Model citizens. Outsourcing helps start-up Medicare HMO.

PubMed

Slavic, B; Adami, S

1999-04-01

Health Plans of Pennsylvania (HPP), the managed care arm of Crozer-Keystone Health System, in Media, Pa. Selecting the information systems and building the infrastructure to support the start-up of a new Medicare HMO product. HPP chose to outsource the information systems needed to integrate all the components of managed care administration into a cost-effective and cohesive program. Because of its aggressive programming and start-up of the MedCarePlus product offering, HPP became the first plan in the country to submit Medