pays a price on the basis of quality, and a provider/plan, in the presence of shared elements of quality. The provider compromises in response to divergent incentives from payers. The private sector dilutes Medicare payment initiatives, and may, under some circumstances, repair Medicare payment policy mistakes. If Medicare behaves strategically in the presence of private payers, it can free-ride on the private payer and set its prices too low. Our paper has many testable implications, including a new hypothesis for why Medicare has failed to gain acceptance of health plans in the US.

Medication adherence and Medicare expenditure among beneficiaries with heart failure.

PubMed

Lopert, Ruth; Shoemaker, J Samantha; Davidoff, Amy; Shaffer, Thomas; Abdulhalim, Abdulla M; Lloyd, Jennifer; Stuart, Bruce

2012-09-01

To (1) measure utilization of and adherence to heart failure medications and (2) assess whether better adherence is associated with lower Medicare spending. Pooled cross-sectional design using six 3-year cohorts of Medicare beneficiaries with congestive heart failure (CHF) from 1997 through 2005 (N = 2204). Adherence to treatment was measured using average daily pill counts. Bivariate and multivariate methods were used to examine the relationship between medication adherence and Medicare spending. Multivariate analyses included extensive variables to control for confounding, including healthy adherer bias. Approximately 58% of the cohort were taking an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), 72% a diuretic, 37% a beta-blocker, and 34% a cardiac glycoside. Unadjusted results showed that a 10% increase in average daily pill count for ACE inhibitors or ARBs, beta-blockers, diuretics, or cardiac glycosides was associated with reductions in Medicare spending of $508 (not significant [NS]), $608 (NS), $250 (NS), and $1244 (P <.05), respectively. Estimated adjusted marginal effects of a 10% increase in daily pill counts for beta-blockers and cardiac glycosides were reductions in cumulative 3-year Medicare spending of $510 to $561 and $750 to $923, respectively (P <.05). Higher levels of medication adherence among Medicare beneficiaries with CHF were associated with lower cumulative Medicare spending over 3 years, with savings generally exceeding the costs of the drugs in question.

Medigap premiums and Medicare HMO enrollment.

PubMed

McLaughlin, Catherine G; Chernew, Michael; Taylor, Erin Fries

2002-12-01

Markets for Medicare HMOs (health maintenance organizations) and supplemental Medicare coverage are often treated separately in existing literature. Yet because managed care plans and Medigap plans both cover services not covered by basic Medicare, these markets are clearly interrelated. We examine the extent to which Medigap premiums affect the likelihood of the elderly joining managed care plans. The analysis is based on a sample of Medicare beneficiaries drawn from the 1996-1997 Community Tracking Study (CTS) Household Survey by the Center for Studying Health System Change. Respondents span 56 different CTS sites from 30 different states. Measures of premiums for privately-purchased Medigap policies were collected from a survey of large insurers serving this market. Data for individual, market, and HMO characteristics were collected from the CTS, InterStudy, and HCFA (Health Care Financing Administration). Our analysis uses a reduced-form logit model to estimate the probability of Medicare HMO participation as a function of Medigap premiums controlling for other market- and individual-level characteristics. The logit coefficients were then used to simulate changes in Medicare participation in response to changes in Medigap premiums. We found that Medigap premiums vary considerably among the geographic markets included in our sample. Measures of premiums from different insurers and for different types of Medigap policies were generally highly correlated across markets. Our models consistently indicate a strong positive relationship between Medigap premiums and HMO participation. This result is robust across several specifications. Simulations suggest that a one standard deviation increase in Medigap premiums would increase HMO participation by more than 8 percentage points. This research provides strong evidence that Medigap premiums have a significant effect on seniors' participation in Medicare HMOs. Policy initiatives aimed at lowering Medigap premiums will likely discourage enrollment in Medicare HMOs, holding other factors constant. Although the Medigap premiums are just one factor affecting the future penetration rate of Medicare HMOs, they are an important driver of HMO enrollment and should be considered carefully when creating policy related to seniors' supplemental coverage. Similarly, our results imply that reforms to the Medicare HMO market would influence the demand for Medigap policies.

The Costs of Decedents in the Medicare Program: Implications for Payments to Medicare+Choice Plans

PubMed Central

Buntin, Melinda Beeuwkes; Garber, Alan M; McClellan, Mark; Newhouse, Joseph P

2004-01-01

Objective To discuss and quantify the incentives that Medicare managed care plans have to avoid (through selective enrollment or disenrollment) people who are at risk for very high costs, focusing on Medicare beneficiaries in the last year of life—a group that accounts for more than one-quarter of Medicare's annual expenditures. Data Source Medicare administrative claims for 1994 and 1995. Study Design We calculated the payment a plan would have received under three risk-adjustment systems for each beneficiary in our 1995 sample based on his or her age, gender, county of residence, original reason for Medicare entitlement, and principal inpatient diagnoses received during any hospital stays in 1994. We compared these amounts to the actual costs incurred by those beneficiaries. We then looked for clinical categories that were predictive of costs, including costs in a beneficiary's last year of life, not accounted for by the risk adjusters. Data Extraction Methods The analyses were conducted using claims for a 5 percent random sample of Medicare beneficiaries who died in 1995 and a matched group of survivors. Principal Findings Medicare is currently implementing the Principal Inpatient Diagnostic Cost Groups (PIP-DCG) risk adjustment payment system to address the problem of risk selection in the Medicare+Choice program. We quantify the strong financial disincentives to enroll terminally ill beneficiaries that plans still have under this risk adjustment system. We also show that up to one-third of the selection observed between Medicare HMOs and the traditional fee-for-service system could be due to differential enrollment of decedents. A risk adjustment system that incorporated more of the available diagnostic information would attenuate this disincentive; however, plans could still use clinical information (not included in the risk adjustment scheme) to identify beneficiaries whose expected costs exceed expected payments. Conclusions More disaggregated prospective risk adjustment methods and alternative payment systems that compensate plans for delivering care to certain classes of patients should be considered to ensure access to high-quality managed care for all beneficiaries. PMID:14965080

Brand-name prescription drug use among Veterans Affairs and Medicare Part D patients with diabetes: a national cohort comparison.

PubMed

Gellad, Walid F; Donohue, Julie M; Zhao, Xinhua; Mor, Maria K; Thorpe, Carolyn T; Smith, Jeremy; Good, Chester B; Fine, Michael J; Morden, Nancy E

2013-07-16

Medicare Part D and the U.S. Department of Veterans Affairs (VA) use different approaches to manage prescription drug benefits, with implications for spending. Medicare relies on private plans with distinct formularies, whereas the VA administers its own benefit using a national formulary. To compare overall and regional rates of brand-name drug use among older adults with diabetes in Medicare and the VA. Retrospective cohort. Medicare and the VA, 2008. 1,061,095 Medicare Part D beneficiaries and 510,485 veterans aged 65 years or older with diabetes. Percentage of patients taking oral hypoglycemics, statins, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) who filled brand-name drug prescriptions and percentage of patients taking long-acting insulins who filled analogue prescriptions. Sociodemographic- and health status-adjusted hospital referral region (HRR) brand-name drug use was compared, and changes in spending were calculated if use of brand-name drugs in 1 system mirrored the other. Brand-name drug use in Medicare was 2 to 3 times that in the VA: 35.3% versus 12.7% for oral hypoglycemics, 50.7% versus 18.2% for statins, 42.5% versus 20.8% for ACE inhibitors or ARBs, and 75.1% versus 27.0% for insulin analogues. Adjusted HRR-level brand-name statin use ranged (from the 5th to 95th percentiles) from 41.0% to 58.3% in Medicare and 6.2% to 38.2% in the VA. For each drug group, the 95th-percentile HRR in the VA had lower brand-name drug use than the 5th-percentile HRR in Medicare. Medicare spending in this population would have been $1.4 billion less if brand-name drug use matched that of the VA. This analysis cannot fully describe the factors underlying differences in brand-name drug use. Medicare beneficiaries with diabetes use 2 to 3 times more brand-name drugs than a comparable group within the VA, at substantial excess cost.

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

PubMed Central

Lovett, Annesha

2013-01-01

Background There is much debate currently about how to restructure the Medicare program to achieve better value for the money. Many have cited the Federal Employees Health Benefits Program (FEHBP) as a model for reform. Objective To compare drug coverage and cost-sharing between Medicare Part D and the FEHBP plans. Methods A cross-sectional comparison was conducted of January 2009 data obtained from the Centers for Medicare & Medicaid Services, the Office of Personnel Management, and 3 health plan websites. Regression analysis and t-tests were used to examine drug coverage, copayment, and coinsurance amounts among Medicare Part D and FEHBP plans. The final study sample of Medicare Part D plans consisted of 19 formularies, covering 63% of total Part D enrollment. These 19 formularies represented 232 stand-alone prescription drug plans. In addition, 5 prescription drug plans or formularies in the FEHBP plans were included, which represents 70% of total FEHBP enrollment. Results The results of this study reveal that formulary coverage of the top drugs dispensed and sold in the United States in 2009 ranged from 72% to 94% (average, 84%) in Medicare Part D plans and from 85% to 99% (average, 94%) in the FEHBP plans (P <.01). The mean copayment for generic drugs in Medicare Part D plans was $4.53 compared with a mean of $7.67 (P <.05) in the FEHBP plans. The difference between the 2 programs in mean copayment for brand-name drugs was nonsignificant. For generic drugs, the mean coinsurance rate was 17% for Medicare Part D plans and a mean of 20% for the FEHBP plans (P <.05). Conclusions This analysis shows that there are differences in prescription drug coverage and cost-sharing among plans within Medicare Part D and the FEHBP. To avoid extreme increases in payroll taxes and other revenues or major cutbacks in services, Medicare must explore ways to change the healthcare system to achieve better value for the money. The experience of the FEHBP suggests a possible means of accomplishing this objective. PMID:24991346

Medigap Premiums and Medicare HMO Enrollment

PubMed Central

McLaughlin, Catherine G; Chernew, Michael; Taylor, Erin Fries

2002-01-01

Objective Markets for Medicare HMOs (health maintenance organizations) and supplemental Medicare coverage are often treated separately in existing literature. Yet because managed care plans and Medigap plans both cover services not covered by basic Medicare, these markets are clearly interrelated. We examine the extent to which Medigap premiums affect the likelihood of the elderly joining managed care plans. Data Sources The analysis is based on a sample of Medicare beneficiaries drawn from the 1996–1997 Community Tracking Study (CTS) Household Survey by the Center for Studying Health System Change. Respondents span 56 different CTS sites from 30 different states. Measures of premiums for privately-purchased Medigap policies were collected from a survey of large insurers serving this market. Data for individual, market, and HMO characteristics were collected from the CTS, InterStudy, and HCFA (Health Care Financing Administration). Study Design Our analysis uses a reduced-form logit model to estimate the probability of Medicare HMO participation as a function of Medigap premiums controlling for other market- and individual-level characteristics. The logit coefficients were then used to simulate changes in Medicare participation in response to changes in Medigap premiums. Principal Findings We found that Medigap premiums vary considerably among the geographic markets included in our sample. Measures of premiums from different insurers and for different types of Medigap policies were generally highly correlated across markets. Our models consistently indicate a strong positive relationship between Medigap premiums and HMO participation. This result is robust across several specifications. Simulations suggest that a one standard deviation increase in Medigap premiums would increase HMO participation by more than 8 percentage points. Conclusions This research provides strong evidence that Medigap premiums have a significant effect on seniors' participation in Medicare HMOs. Policy initiatives aimed at lowering Medigap premiums will likely discourage enrollment in Medicare HMOs, holding other factors constant. Although the Medigap premiums are just one factor affecting the future penetration rate of Medicare HMOs, they are an important driver of HMO enrollment and should be considered carefully when creating policy related to seniors' supplemental coverage. Similarly, our results imply that reforms to the Medicare HMO market would influence the demand for Medigap policies. PMID:12546281

Brand-Name Prescription Drug Use Among Veterans Affairs and Medicare Part D Patients With Diabetes

PubMed Central

Gellad, Walid F.; Donohue, Julie M.; Zhao, Xinhua; Mor, Maria K.; Thorpe, Carolyn T.; Smith, Jeremy; Good, Chester B.; Fine, Michael J.; Morden, Nancy E.

2013-01-01

Background: Medicare Part D and the U.S. Department of Veterans Affairs (VA) use different approaches to manage prescription drug benefits, with implications for spending. Medicare relies on private plans with distinct formularies, whereas the VA administers its own benefit using a national formulary. Objective: To compare overall and regional rates of brand-name drug use among older adults with diabetes in Medicare and the VA. Design: Retrospective cohort. Setting: Medicare and the VA, 2008. Patients: 1 061 095 Medicare Part D beneficiaries and 510 485 veterans aged 65 years or older with diabetes. Measurements: Percentage of patients taking oral hypoglycemics, statins, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) who filled brand-name drug prescriptions and percentage of patients taking long-acting insulins who filled analogue prescriptions. Sociodemographic- and health status–adjusted hospital referral region (HRR) brand-name drug use was compared, and changes in spending were calculated if use of brand-name drugs in 1 system mirrored the other. Results: Brand-name drug use in Medicare was 2 to 3 times that in the VA: 35.3% versus 12.7% for oral hypoglycemics, 50.7% versus 18.2% for statins, 42.5% versus 20.8% for ACE inhibitors or ARBs, and 75.1% versus 27.0% for insulin analogues. Adjusted HRR-level brand-name statin use ranged (from the 5th to 95th percentiles) from 41.0% to 58.3% in Medicare and 6.2% to 38.2% in the VA. For each drug group, the 95th-percentile HRR in the VA had lower brand-name drug use than the 5th-percentile HRR in Medicare. Medicare spending in this population would have been $1.4 billion less if brand-name drug use matched that of the VA. Limitation: This analysis cannot fully describe the factors underlying differences in brand-name drug use. Conclusion: Medicare beneficiaries with diabetes use 2 to 3 times more brand-name drugs than a comparable group within the VA, at substantial excess cost. Primary Funding Source: U.S. Department of Veterans Affairs, National Institutes of Health, and Robert Wood Johnson Foundation. PMID:19264942

78 FR 2407 - Medicare Payment Advisory Commission Nomination Letters

Federal Register 2010, 2011, 2012, 2013, 2014

2013-01-11

... GOVERNMENT ACCOUNTABILITY OFFICE Medicare Payment Advisory Commission Nomination Letters AGENCY: Government Accountability Office (GAO). ACTION: Notice on letters of nomination. SUMMARY: The Balanced Budget Act of 1997 established the Medicare Payment Advisory Commission (MedPAC) and gave the Comptroller...

76 FR 81503 - Medicare Payment Advisory Commission Nomination Letters

Federal Register 2010, 2011, 2012, 2013, 2014

2011-12-28

... GOVERNMENT ACCOUNTABILITY OFFICE Medicare Payment Advisory Commission Nomination Letters AGENCY: Government Accountability Office (GAO). ACTION: Notice on letters of nomination. SUMMARY: The Balanced Budget Act of 1997 established the Medicare Payment Advisory Commission (MedPAC) and gave the Comptroller...

42 CFR 423.466 - Timeframes for coordination of benefits.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Section 423.466 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Coordination of Part D...) Retroactive claims adjustments, underpayment refunds, and overpayment recoveries. Whenever a sponsor receives...

42 CFR 423.150 - Scope.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Scope. 423.150 Section 423.150 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 Improvement Requirements...

42 CFR 423.168 - Accreditation organizations.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Accreditation organizations. 423.168 Section 423.168 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...

75 FR 43178 - Medicare Program; Solicitation for Proposals for the Medicare Imaging Demonstration

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-23

..., medical specialty societies, physician groups, integrated health care delivery systems, independent practice associations, radiology benefit managers, health plans, information technology vendors, and... societies. The Centers for Medicare & Medicaid Services (CMS) worked with medical specialty societies and...

42 CFR 422.2260 - Definitions concerning marketing materials.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Definitions concerning marketing materials. 422... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Medicare Advantage Marketing Requirements § 422.2260 Definitions concerning marketing materials. As used in this subpart— Marketing...

Health plan decision making with new medicare information materials.

PubMed Central

McCormack, L A; Garfinkel, S A; Hibbard, J H; Norton, E C; Bayen, U J

2001-01-01

OBJECTIVE: To examine the effect of providing new Medicare information materials on consumers' attitudes and behavior about health plan choice. DATA SOURCE: New and experienced Medicare beneficiaries who resided in the Kansas City metropolitan statistical area during winter 1998-99 were surveyed. More than 2,000 computer-assisted telephone interviews were completed across the two beneficiary populations with a mean response rate of 60 percent. STUDY DESIGN: Medicare beneficiaries were randomly assigned to a control group or one of three treatment groups that received varying amounts and types of new Medicare information materials. One treatment group received the Health Care Financing Administrations's pilot Medicare & You 1999 handbook, a second group received the same version of the handbook and a Medicare version of the Consumer Assessment of Health Plans (CAHPS) report, and a third treatment group received the Medicare & You bulletin, an abbreviated version of the handbook. PRINCIPAL FINDINGS: Results of the study suggest that the federal government's new consumer information materials are having some influence on Medicare beneficiaries' attitudes and behaviors about health plan decision making. Experienced beneficiary treatment group members were significantly more confident with their current health plan choice than control group members, but new beneficiaries were significantly less likely to use the new materials to choose or change health plans than control group members. In general the effects on confidence and health plan switching did not vary across the different treatment materials. CONCLUSIONS: The 1999 version of the Medicare & You materials contained a message that it is not necessary to change health plans. This message appears to have decreased the likelihood of using the new materials to choose or change plans, whereas other materials to which beneficiaries are exposed may encourage plan switching. Because providing more information to beneficiaries did not result in commensurate increases in confidence levels or rate of health plan switching, factors other than the amount of information, such as how the information is presented, may be more critical than volume. PMID:11482588

Health plan decision making with new medicare information materials.

PubMed

McCormack, L A; Garfinkel, S A; Hibbard, J H; Norton, E C; Bayen, U J

2001-07-01

To examine the effect of providing new Medicare information materials on consumers' attitudes and behavior about health plan choice. New and experienced Medicare beneficiaries who resided in the Kansas City metropolitan statistical area during winter 1998-99 were surveyed. More than 2,000 computer-assisted telephone interviews were completed across the two beneficiary populations with a mean response rate of 60 percent. Medicare beneficiaries were randomly assigned to a control group or one of three treatment groups that received varying amounts and types of new Medicare information materials. One treatment group received the Health Care Financing Administrations's pilot Medicare & You 1999 handbook, a second group received the same version of the handbook and a Medicare version of the Consumer Assessment of Health Plans (CAHPS) report, and a third treatment group received the Medicare & You bulletin, an abbreviated version of the handbook. Results of the study suggest that the federal government's new consumer information materials are having some influence on Medicare beneficiaries' attitudes and behaviors about health plan decision making. Experienced beneficiary treatment group members were significantly more confident with their current health plan choice than control group members, but new beneficiaries were significantly less likely to use the new materials to choose or change health plans than control group members. In general the effects on confidence and health plan switching did not vary across the different treatment materials. The 1999 version of the Medicare & You materials contained a message that it is not necessary to change health plans. This message appears to have decreased the likelihood of using the new materials to choose or change plans, whereas other materials to which beneficiaries are exposed may encourage plan switching. Because providing more information to beneficiaries did not result in commensurate increases in confidence levels or rate of health plan switching, factors other than the amount of information, such as how the information is presented, may be more critical than volume.

Self-report of diabetes and claims-based identification of diabetes among Medicare beneficiaries.

PubMed

Day, Hannah R; Parker, Jennifer D

2013-11-01

This report compares self-reported diabetes in the National Health Interview Survey (NHIS) with diabetes identified using the Medicare Chronic Condition (CC) Summary file. NHIS records have been linked with Medicare data from the Centers for Medicare & Medicaid Services. The CC Summary file, one of several linked files derived from Medicare claims data, contains indicators for chronic conditions based on an established algorithm. This analysis was limited to 2005 NHIS participants aged 65 and over whose records were linked to 2005 Medicare data. Linked NHIS participants had at least 1 month of fee-for-service Medicare coverage in 2005. Concordance between self-reported diabetes and the CC Summary indicator for diabetes is compared and described by demographics, socioeconomic status, health status indicators, and geographic characteristics. Of the Medicare beneficiaries in the 2005 NHIS, 20.0% self-reported diabetes and 27.8% had an indicator for diabetes in the CC Summary file. Of those who self-reported diabetes in NHIS, the percentage with a CC Summary indicator for diabetes was high (93.1%). Of those with a CC Summary indicator for diabetes, the percentage self-reporting diabetes was comparatively lower (67.0%). Statistically significant differences by subgroup existed in the percentage concordance between the two sources. Of those with self-reported diabetes, the percentage with a CC Summary indicator differed by sex and age. Of those with a CC Summary indicator for diabetes, the percentage with self-reported diabetes differed by age, self-rated health, number of self-reported conditions, and geographic location. Among Medicare beneficiaries who self-reported diabetes in NHIS, a high concordance was observed with identification of diabetes in the CC Summary file. However, among Medicare beneficiaries with an indicator for diabetes in the CC Summary file, concordance with self-reported diabetes in NHIS is comparatively lower. Differences exist by subgroup.

Market variations in intensity of Medicare service use and beneficiary experiences with care.

PubMed

Mittler, Jessica N; Landon, Bruce E; Fisher, Elliot S; Cleary, Paul D; Zaslavsky, Alan M

2010-06-01

Examine associations between patient experiences with care and service use across markets. Medicare fee-for-service (FFS) and managed care (Medicare Advantage [MA]) beneficiaries in 306 markets from the 2003 Consumer Assessments of Healthcare Providers and Systems (CAHPS) surveys. Resource use intensity is measured by the 2003 end-of-life expenditure index. We estimated correlations and linear regressions of eight measures of case-mix-adjusted beneficiary experiences with intensity of service use across markets. We merged CAHPS data with service use data, excluding beneficiaries under 65 years of age or receiving Medicaid. Overall, higher intensity use was associated (p<.05) with worse (seven measures) or no better care experiences (two measures). In higher-intensity markets, Medicare FFS and MA beneficiaries reported more problems getting care quickly and less helpful office staff. However, Medicare FFS beneficiaries in higher-intensity markets reported higher overall ratings of their personal physician and main specialist. Medicare MA beneficiaries in higher-intensity markets also reported worse quality of communication with physicians, ability to get needed care, and overall ratings of care. Medicare beneficiaries in markets characterized by high service use did not report better experiences with care. This trend was strongest for those in managed care.

Financial Performance of Rural Medicare ACOs.

PubMed

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

2018-12-01

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

42 CFR 416.60 - General rules.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false General rules. 416.60 Section 416.60 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE... Medicare beneficiaries, by a participating facility, in connection with covered surgical procedures...

42 CFR 416.60 - General rules.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false General rules. 416.60 Section 416.60 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE... Medicare beneficiaries, by a participating facility, in connection with covered surgical procedures...

42 CFR 423.1006 - Appeal rights.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Appeal rights. 423.1006 Section 423.1006 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Appeal Procedures for Civil Money...

42 CFR 422.1062 - Dismissal for cause.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Dismissal for cause. 422.1062 Section 422.1062 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil Money...

42 CFR 423.1006 - Appeal rights.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Appeal rights. 423.1006 Section 423.1006 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Appeal Procedures for Civil Money...

42 CFR 422.1062 - Dismissal for cause.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Dismissal for cause. 422.1062 Section 422.1062 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil Money...

42 CFR 423.1006 - Appeal rights.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Appeal rights. 423.1006 Section 423.1006 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Appeal Procedures for Civil Money Penalties...

42 CFR 423.1006 - Appeal rights.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Appeal rights. 423.1006 Section 423.1006 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Appeal Procedures for Civil Money Penalties...

42 CFR 422.1062 - Dismissal for cause.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Dismissal for cause. 422.1062 Section 422.1062 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil Money...

42 CFR 423.1006 - Appeal rights.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Appeal rights. 423.1006 Section 423.1006 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Appeal Procedures for Civil Money...

42 CFR 417.576 - Final settlement.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED... capita costs incurred in furnishing covered services to its Medicare enrollees, determined in accordance... January 1, 1996, the costs of hospital and SNF services paid by Medicare's intermediaries under the option...

42 CFR 422.102 - Supplemental benefits.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Supplemental benefits. 422.102 Section 422.102 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Benefits and Beneficiary Protections § 422.102...

42 CFR 423.156 - Consumer satisfaction surveys.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Consumer satisfaction surveys. 423.156 Section 423.156 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 423.162 - Quality improvement organization activities.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Quality improvement organization activities. 423.162 Section 423.162 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Cost Control...

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

Code of Federal Regulations, 2010 CFR

2010-10-01

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

42 CFR 482.70 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... geographic area specified by CMS. Heart-Lung transplant center means a transplant center that is located in a hospital with an existing Medicare-approved heart transplant center and an existing Medicare-approved lung center that performs combined heart-lung transplants. Intestine transplant center means a Medicare...

42 CFR 423.508 - Modification or termination of contract by mutual consent.

Code of Federal Regulations, 2011 CFR

2011-10-01

...) Prohibition against Part D program participation by organizations whose owners, directors, or management employees served in a similar capacity with another organization that mutually terminated its Medicare... HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT...

42 CFR 423.508 - Modification or termination of contract by mutual consent.

Code of Federal Regulations, 2013 CFR

2013-10-01

...) Prohibition against Part D program participation by organizations whose owners, directors, or management employees served in a similar capacity with another organization that mutually terminated its Medicare... HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG...

42 CFR 423.508 - Modification or termination of contract by mutual consent.

Code of Federal Regulations, 2014 CFR

2014-10-01

...) Prohibition against Part D program participation by organizations whose owners, directors, or management employees served in a similar capacity with another organization that mutually terminated its Medicare... HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG...

42 CFR 423.508 - Modification or termination of contract by mutual consent.

Code of Federal Regulations, 2012 CFR

2012-10-01

...) Prohibition against Part D program participation by organizations whose owners, directors, or management employees served in a similar capacity with another organization that mutually terminated its Medicare... HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG...

42 CFR 422.1002 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Definitions. 422.1002 Section 422.1002 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil Money Penalties § 422.1002...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-28

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

Medicare Preventive and Screening Services

MedlinePlus

... gov Medicare forms Advance directives & long-term care Electronic prescribing Electronic Health Records (EHRs) Download claims with Medicare’s Blue ... attr("role", "status").addClass("sr-only HiddenText").appendTo(document.body); } } function notify(strFeedback) { setTimeout(function() { var $channel = $(" "). ...

78 FR 6272 - Rules Relating to Additional Medicare Tax; Correction

Federal Register 2010, 2011, 2012, 2013, 2014

2013-01-30

... Rules Relating to Additional Medicare Tax; Correction AGENCY: Internal Revenue Service (IRS), Treasury... regulations are relating to Additional Hospital Insurance Tax on income above threshold amounts (``Additional Medicare Tax''), as added by the Affordable Care Act. Specifically, these proposed regulations provide...

42 CFR 417.400 - Basis and scope.

Code of Federal Regulations, 2010 CFR

2010-10-01

...) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Qualifying Conditions for Medicare Contracts § 417.400 Basis and scope. (a) Statutory basis. The... CMPs that contract with CMS to furnish covered services to Medicare beneficiaries. (b) Scope. (1) This...

42 CFR 422.500 - Scope and definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Application Procedures and Contracts for Medicare Advantage Organizations § 422.500 Scope and definitions. (a) Scope. This subpart sets forth application... requirements of part 423 of this chapter specifically related to the prescription drug benefit. (b) Definitions...

42 CFR 422.2276 - Employer group retiree marketing.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Employer group retiree marketing. 422.2276 Section... SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Medicare Advantage Marketing Requirements § 422.2276 Employer group retiree marketing. MA organizations may develop marketing materials designed...

42 CFR 422.2276 - Employer group retiree marketing.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Employer group retiree marketing. 422.2276 Section... SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Medicare Advantage Marketing Requirements § 422.2276 Employer group retiree marketing. MA organizations may develop marketing materials...

42 CFR 422.2276 - Employer group retiree marketing.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Employer group retiree marketing. 422.2276 Section... SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Medicare Advantage Marketing Requirements § 422.2276 Employer group retiree marketing. MA organizations may develop marketing materials...

42 CFR 422.2276 - Employer group retiree marketing.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Employer group retiree marketing. 422.2276 Section... SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Medicare Advantage Marketing Requirements § 422.2276 Employer group retiree marketing. MA organizations may develop marketing materials...

42 CFR 482.70 - Definitions.

Code of Federal Regulations, 2013 CFR

2013-10-01

... geographic area specified by CMS. Heart-Lung transplant center means a transplant center that is located in a hospital with an existing Medicare-approved heart transplant center and an existing Medicare-approved lung center that performs combined heart-lung transplants. Intestine transplant center means a Medicare...

42 CFR 482.70 - Definitions.

Code of Federal Regulations, 2014 CFR

2014-10-01

... geographic area specified by CMS. Heart-Lung transplant center means a transplant center that is located in a hospital with an existing Medicare-approved heart transplant center and an existing Medicare-approved lung center that performs combined heart-lung transplants. Intestine transplant center means a Medicare...

42 CFR 482.70 - Definitions.

Code of Federal Regulations, 2012 CFR

2012-10-01

... geographic area specified by CMS. Heart-Lung transplant center means a transplant center that is located in a hospital with an existing Medicare-approved heart transplant center and an existing Medicare-approved lung center that performs combined heart-lung transplants. Intestine transplant center means a Medicare...

42 CFR 421.401 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... perform a particular Medicare administrative function in relation to: (1) A particular individual entitled... 42 Public Health 3 2010-10-01 2010-10-01 false Definitions. 421.401 Section 421.401 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE...

Fixing unfair advantages? Providers hope to see more transparency, networks with Medicare private fee-for-service plans in wake of veto override.

PubMed

Lubell, Jennifer

2008-07-21

The new Medicare law delivers a raft of changes. But physicians are cheering the loudest for the rollback of the 10.6% reimbursement cut and the revamping of Medicare Advantage. "It doesn't make any sense that these private plans are paid 17% more than traditional Medicare and don't have to share a dime with the hospitals or physicians," says Albert Fisk, left, a Washington state physician.

The Attempted Dismantling of the Medicare Home Care Benefit. A Report by the Chairman of the Subcommittee on Health and Long-Term Care of the Select Committee on Aging. House of Representatives, Ninety-Ninth Congress, Second Session.

ERIC Educational Resources Information Center

Pepper, Claude

This document presents Congressman Claude Pepper's report on the Medicare Home Care Benefit. Section I traces the history of home health care in the United States. Section II offers statistics and general background information about older Americans and Medicare. The beginning of the Medicare home care benefit and its present operation are…

Medicare up, up and ... a way for the industry to get more money may be difficult, experts says, since CMS finds Medicare spending rose 19% in '06.

PubMed

DoBias, Matthew

2008-01-14

Medicare spending skyrocketed nearly 19% in 2006, fueled by the Part D drug benefit and expanded Medicare Advantage enrollment. That's likely to put pressure on lawmakers to rein in spending, but one expert said it could have been worse. "We are fortunate that the actual cost of Part D has continued to come in under what our earlier projections were," says CMS Chief Actuary Richard Foster, left.

Genetic Predisposition to Obesity and Medicare Expenditures.

PubMed

Wehby, George L; Domingue, Benjamin W; Ullrich, Fred; Wolinsky, Fredric D

2017-12-12

The relationship between obesity and health expenditures is not well understood. We examined the relationship between genetic predisposition to obesity measured by a polygenic risk score for body mass index (BMI) and Medicare expenditures. Biennial interview data from the Health and Retirement Survey for a nationally representative sample of older adults enrolled in fee-for-service Medicare were obtained from 1991 through 2010 and linked to Medicare claims for the same period and to Genome-Wide Association Study (GWAS) data. The study included 6,628 Medicare beneficiaries who provided 68,627 complete person-year observations during the study period. Outcomes were total and service-specific Medicare expenditures and indicators for expenditures exceeding the 75th and 90th percentiles. The BMI polygenic risk score was derived from GWAS data. Regression models were used to examine how the BMI polygenic risk score was related to health expenditures adjusting for demographic factors and GWAS-derived ancestry. Greater genetic predisposition to obesity was associated with higher Medicare expenditures. Specifically, a 1 SD increase in the BMI polygenic risk score was associated with a $805 (p < .001) increase in annual Medicare expenditures per person in 2010 dollars (~15% increase), a $370 (p < .001) increase in inpatient expenses, and a $246 (p < .001) increase in outpatient services. A 1 SD increase in the polygenic risk score was also related to increased likelihood of expenditures exceeding the 75th percentile by 18% (95% CI: 10%-28%) and the 90th percentile by 27% (95% CI: 15%-40%). Greater genetic predisposition to obesity is associated with higher Medicare expenditures. © The Author(s) 2017. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Concentration of Potentially Preventable Spending Among High-Cost Medicare Subpopulations: An Observational Study.

PubMed

Figueroa, Jose F; Joynt Maddox, Karen E; Beaulieu, Nancy; Wild, Robert C; Jha, Ashish K

2017-11-21

Little is known about whether potentially preventable spending is concentrated among a subset of high-cost Medicare beneficiaries. To determine the proportion of total spending that is potentially preventable across distinct subpopulations of high-cost Medicare beneficiaries. Beneficiaries in the highest 10% of total standardized individual spending were defined as "high-cost" patients, using a 20% sample of Medicare fee-for-service claims from 2012. The following 6 subpopulations were defined using a claims-based algorithm: nonelderly disabled, frail elderly, major complex chronic, minor complex chronic, simple chronic, and relatively healthy. Potentially preventable spending was calculated by summing costs for avoidable emergency department visits using the Billings algorithm plus inpatient and associated 30-day postacute costs for ambulatory care-sensitive conditions (ACSCs). The amount and proportion of potentially preventable spending were then compared across the high-cost subpopulations and by individual ACSCs. Medicare. 6 112 450 Medicare beneficiaries. Proportion of spending deemed potentially preventable. In 2012, 4.8% of Medicare spending was potentially preventable, of which 73.8% was incurred by high-cost patients. Despite making up only 4% of the Medicare population, high-cost frail elderly persons accounted for 43.9% of total potentially preventable spending ($6593 per person). High-cost nonelderly disabled persons accounted for 14.8% of potentially preventable spending ($3421 per person) and the major complex chronic group for 11.2% ($3327 per person). Frail elderly persons accounted for most spending related to admissions for urinary tract infections, dehydration, heart failure, and bacterial pneumonia. Potential misclassification in the identification of preventable spending and lack of detailed clinical data in administrative claims. Potentially preventable spending varied across Medicare subpopulations, with the majority concentrated among frail elderly persons. The Commonwealth Fund.

Patterns of care for clinically distinct segments of high cost Medicare beneficiaries.

PubMed

Clough, Jeffrey D; Riley, Gerald F; Cohen, Melissa; Hanley, Sheila M; Sanghavi, Darshak; DeWalt, Darren A; Rajkumar, Rahul; Conway, Patrick H

2016-09-01

Efforts to improve the efficiency of care for the Medicare population commonly target high cost beneficiaries. We describe and evaluate a novel management approach, population segmentation, for identifying and managing high cost beneficiaries. A retrospective cross-sectional analysis of 6,919,439 Medicare fee-for-service beneficiaries in 2012. We defined and characterized eight distinct clinical population segments, and assessed heterogeneity in managing practitioners. The eight segments comprised 9.8% of the population and 47.6% of annual Medicare payments. The eight segments included 61% and 69% of the population in the top decile and top 5% of annual Medicare payments. The positive-predictive values within each segment for meeting thresholds of Medicare payments ranged from 72% to 100%, 30% to 83%, and 14% to 56% for the upper quartile, upper decile, and upper 5% of Medicare payments respectively. Sensitivity and positive-predictive values were substantially improved over predictive algorithms based on historical utilization patterns and comorbidities. The mean [95% confidence interval] number of unique practitioners and practices delivering E&M services ranged from 1.82 [1.79-1.84] to 6.94 [6.91-6.98] and 1.48 [1.46-1.50] to 4.98 [4.95-5.00] respectively. The percentage of cognitive services delivered by primary care practitioners ranged from 23.8% to 67.9% across segments, with significant variability among specialty types. Most high cost Medicare beneficiaries can be identified based on a single clinical reason and are managed by different practitioners. Population segmentation holds potential to improve efficiency in the Medicare population by identifying opportunities to improve care for specific populations and managing clinicians, and forecasting and evaluating the impact of specific interventions. Copyright © 2015 Elsevier Inc. All rights reserved.

Disenrollment from Medicare HMOs.

PubMed

Call, K T; Dowd, B E; Feldman, R; Lurie, N; McBean, M A; Maciejewski, M

2001-01-01

Since the program's inception, there has been great interest in determining whether beneficiaries who enter and subsequently leave Medicare health maintenance organizations (HMOs) are more or less costly than those remaining in fee-for-service (FFS) Medicare. To examine whether relatively high-cost beneficiaries disenroll from Medicare HMOs (disenrollment bias) and whether disenrollment bias varies by Medicare HMO market characteristics. In addition, we compare rates of surgical procedures and hospitalizations for ambulatory care-sensitive conditions for disenrollees and continuing FFS beneficiaries. Cross-sectional analysis of 1994 Medicare data. Medicare beneficiaries were first sampled from the 124 counties with at least 1000 Medicare HMO enrollees. From this pool, HMO disenrollees and a sample of continuing FFS beneficiaries were drawn. The FFS beneficiaries were assigned dates of "pseudodisenrollment." Expenditures and inpatient service use were compared for 6 months after disenrollment or pseudodisenrollment. The HMO disenrollees were no more likely than the continuing FFS beneficiaries to have positive total expenditures (Part A plus Part B) or Part B expenditures in the first 6 months after disenrollment. However, disenrollees were more likely to have Part A expenditures. Among beneficiaries with spending, disenrollees had higher total and Part B expenditures than continuing FFS beneficiaries. Moreover, the disparity in total and Part B spending between disenrollees and continuing FFS beneficiaries increased with HMO market penetration. Although Part A spending was higher for disenrollees with spending, it was not sensitive to changes in market share. The HMO disenrollees received more surgical procedures and were hospitalized for more of the ambulatory care-sensitive conditions than the FFS beneficiaries. On several measures, Medicare HMOs experienced favorable disenrollment relative to continuing FFS beneficiaries as recently as 1994, which increased as HMO market share increased.

What Incentives Are Created by Medicare Payments for Total Hip Arthroplasty?

PubMed

Clement, R Carter; Soo, Adrianne E; Kheir, Michael M; Derman, Peter B; Flynn, David N; Levin, L Scott; Fleisher, Lee A

2016-09-01

Differences in profitability and contribution margin (CM) between various patient populations may make certain patients particularly attractive (or unattractive) to providers. This study seeks to identify patient characteristics associated with increased profit and CM among Medicare patients undergoing total hip arthroplasty (THA). The expected Medicare reimbursement for consecutive patients of Medicare-eligible age (65+ years) undergoing primary unilateral elective THA (n = 498) was calculated in accordance with Center for Medicare and Medicaid Services policy. Costs were derived from the hospital's cost accounting system. Profit and CM were calculated for each patient as reimbursement less total and variable costs, respectively. Patients were compared based on clinical and demographic factors by univariate and multivariate analyses. Medicare patients undergoing THA generated negative average profits but substantial positive CMs. Lower profit and CM were associated with higher American Society of Anesthesiologists Physical Status Classification (P < .01, P = .03), older age (P < .01), and longer length of stay (P < .01, P = .03). No association was found with gender, body mass index, or race. If our results are generalizable, Medicare patients requiring THA are currently financially attractive, but institutions have a long-term incentive to shift resources to more profitable patients and service lines, which may eventually restrict access to care for this population. THA providers have a financial incentive to favor Medicare patients with younger age, lower American Society of Anesthesiologists Physical Status Classification, and those who can be expected to require relatively short admissions. The Center for Medicare and Medicaid Services must strive to accurately match reimbursement rates to provider costs to avoid inequitable payments to providers and financial incentives discouraging treatment of high-risk patients or other patient subpopulations. Copyright © 2016 Elsevier Inc. All rights reserved.

Trends in Aortic Valve Replacement Procedures Between 2009 and 2015: Has Transcatheter Aortic Valve Replacement Made a Difference?

PubMed

Culler, Steven D; Cohen, David J; Brown, Phillip P; Kugelmass, Aaron D; Reynolds, Matthew R; Ambrose, Karen; Schlosser, Michael L; Simon, April W; Katz, Marc R

2018-04-01

This study reports trends in volume and adverse events associated with isolated aortic valve procedures performed in Medicare beneficiaries between 2009 and 2015. This retrospective study used the annual fiscal year Medicare Provider Analysis and Review file to identify all Medicare beneficiaries undergoing an isolated aortic valve procedure. Outcome measures included three mortality rates and nine in-hospital adverse events. The final study population consisted of 233,660 hospitalizations. During the study period, Medicare beneficiaries undergoing an aortic valve procedure increased from 22,076 to 49,362, for an average annual growth rate of 14.45%. Transcatheter aortic valve replacement (TAVR) procedures per 100,000 Medicare beneficiaries grew from 10.7 in 2012 to 41.1 in 2015. Overall, in-hospital mortality rates, cumulative 30-day mortality rates, and 90-day postdischarge mortality rates declined annually during the study period. However, the 90-day mortality rate for TAVR was nearly double the rate for the tissue surgical aortic valve replacement group. Nearly 68% of Medicare beneficiaries experienced at least one in-hospital adverse event during their index hospitalization. Medicare beneficiaries undergoing TAVR had the lowest observed adverse events rates among the aortic valve procedures in 2015. The total number of Medicare beneficiaries undergoing isolated aortic valve procedures increased from 47.5 to 88.9 per 100,000 Medicare beneficiaries during the study period. Aortic valve procedures increased significantly during this study period primarily due to the increase in TAVR, with clinical outcomes improving as well. Although long-term outcomes of TAVR are still under investigation, these results are promising. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Development of a Medicare Beneficiary Comprehension Test: Assessing Medicare Part D Beneficiaries' Comprehension of Their Benefits

PubMed Central

Aruru, Meghana V.; Salmon, J. Warren

2013-01-01

Background Medicare Part D, the senior prescription drug benefit plan, was introduced through the Medicare Modernization Act of 2003. Medicare beneficiaries receive information about plan options through multiple sources, and it is often assumed by consumer health plans and healthcare providers that beneficiaries can understand and compare plan information. Medicare beneficiaries are older, may have cognitive problems, and may not have a true understanding of managed care. They are more likely than younger persons to have inadequate health literacy, thereby demonstrating significant gaps in knowledge and information about healthcare. Objective To develop a Medicare Beneficiary Comprehension Test (MBCT) to evaluate Medicare beneficiaries' understanding of Part D plan concepts, as presented in the 2008 Medicare & You handbook. Methods A 10-question MBCT was developed using a case-vignette approach that required beneficiaries to read portions of the Medicare & You handbook and answer Part D–related questions associated with healthcare decision-making. The test was divided into 2 sections: (I) insurance concepts and (II) utilization management/appeals and grievances to cover standard terminology, as well as newer utilization management and appeals and grievances procedures that are unique to Part D. The test was administered to 100 beneficiaries at 2 sites—a university geriatrics clinic and a private retirement facility. Beneficiaries were tested for cognition and health literacy before being administered the test. Results The mean score on the MBCT was 3.5 of a maximum of 5, with no statistical difference found between both sites. Ten faculty members and 4 graduate students assessed the content validity of the instrument using a 4-point Likert rating rubric. The construct validity of the instrument was assessed using a principal components analysis with varimax rotation. The principal components analysis yielded 4 factors that were labeled as “Plan D concepts,” “managed care/utilization management,” “cost-sharing,” and “plan comparisons.” The factor analysis indicated that the test is multidimensional and did measure the construct. Conclusions Medicare beneficiaries' understanding of Part D may play a key role in the management of their drug use and health and the associated outcomes. The MBCT and its pending revisions can be administered to beneficiaries with differing health outcomes. Medicare beneficiaries are often faced with several pieces of information involving a complex array of choices amidst bewildering plan options. It is crucial that beneficiaries and/or their family members involved in the decision-making process understand the plan benefits to truly make an informed decision. As the number of Medicare beneficiaries increases over the coming years with the baby boomers, it becomes even more imperative that the elderly have improved access to treatments that can achieve desirable outcomes. Measuring comprehension by Medicare beneficiaries may be an initial step toward understanding more complex issues, such as treatment adherence, decision-making, and, ultimately, trends in healthcare utilization and outcomes. PMID:24991375

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

PubMed

Schlesinger, Mark; Hacker, Jacob S

2007-04-01

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

78 FR 12322 - Agency Information Collection Activities: OMB Review; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2013-02-22

... Interchange (EDI) Registration and Electronic Data Interchange (EDI) Enrollment Form; Use: The purpose of this... identification of Medicare providers/suppliers and authorization of requested Electronic Data Interface (EDI) functions. The EDI Enrollment and the Medicare Registration Forms are completed by Medicare providers...

42 CFR 422.1006 - Appeal rights.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Appeal rights. 422.1006 Section 422.1006 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil Money Penalties § 422...

42 CFR 422.1006 - Appeal rights.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Appeal rights. 422.1006 Section 422.1006 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil Money Penalties § 422.1006 Appeal...

42 CFR 422.1062 - Dismissal for cause.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Dismissal for cause. 422.1062 Section 422.1062 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil Money Penalties § 422...

42 CFR 422.1062 - Dismissal for cause.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Dismissal for cause. 422.1062 Section 422.1062 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil Money Penalties § 422...

42 CFR 422.1006 - Appeal rights.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Appeal rights. 422.1006 Section 422.1006 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil Money Penalties § 422...

42 CFR 422.1006 - Appeal rights.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Appeal rights. 422.1006 Section 422.1006 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil Money Penalties § 422.1006 Appeal...

42 CFR 422.1006 - Appeal rights.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Appeal rights. 422.1006 Section 422.1006 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil Money Penalties § 422...

42 CFR 423.1062 - Dismissal for cause.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Dismissal for cause. 423.1062 Section 423.1062 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Appeal Procedures for Civil Money...

42 CFR 422.1092 - Revision of reopened decision.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Revision of reopened decision. 422.1092 Section 422.1092 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil Money...

42 CFR 423.1062 - Dismissal for cause.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Dismissal for cause. 423.1062 Section 423.1062 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Appeal Procedures for Civil Money...

76 FR 48798 - Agency Information Collection Activities: Proposed Collection; Comment Request-Study of the...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-08-09

... Nutrition Assistance Program Participation Among Medicare's Extra Help Population Pilot Projects AGENCY... Participation Among Medicare's Extra Help Population Pilot Projects. DATES: Written comments must be received on... Efforts to Increase Supplemental Nutrition Assistance Program Participation Among Medicare's Extra Help...

78 FR 51730 - Agency Information Collection Activities: Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-21

... Evaluation of the Medicare Health Care Quality (MHCQ) Demonstration Evaluation: Focus Group and Interview... Collection: Evaluation of the Medicare Health Care Quality (MHCQ) Demonstration Evaluation: Focus Group and Interview Protocols; Use: The Medicare Health Care Quality (MHCQ) Demonstration was developed to address...

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 423.773 - Requirements for eligibility.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Requirements for eligibility. 423.773 Section 423.773 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Premiums and Cost-Sharing Subsidies...

42 CFR 423.159 - Electronic prescription drug program.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Electronic prescription drug program. 423.159 Section 423.159 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 423.1014 - Charge for transcripts.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Charge for transcripts. 423.1014 Section 423.1014 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Appeal Procedures for Civil Money...

42 CFR 423.800 - Administration of subsidy program.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Administration of subsidy program. 423.800 Section 423.800 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Premiums and Cost...

42 CFR 405.2466 - Annual reconciliation.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 2 2011-10-01 2011-10-01 false Annual reconciliation. 405.2466 Section 405.2466 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE..., payment for pneumococcal and influenza vaccine and their administration is 100 percent of Medicare...

42 CFR 405.2466 - Annual reconciliation.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Annual reconciliation. 405.2466 Section 405.2466 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE..., payment for pneumococcal and influenza vaccine and their administration is 100 percent of Medicare...

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...

42 CFR 423.1046 - Conduct of hearing.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Conduct of hearing. 423.1046 Section 423.1046 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Appeal Procedures for Civil Money...

42 CFR 422.2274 - Broker and agent requirements.

Code of Federal Regulations, 2010 CFR

2010-10-01

... (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Medicare Advantage Marketing Requirements § 422.2274... with a third party entity such as a Field Marketing Organization or similar type entity to sell its insurance products, or perform services (for example, training, customer service, or agent recruitment), the...

42 CFR 403.310 - Reduction in payments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS SPECIAL PROGRAMS AND PROJECTS Recognition of State Reimbursement Control Systems § 403.310... amount by which the Medicare payments under the system exceed the amount of Medicare payments to such...

42 CFR 417.456 - Refunds to Medicare enrollees.

Code of Federal Regulations, 2010 CFR

2010-10-01

... (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Enrollment, Entitlement, and Disenrollment under Medicare Contract § 417.456 Refunds to... accordance with paragraphs (b) through (d) of this section by the end of the contract period following the...

42 CFR 422.404 - State premium taxes prohibited.

Code of Federal Regulations, 2010 CFR

2010-10-01

....404 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Organization Compliance With State Law and Preemption by Federal Law § 422.404 State premium taxes prohibited. (a) Basic rule. No premium tax, fee, or...

42 CFR 422.212 - Limitations on provider indemnification.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Limitations on provider indemnification. 422.212 Section 422.212 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Relationships With Providers § 422.212...

Making Medicare Advantage a Middle-Class Program

PubMed Central

Glazer, Jacob; McGuire, Thomas

2013-01-01

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

Additional reductions in Medicare spending growth will likely require shifting costs to beneficiaries.

PubMed

Chernew, Michael E

2013-05-01

Policy makers have considerable interest in reducing Medicare spending growth. Clarity in the debate on reducing Medicare spending growth requires recognition of three important distinctions: the difference between public and total spending on health, the difference between the level of health spending and rate of health spending growth, and the difference between growth per beneficiary and growth in the number of beneficiaries in Medicare. The primary policy issue facing the US health care system is the rate of spending growth in public programs, and solving that problem will probably require reforms to the entire health care sector. The Affordable Care Act created a projected trajectory for Medicare spending per beneficiary that is lower than historical growth rates. Although opportunities for one-time savings exist, any long-term savings from Medicare, beyond those already forecast, will probably require a shift in spending from taxpayers to beneficiaries via higher beneficiary premium contributions (overall or via means testing), changes in eligibility, or greater cost sharing at the point of service.

Making Medicare advantage a middle-class program.

PubMed

Glazer, Jacob; McGuire, Thomas G

2013-03-01

This paper studies the role of Medicare's premium policy in sorting beneficiaries between traditional Medicare (TM) and managed care plans in the Medicare advantage (MA) program. Beneficiaries vary in their demand for care. TM fully accommodates demand but creates a moral hazard inefficiency. MA rations care but disregards some elements of the demand. We describe an efficient assignment of beneficiaries to these two options, and argue that efficiency requires an MA program oriented to serve the large middle part of the distribution of demand: the "middle class." Current Medicare policy of a "single premium" for MA plans cannot achieve efficient sorting. We characterize the demand-based premium policy that can implement the efficient assignment of enrollees to plans. If only a single premium is feasible, the second-best policy involves too many of the low-demand individuals in MA and a too low level of services relative to the first best. We identify approaches to using premium policy to revitalize MA and improve the efficiency of Medicare. Copyright © 2012 Elsevier B.V. All rights reserved.

Medicare Expenditures Associated With Hospital and Emergency Department Use Among Beneficiaries With Dementia

PubMed Central

Daras, Laura Coots; Feng, Zhanlian; Wiener, Joshua M.; Kaganova, Yevgeniya

2017-01-01

Understanding expenditure patterns for hospital and emergency department (ED) use among individuals with dementia is crucial to controlling Medicare spending. We analyzed Health and Retirement Study data and Medicare claims, stratified by beneficiaries’ residence and proximity to death, to estimate Medicare expenditures for all-cause and potentially avoidable hospitalizations and ED visits. Analysis was limited to the Medicare fee-for-service population age 65 and older. Compared with people without dementia, community residents with dementia had higher average expenditures for hospital and ED services; nursing home residents with dementia had lower average expenditures for all-cause hospitalizations. Decedents with dementia had lower expenditures than those without dementia in the last year of life. Medicare expenditures for individuals with and without dementia vary by residential setting and proximity to death. Results highlight the importance of addressing the needs specific to the population with dementia. There are many initiatives to reduce hospital admissions, but few focus on people with dementia. PMID:28301976

Giving EMS flexibility in transporting low-acuity patients could generate substantial Medicare savings.

PubMed

Alpert, Abby; Morganti, Kristy G; Margolis, Gregg S; Wasserman, Jeffrey; Kellermann, Arthur L

2013-12-01

Some Medicare beneficiaries who place 911 calls to request an ambulance might safely be cared for in settings other than the emergency department (ED) at lower cost. Using 2005-09 Medicare claims data and a validated algorithm, we estimated that 12.9-16.2 percent of Medicare-covered 911 emergency medical services (EMS) transports involved conditions that were probably nonemergent or primary care treatable. Among beneficiaries not admitted to the hospital, about 34.5 percent had a low-acuity diagnosis that might have been managed outside the ED. Annual Medicare EMS and ED payments for these patients were approximately $1 billion per year. If Medicare had the flexibility to reimburse EMS for managing selected 911 calls in ways other than transport to an ED, we estimate that the federal government could save $283-$560 million or more per year, while improving the continuity of patient care. If private insurance companies followed suit, overall societal savings could be twice as large.

Reductions in mortality among Medicare beneficiaries following the implementation of Medicare Part D.

PubMed

Semilla, April P; Chen, Fang; Dall, Timothy M

2015-07-01

Medicare Part D is a prescription drug program that provides seniors and disabled individuals enrolled in Medicare with outpatient drug coverage benefits. Part D has been shown to increase access to medicines and improve medication adherence; however, the effect of Part D on health outcomes has not yet been extensively studied. In this study, we used a published and validated Markov-based microsimulation model to quantify the relationships among medication use, disease incidence and severity, and mortality. Based on the simulation results, we estimate that since the implementation of Part D in 2006, nearly 200,000 Medicare beneficiaries have lived at least 1 year longer. Reductions in mortality have occurred because of fewer deaths associated with medication-sensitive conditions such as diabetes, congestive heart failure, stroke, and myocardial infarction. Improved access to medication through Medicare Part D helps patients improve blood pressure, cholesterol, and blood glucose levels, which in turn can prevent or delay the onset of disease and the incidence of adverse health events, thus reducing mortality.

Effect of Long-term Care Use on Medicare and Medicaid Expenditures for Dual Eligible and Non-dual Eligible Elderly Beneficiaries

PubMed Central

Kane, Robert L; Wysocki, Andrea; Parashuram, Shriram; Shippee, Tetyana; Lum, Terry

2013-01-01

Background: Dual eligible Medicare and Medicaid beneficiaries consume disproportionate shares of both programs. Objectives: To compare Medicare and Medicaid expenditures of elderly dual eligible beneficiaries with non-dual eligible beneficiaries based on their long-term care (LTC) use. Research Design: Secondary analysis of linked MAX and Medicare data in seven states. Subjects: Dual eligible adults (65+) receiving LTC in institutions, in the community, or not at all; and Medicare non-dual eligibles. Measures: Medicaid acute medical and LTC expenditures per beneficiary year, Medicare expenditures. Results: Among dual eligibles and non-dual eligibles, the average number of diseases and case mix scores are higher for LTC users. Adjusting for case mix virtually eliminates the difference for medical costs, but not for LTC expenditures. Adjusting for LTC status reduces the difference in LTC costs, but increases the difference in medical costs. Conclusions: Efforts to control costs for dual eligibles should target those in LTC while better coordinating medical and LTC expenditures. PMID:24753971

Characteristics of patients seen by visiting psychiatrists through Medicare in a rural community mental health service with an established telemedicine service.

PubMed

Bidargaddi, Niranjan; Schrader, Geoffrey; Smith, David; Carson, Dean; Strobel, Jörg

2017-06-01

We aimed to determine characteristics of patients receiving Medicare-funded face-to-face consultations by psychiatrists in a rural service with an established telemedicine service. For this study, 55 case-managed patients from four rural community mental health teams in South Australia provided information through questionnaires regarding psychological symptoms, quality of life, body mass index (BMI) and gave access to their Medicare data. In a logistic regression, it was found that being younger was more likely associated with a Medicare psychiatric consultation ( p<0.05). Participants with at least one recorded visit to a Medicare psychiatrist consultation also tended to have lower levels of psychological distress at the end of the 4-year period, have a higher BMI, and more general practitioner consultations. The study provides clinicians and policy makers with preliminary information on the subtle differences in clinical profile of patients seen by Medicare-funded psychiatrists within an established state-managed telepsychiatry service.

The financial status of Medicare.

PubMed Central

Foster, R S

1998-01-01

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

The Balanced Budget Act (1997) and the supplyof nursing home subacute care.

PubMed

Qaseem, Amir; Weech-Maldonado, Robert; Mkanta, William

2007-01-01

This article examines the impact of the Medicare prospective payment system (PPS) on the supply of subacute care services by nursing homes. A quasi-experimental interrupted time-series design using Heckman's two-stage regression model is employed to test for changes before and after the implementation of Medicare PPS. Our findings suggest that the change in Medicare reimbursement from cost-based to PPS under the Balanced Budget Act of 1997 resulted in a decrease of 1.7 percent in the supply of subacute care beds by nursing homes. However, this was a one-time, short-term negative effect. The supply of nursing home subacute care remained stable in the long-term. Other environmental factors, such as Medicare hospital discharges, hospital-based subacute care, Medicare managed care penetration, availability of home health, and per capita income were associated with nursing home subacute care supply. Organizational-level factors, such as occupancy rate, RN staff mix, and Medicare payer mix were also predictors of nursing home subacute care supply.

Medicare Prescription Drug Plan Enrollees Report Less Positive Experiences Than Their Medicare Advantage Counterparts.

PubMed

Elliott, Marc N; Landon, Bruce E; Zaslavsky, Alan M; Edwards, Carol; Orr, Nathan; Beckett, Megan K; Mallett, Joshua; Cleary, Paul D

2016-03-01

Since 2006, Medicare beneficiaries have been able to obtain prescription drug coverage through standalone prescription drug plans or their Medicare Advantage (MA) health plan, options exercised in 2015 by 72 percent of beneficiaries. Using data from community-dwelling Medicare beneficiaries older than age sixty-four in 700 plans surveyed from 2007 to 2014, we compared beneficiaries' assessments of Medicare prescription drug coverage when provided by standalone plans or integrated into an MA plan. Beneficiaries in standalone plans consistently reported less positive experiences with prescription drug plans (ease of getting medications, getting coverage information, and getting cost information) than their MA counterparts. Because MA plans are responsible for overall health care costs, they might have more integrated systems and greater incentives than standalone prescription drug plans to provide enrollees medications and information effectively, including, since 2010, quality bonus payments to these MA plans under provisions of the Affordable Care Act. Project HOPE—The People-to-People Health Foundation, Inc.

Association Between Medicare Accountable Care Organization Implementation and Spending Among Clinically Vulnerable Beneficiaries.

PubMed

Colla, Carrie H; Lewis, Valerie A; Kao, Lee-Sien; O'Malley, A James; Chang, Chiang-Hua; Fisher, Elliott S

2016-08-01

Accountable care contracts hold physician groups financially responsible for the quality and cost of health care delivered to patients. Focusing on clinically vulnerable patients, those with serious conditions who are responsible for the greatest proportion of spending, may result in the largest effects on both patient outcomes and financial rewards for participating physician groups. To estimate the effect of Medicare accountable care organization (ACO) contracts on spending and high-cost institutional use for all Medicare beneficiaries and for clinically vulnerable beneficiaries. For this cohort study, 2 study populations were defined: the overall Medicare population and the clinically vulnerable subgroup of Medicare beneficiaries. The overall Medicare population was based on a random 40% sample drawn from continuously enrolled fee-for-service beneficiaries with at least 1 evaluation and management visit in a calendar year. The clinically vulnerable study population included all Medicare beneficiaries 66 years or older who had at least 3 Hierarchical Condition Categories (HCCs). Beneficiaries entered the cohort during the quarter between January 2009 to December 2011 when they first had at least 3 HCCs and remained in the cohort until death. Cohort entry was restricted to the preperiod to account for potential changes in coding practices after ACO implementation. Difference-in-difference estimations were used to compare changes in health care outcomes for Medicare beneficiaries attributed to physicians in ACOs with those attributed to non-ACO physicians from January 2009 to December 2013. Medicare ACOs beginning contracts in January 2012, April 2012, July 2012, and January 2013 through the Pioneer and Medicare Shared Savings Programs. Total spending per beneficiary-quarter, spending categories, use of hospitals and emergency departments, ambulatory care sensitive admissions, and 30-day readmissions. Total spending decreased by $34 (95% CI, -$52 to -$15) per beneficiary-quarter after ACO contract implementation across the overall Medicare population (n = 15 592 600) and decreased $114 in clinically vulnerable patients (n = 8 673 823) (95% CI, -$178 to -$50). In the overall Medicare cohort, hospitalizations and emergency department visits decreased by 1.3 and 3.0 events per 1000 beneficiaries per quarter, respectively (95% CIs: -2.1 to -0.4 and -4.8 to -1.3), and hospitalizations and emergency department visits decreased in the clinically vulnerable cohort by 2.9 and 4.1 events per 1000 beneficiaries per quarter, respectively (95% CIs: -5.2 to -0.7 and -7.1 to -1.2). Changes in total spending associated with ACOs did not vary by clinical condition of beneficiaries. Medicare ACO programs are associated with modest reductions in spending and use of hospitals and emergency departments. Savings were realized through reductions in use of institutional settings in clinically vulnerable patients.

Beyond spinal manipulation: should Medicare expand coverage for chiropractic services? A review and commentary on the challenges for policy makers

PubMed Central

Whedon, James M.; Goertz, Christine M.; Lurie, Jon D.; Stason, William B.

2013-01-01

Objectives Private insurance plans typically reimburse doctors of chiropractic for a range of clinical services, but Medicare reimbursements are restricted to spinal manipulation procedures. Medicare pays for evaluations performed by medical and osteopathic physicians, nurse practitioners, physician assistants, podiatrists, physical therapists, and occupational therapists; however, it does not reimburse the same services provided by chiropractic physicians. Advocates for expanded coverage of chiropractic services under Medicare cite clinical effectiveness and patient satisfaction, whereas critics point to unnecessary services, inadequate clinical documentation, and projected cost increases. To further inform this debate, the purpose of this commentary is to address the following questions: (1) What are the barriers to expand coverage for chiropractic services? (2) What could potentially be done to address these issues? (3) Is there a rationale for Centers for Medicare and Medicaid Services to expand coverage for chiropractic services? Methods A literature search was conducted of Google and PubMed for peer-reviewed articles and US government reports relevant to the provision of chiropractic care under Medicare. We reviewed relevant articles and reports to identify key issues concerning the expansion of coverage for chiropractic under Medicare, including identification of barriers and rationale for expanded coverage. Results The literature search yielded 29 peer-reviewed articles and 7 federal government reports. Our review of these documents revealed 3 key barriers to full coverage of chiropractic services under Medicare: inadequate documentation of chiropractic claims, possible provision of unnecessary preventive care services, and the uncertain costs of expanded coverage. Our recommendations to address these barriers include the following: individual chiropractic physicians, as well as state and national chiropractic organizations, should continue to strengthen efforts to improve claims and documentation practices; and additional rigorous efficacy/effectiveness research and clinical studies for chiropractic services need to be performed. Research of chiropractic services should target the triple aim of high-quality care, affordability, and improved health. Conclusions The barriers that were identified in this study can be addressed. To overcome these barriers, the chiropractic profession and individual physicians must assume responsibility for correcting deficiencies in compliance and documentation; further research needs to be done to evaluate chiropractic services; and effectiveness of extended episodes of preventive chiropractic care should be rigorously evaluated. Centers for Medicare and Medicaid Services policies related to chiropractic reimbursement should be reexamined using the same standards applicable to other health care providers. The integration of chiropractic physicians as fully engaged Medicare providers has the potential to enhance the capacity of the Medicare workforce to care for the growing population. We recommend that Medicare policy makers consider limited expansion of Medicare coverage to include, at a minimum, reimbursement for evaluation and management services by chiropractic physicians. PMID:25067927

Use of Outpatient Care in Veterans Health Administration and Medicare among Veterans Receiving Primary Care in Community-Based and Hospital Outpatient Clinics

PubMed Central

Liu, Chuan-Fen; Chapko, Michael; Bryson, Chris L; Burgess, James F; Fortney, John C; Perkins, Mark; Sharp, Nancy D; Maciejewski, Matthew L

2010-01-01

Objective To examine differences in use of Veterans Health Administration (VA) and Medicare outpatient services by VA primary care patients. Data Sources/Study Setting VA administrative and Medicare claims data from 2001 to 2004. Study Design Retrospective cohort study of outpatient service use by 8,964 community-based and 6,556 hospital-based VA primary care patients. Principal Findings A significant proportion of VA patients used Medicare-reimbursed primary care (>30 percent) and specialty care (>60 percent), but not mental health care (3–4 percent). Community-based patients had 17 percent fewer VA primary care visits (p<.001), 9 percent more Medicare-reimbursed visits (p<.001), and 6 percent fewer total visits (p<.05) than hospital-based patients. Community-based patients had 22 percent fewer VA specialty care visits (p<.0001) and 21 percent more Medicare-reimbursed specialty care visits (p<.0001) than hospital-based patients, but no difference in total visits (p=.80). Conclusions Medicare-eligible VA primary care patients followed over 4 consecutive years used significant primary care and specialty care outside of VA. Community-based patients offset decreased VA use with increased service use paid by Medicare, suggesting that increasing access to VA primary care via community clinics may fragment veteran care in unintended ways. Coordination of care between VA and non-VA providers and health care systems is essential to improve the quality and continuity of care. PMID:20831716

The Impact of Green House Adoption on Medicare Spending and Utilization.

PubMed

Grabowski, David C; Afendulis, Christopher C; Caudry, Daryl J; O'Malley, A James; Kemper, Peter

2016-02-01

To evaluate the impact of the Green House (GH) model of nursing home care on Medicare acute hospital, other hospital, skilled nursing facility, and hospice spending and utilization. Medicare claims and enrollment data from 2005 through 2010 merged with resident-level minimum data set (MDS) assessments. Using a difference-in-differences framework, we compared Medicare Part A and hospice expenditures and utilization in 15 nursing homes that adopted the GH model relative to changes over the same time period in 223 matched nonadopting nursing homes. We applied the same method for residents of GH homes and for residents of "legacy" homes, the original nursing homes that stay open alongside the GH home(s). The adoption of GH had no detectable impact on Medicare Part A (plus hospice) spending and utilization across all residents living in the nursing home. When we analyzed residents living in GH homes and legacy units separately, however, we found that the adoption of the GH model reduced overall annual Medicare Part A spending by $7,746 per resident, although this appeared to be partially offset by an increase in spending in legacy homes. To the extent that the GH model reduces Medicare spending, adopting nursing homes do not receive any of the related Medicare savings under traditional payment mechanisms. New approaches that are currently being developed and piloted, which better align financial incentives for providers and payers, could incentivize greater adoption of the GH model. © Health Research and Educational Trust.

Geographic Correlation Between Large-Firm Commercial Spending and Medicare Spending

PubMed Central

Chernew, Michael E.; Sabik, Lindsay M.; Chandra, Amitabh; Gibson, Teresa B.; Newhouse, Joseph P.

2012-01-01

Objective To investigate the correlation between geographic variation in inpatient days, total spending, and spending growth in traditional Medicare versus the large-firm commercial sector. Study Design Retrospective descriptive analysis. Methods Medicare spending data at the hospital referral region (HRR) level were obtained from the Dartmouth Atlas. Commercial claims data from large employers were obtained from Thomson Reuters MarketScan Database for 1996-2006 and aggregated to the HRR level. County-level data on inpatient days per capita and market characteristics were obtained from the Area Resource File. We computed correlations between Medicare and commercial spending and spending growth, as well as Medicare and non-Medicare inpatient days, and examined traits of high- and low-spending HRRs in both sectors. Results We found a positive correlation between inpatient days per capita across counties, but a small inverse correlation between measures of commercial and Medicare spending across HRRs. Spending growth was weakly positively correlated across HRRs. Markets in the upper third of commercial spending had more concentrated hospital markets than markets in the lower third of commercial spending. The reverse was true for Medicare spending. Conclusions The positive correlation in utilization and lack of correlation in spending implies an inverse correlation in prices. This is consistent with evidence that the differences appear to be, at least partially, related to aspects of the market structure. If private markets are to work better to reduce cost, stronger efforts are needed to reduce provider market concentration and promote competitive pricing for healthcare services. PMID:20148618

Geographic correlation between large-firm commercial spending and Medicare spending.

PubMed

Chernew, Michael E; Sabik, Lindsay M; Chandra, Amitabh; Gibson, Teresa B; Newhouse, Joseph P

2010-02-01

To investigate the correlation between geographic variation in inpatient days, total spending, and spending growth in traditional Medicare versus the large-firm commercial sector. Retrospective descriptive analysis. Medicare spending data at the hospital referral region (HRR) level were obtained from the Dartmouth Atlas. Commercial claims data from large employers were obtained from Thomson Reuters MarketScan Database for 1996-2006 and aggregated to the HRR level. County-level data on inpatient days per capita and market characteristics were obtained from the Area Resource File. We computed correlations between Medicare and commercial spending and spending growth, as well as Medicare and non-Medicare inpatient days, and examined traits of high- and low-spending HRRs in both sectors. We found a positive correlation between inpatient days per capita across counties, but a small inverse correlation between measures of commercial and Medicare spending across HRRs. Spending growth was weakly positively correlated across HRRs. Markets in the upper third of commercial spending had more concentrated hospital markets than markets in the lower third of commercial spending. The reverse was true for Medicare spending. The positive correlation in utilization and lack of correlation in spending implies an inverse correlation in prices. This is consistent with evidence that the differences appear to be, at least partially, related to aspects of the market structure. If private markets are to work better to reduce cost, stronger efforts are needed to reduce provider market concentration and promote competitive pricing for healthcare services.

42 CFR 423.1092 - Revision of reopened decision.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Revision of reopened decision. 423.1092 Section 423.1092 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Appeal Procedures for Civil Money...

42 CFR 422.1092 - Revision of reopened decision.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Revision of reopened decision. 422.1092 Section 422.1092 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil Money Penalties § 422...

78 FR 31556 - Agency Information Collection Activities: Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2013-05-24

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [Document...: Centers for Medicare & Medicaid Services, HHS. In compliance with the requirement of section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995, the Centers for Medicare & Medicaid Services (CMS) is...

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 423.104 - Requirements related to qualified prescription drug coverage.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Requirements related to qualified prescription drug coverage. 423.104 Section 423.104 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT...

42 CFR 423.771 - Basis and scope.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Basis and scope. 423.771 Section 423.771 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Premiums and Cost-Sharing Subsidies for Low...

42 CFR 423.886 - Retiree drug subsidy amounts.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Retiree drug subsidy amounts. 423.886 Section 423.886 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Payments to Sponsors of Retiree...

42 CFR 489.71 - Surety's standing to appeal Medicare determinations.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false Surety's standing to appeal Medicare determinations. 489.71 Section 489.71 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION PROVIDER AGREEMENTS AND SUPPLIER APPROVAL Surety...

42 CFR 489.71 - Surety's standing to appeal Medicare determinations.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 5 2011-10-01 2011-10-01 false Surety's standing to appeal Medicare determinations. 489.71 Section 489.71 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION PROVIDER AGREEMENTS AND SUPPLIER APPROVAL Surety...

78 FR 37545 - Agency Information Collection Activities: Submission for OMB Review; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2013-06-21

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [Document... Information Collection: Medicare Participating Physician or Supplier Agreement; Use: Section 1842(h) of the Social Security Act permits physicians and suppliers to voluntarily participate in Medicare Part B by...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-06-08

... Care Act Medicare Beneficiary Outreach and Assistance Program Funding for Title VI Native American Programs Purpose of Notice: Availability of funding opportunity announcement. Funding Opportunity Title/Program Name: Affordable Care Act Medicare Beneficiary Outreach and Assistance Program Funding for Title...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-15

...] Medicare Program; Town Hall Meeting on Physician Quality Reporting System AGENCY: Centers for Medicare... to discuss the Physician Quality Reporting System (previously known as the Physician Quality... stakeholders on the individual quality measures and measures groups being considered for possible inclusion in...

20 CFR 404.1018b - Medicare qualified government employment.

Code of Federal Regulations, 2013 CFR

2013-04-01

... AND DISABILITY INSURANCE (1950- ) Employment, Wages, Self-Employment, and Self-Employment Income Work Excluded from Employment § 404.1018b Medicare qualified government employment. (a) General. The work of a... 20 Employees' Benefits 2 2013-04-01 2013-04-01 false Medicare qualified government employment. 404...

20 CFR 404.1018b - Medicare qualified government employment.

Code of Federal Regulations, 2014 CFR

2014-04-01

... AND DISABILITY INSURANCE (1950- ) Employment, Wages, Self-Employment, and Self-Employment Income Work Excluded from Employment § 404.1018b Medicare qualified government employment. (a) General. The work of a... 20 Employees' Benefits 2 2014-04-01 2014-04-01 false Medicare qualified government employment. 404...

20 CFR 404.1018b - Medicare qualified government employment.

Code of Federal Regulations, 2012 CFR

2012-04-01

... AND DISABILITY INSURANCE (1950- ) Employment, Wages, Self-Employment, and Self-Employment Income Work Excluded from Employment § 404.1018b Medicare qualified government employment. (a) General. The work of a... 20 Employees' Benefits 2 2012-04-01 2012-04-01 false Medicare qualified government employment. 404...

42 CFR § 414.1435 - Qualifying APM participant determination: Medicare option.

Code of Federal Regulations, 2010 CFR

2017-10-01

..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Merit-Based Incentive Payment System and Alternative Payment Model Incentive § 414.1435 Qualifying APM participant determination: Medicare option. (a) Payment amount method. The...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-11-02

... Community Care Network NP Nurse Practitioner NPI National Provider Identifier NQF National Quality Forum OIG...: Accountable Care Organizations; Final Rule #0;#0;Federal Register / Vol. 76 , No. 212 / Wednesday, November 2... Savings Program: Accountable Care Organizations AGENCY: Centers for Medicare & Medicaid Services (CMS...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-08

... economics of health care, medical ethics and other related professions such as epidemiology and... basis. The MEDCAC--(1) Hears public testimony; (2) reviews medical literature, technology assessments... Federal Domestic Assistance Program No. 93.774, Medicare--Supplementary Medical Insurance Program). Dated...

42 CFR 417.404 - General requirements.

Code of Federal Regulations, 2010 CFR

2010-10-01

... (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Qualifying Conditions for Medicare Contracts § 417.404 General requirements. (a) In order to contract with CMS under the Medicare program, an entity must— (1) Be determined by CMS to be an HMO or CMP...

42 CFR 422.2262 - Review and distribution of marketing materials.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Review and distribution of marketing materials. 422... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Medicare Advantage Marketing Requirements § 422.2262 Review and distribution of marketing materials. (a) CMS review of marketing materials...

Enrollees Choose Priorities for Medicare

ERIC Educational Resources Information Center

Danis, Marion; Biddle, Andrea K.; Goold, Susan Dorr

2004-01-01

Purpose: The purpose of this study was to demonstrate the feasibility and results of ascertaining Medicare enrollees' priorities for insured medical benefits. Design and Methods: Structured group exercises were conducted with Medicare enrollees from clinical and community settings in central North Carolina. By participating in a decision exercise,…

42 CFR 422.402 - Federal preemption of State law.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Federal preemption of State law. 422.402 Section 422.402 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Organization Compliance With State Law and...

42 CFR 422.200 - Basis and scope.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Basis and scope. 422.200 Section 422.200 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Relationships With Providers § 422.200 Basis and scope. This...

42 CFR 422.118 - Confidentiality and accuracy of enrollee records.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Confidentiality and accuracy of enrollee records. 422.118 Section 422.118 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Benefits and Beneficiary...

42 CFR 422.210 - Assurances to CMS.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Assurances to CMS. 422.210 Section 422.210 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Relationships With Providers § 422.210 Assurances to CMS. (a...

MediCaring: development and test marketing of a supportive care benefit for older people.

PubMed

Lynn, J; O'Connor, M A; Dulac, J D; Roach, M J; Ross, C S; Wasson, J H

1999-09-01

To develop an alternative healthcare benefit (called MediCaring) and to assess the preferences of older Medicare beneficiaries concerning this benefit, which emphasizes more home-based and supportive health care and discourages use of hospitalization and aggressive treatment. To evaluate the beneficiaries' ability to understand and make a choice regarding health insurance benefits; to measure their likelihood to change from traditional Medicare to the new MediCaring benefit; and to determine the short-term stability of that choice. Focus groups of persons aged 65+ and family members shaped the potential MediCaring benefit. A panel of 50 national experts critiqued three iterations of the benefit. The final version was test marketed by discussing it with 382 older people (men > or = 75 years and women > or = 80 years) in their homes. Telephone surveys a few days later, and again 1 month after the home interview, assessed the potential beneficiaries' understanding and preferences concerning MediCaring and the stability of their responses. Focus groups were held in community settings in New Hampshire, Washington, DC, Cleveland, OH, and Columbia, SC. Test marketing occurred in New Hampshire, Cleveland, OH; Columbia, SC, and Los Angeles, CA. Focus group participants were persons more than 65 years old (11 focus groups), healthcare providers (9 focus groups), and family decision-makers (3 focus groups). Participants in the in-home informing (test marketing group) were persons older than 75 years who were identified through contact with a variety of services. Demographics, health characteristics, understanding, and preferences. Focus group beneficiaries between the ages of 65 and 74 generally wanted access to all possible medical treatment and saw MediCaring as a need of persons older than themselves. Those older than age 80 were mostly in favor of it. Test marketing participants understood the key points of the new benefit: 74% generally liked it, and 34% said they would take it now. Preferences were generally stable at 1 month. In multivariate regression, those preferring MediCaring were wealthier, more often white, more often living in senior housing, and using more homecare services. However, they were not more often in poor health or needing ADL assistance. Older persons aged more than 80 years can understand a health benefit choice; most liked the aims of a new supportive care benefit, and 34% would change immediately from Medicare to a supportive care benefit such as MediCaring,. These findings encourage further development of special programs of care, such as MediCaring, that prioritize comfort and support for the old old.

42 CFR 411.384 - Disclosing advisory opinions and supporting information.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT... Department of Justice, or any other Department or agency of the United States in connection with an advisory..., and will not be made publicly available. (d) Documents submitted by the requestor to CMS in connection...

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

Code of Federal Regulations, 2010 CFR

2010-10-01

... enrollment application to the type of provider or supplier enrolling, and has not submitted a plan of... the provider or supplier is not operational, or is not meeting Medicare enrollment requirements to... A provider is no longer operational to furnish Medicare covered items or services, or the provider...

42 CFR 417.531 - Hospice care services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Hospice care services. 417.531 Section 417.531... (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Medicare Payment: Cost Basis § 417.531 Hospice care services. (a) If a Medicare enrollee of...

76 FR 49836 - Proposed Collection; Comment Request for Form 8846

Federal Register 2010, 2011, 2012, 2013, 2014

2011-08-11

... concerning Form 8846, Credit for Employer Social Security and Medicare Taxes Paid on Certain Employee Tips... Social Security and Medicare Taxes Paid on Certain Employee Tips. OMB Number: 1545-1414. Form Number... income tax credit for the amount of social security and Medicare taxes paid (employer's share) on tips...

76 FR 65320 - Proposed Collection; Comment Request for Form 4029

Federal Register 2010, 2011, 2012, 2013, 2014

2011-10-20

... 4029, Application for Exemption from Social Security and Medicare Taxes and Waiver of Benefits. DATES... Exemption from Social Security and Medicare Taxes and Waiver of Benefits. OMB Number: 1545-0064. Form Number... exemption from social security and Medicare taxes under Internal Revenue Code sections 1402(g) and 3127. The...

42 CFR 422.1094 - Notice and effect of revised decision.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Notice and effect of revised decision. 422.1094 Section 422.1094 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil...

42 CFR 422.1094 - Notice and effect of revised decision.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Notice and effect of revised decision. 422.1094 Section 422.1094 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil Money...

42 CFR 422.1018 - Notice and effect of initial determinations.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Notice and effect of initial determinations. 422.1018 Section 422.1018 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil Money...

42 CFR 422.1094 - Notice and effect of revised decision.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Notice and effect of revised decision. 422.1094 Section 422.1094 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil...

42 CFR 422.1094 - Notice and effect of revised decision.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Notice and effect of revised decision. 422.1094 Section 422.1094 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil Money...

42 CFR 422.1018 - Notice and effect of initial determinations.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Notice and effect of initial determinations. 422.1018 Section 422.1018 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil Money...

42 CFR 422.1094 - Notice and effect of revised decision.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Notice and effect of revised decision. 422.1094 Section 422.1094 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Appeal procedures for Civil...

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 405.809 - Opportunity to submit evidence.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 2 2011-10-01 2011-10-01 false Opportunity to submit evidence. 405.809 Section 405.809 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED Appeals Under the Medicare Part B...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-07-17

... ESRD Care Model would result in improved health outcomes for beneficiaries with ESRD regarding the... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-5506-N2] Medicare Program; Comprehensive ESRD Care Initiative; Extension of the Submission Deadlines for the Letters...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-26

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

42 CFR 422.308 - Adjustments to capitation rates, benchmarks, bids, and payments.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Adjustments to capitation rates, benchmarks, bids, and payments. 422.308 Section 422.308 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM...

42 CFR 422.308 - Adjustments to capitation rates, benchmarks, bids, and payments.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Adjustments to capitation rates, benchmarks, bids, and payments. 422.308 Section 422.308 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Payments to...

42 CFR 422.308 - Adjustments to capitation rates, benchmarks, bids, and payments.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Adjustments to capitation rates, benchmarks, bids, and payments. 422.308 Section 422.308 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM...

42 CFR 422.308 - Adjustments to capitation rates, benchmarks, bids, and payments.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Adjustments to capitation rates, benchmarks, bids, and payments. 422.308 Section 422.308 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM...

42 CFR 423.165 - Compliance deemed on the basis of accreditation.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Compliance deemed on the basis of accreditation. 423.165 Section 423.165 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Cost...

42 CFR 423.2110 - MAC reviews on its own motion.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false MAC reviews on its own motion. 423.2110 Section 423.2110 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Reopening, ALJ Hearings, MAC review...

42 CFR 405.908 - Medicaid State agencies.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Medicaid State agencies. 405.908 Section 405.908 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE..., Reconsiderations, and Appeals Under Original Medicare (Part A and Part B) § 405.908 Medicaid State agencies. When a...

42 CFR 460.180 - Medicare payment to PACE organizations.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Medicare payment to PACE organizations. 460.180... FOR THE ELDERLY (PACE) Payment § 460.180 Medicare payment to PACE organizations. (a) Principle of payment. Under a PACE program agreement, CMS makes a prospective monthly payment to the PACE organization...

42 CFR 422.2 - Definitions.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Definitions. 422.2 Section 422.2 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM General Provisions § 422.2 Definitions. As used in this part— Arrangement means a written agreement...

42 CFR 422.2 - Definitions.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Definitions. 422.2 Section 422.2 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM General Provisions § 422.2 Definitions. As used in this part— Arrangement means a written agreement...

42 CFR 422.2 - Definitions.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Definitions. 422.2 Section 422.2 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM General Provisions § 422.2 Definitions. As used in this part— Arrangement means a written agreement...

75 FR 37971 - Providing Stability and Security for Medicare Reimbursements

Federal Register 2010, 2011, 2012, 2013, 2014

2010-06-30

... disruption to, or administrative burden on, Medicare physicians and other affected providers and to minimize any disruption in the ability of Medicare beneficiaries to access necessary services: (a) Direct the... beneficiaries from any disruption to their access to services that may be occasioned by the reprocessing of...

42 CFR 423.2276 - Employer group retiree marketing.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Employer group retiree marketing. 423.2276 Section 423.2276 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Part D Marketing Requirements § 423.2276 Employer group retiree...

78 FR 14555 - Agency Information Collection Activities: Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-06

... (business or other for-profit and not-for-profit institutions). Number of Respondents: 6,169. Total Annual...: Hospitals have used the IM to inform original Medicare, Medicare Advantage, and other Medicare plan... Sector (business or other for-profit and not-for-profit institutions). Number of Respondents: 6,169...

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...

20 CFR 404.1018b - Medicare qualified government employment.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 20 Employees' Benefits 2 2011-04-01 2011-04-01 false Medicare qualified government employment. 404... Excluded from Employment § 404.1018b Medicare qualified government employment. (a) General. The work of a Federal, State, or local government employee not otherwise subject to Social Security coverage may...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-05-23

... organizations, insurance industry trade groups, provider associations, pharmacist and pharmacy associations, beneficiary advocacy groups, private citizens, and others. Overall, commenters supported our decision to model... enrollees, for 3 consecutive years, it will be forced to stop enrolling new individuals in such Part D...

Medicare "Canada's postwar miracle," US management expert tells CMA conference.

PubMed Central

Rafuse, J

1995-01-01

The diagnosis that Canadian medicare is a fundamentally troubled and gravely threatened system is quite distorted, says a professor of public policy and management at the Yale School of Management. Dr. Theodore Marmor praised medicare as "Canada's postwar miracle" during the CMA's 7th Annual Leadership Conference. PMID:7728703

42 CFR 424.102 - Situations that do not constitute an emergency.

Code of Federal Regulations, 2010 CFR

2010-10-01

... themselves indicate a need for emergency services: (a) Lack of care at home. (b) Lack of transportation to a....102 Section 424.102 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Special Conditions...

75 FR 30043 - Medicare Program; Meeting of the Advisory Panel on Medicare Education

Federal Register 2010, 2011, 2012, 2013, 2014

2010-05-28

... [Medicare Advantage] in order to promote an active, informed selection among such options.'' The Panel is... Program; Yanira Cruz, PhD, President and Chief Executive Officer, National Hispanic Council on Aging... Health; Sandy Markwood, Chief Executive Officer, National Association of Area Agencies on Aging; David W...

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 405.2416 - Visiting nurse services.

Code of Federal Regulations, 2012 CFR

2012-10-01

...; and (2) Personal care services, to the extent covered under Medicare as home health services. These... 42 Public Health 2 2012-10-01 2012-10-01 false Visiting nurse services. 405.2416 Section 405.2416 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE...

42 CFR 405.2416 - Visiting nurse services.

Code of Federal Regulations, 2011 CFR

2011-10-01

...; and (2) Personal care services, to the extent covered under Medicare as home health services. These... 42 Public Health 2 2011-10-01 2011-10-01 false Visiting nurse services. 405.2416 Section 405.2416 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE...

42 CFR 405.2416 - Visiting nurse services.

Code of Federal Regulations, 2013 CFR

2013-10-01

...; and (2) Personal care services, to the extent covered under Medicare as home health services. These... 42 Public Health 2 2013-10-01 2013-10-01 false Visiting nurse services. 405.2416 Section 405.2416 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE...

42 CFR 405.2416 - Visiting nurse services.

Code of Federal Regulations, 2014 CFR

2014-10-01

... achieved. (2) Personal care services, to the extent covered under Medicare as home health services. These... 42 Public Health 2 2014-10-01 2014-10-01 false Visiting nurse services. 405.2416 Section 405.2416 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE...

42 CFR 400.202 - Definitions specific to Medicare.

Code of Federal Regulations, 2010 CFR

2010-10-01

... mental health center that has in effect a similar agreement but only to furnish partial hospitalization... 42 Public Health 2 2010-10-01 2010-10-01 false Definitions specific to Medicare. 400.202 Section 400.202 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN...

42 CFR 424.80 - Prohibition of reassignment of claims by suppliers.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Limitations on Assignment and Reassignment of Claims § 424.80 Prohibition of reassignment of claims by suppliers. (a) Basic... the basic rule—(1) Payment to employer. Medicare may pay the supplier's employer if the supplier is...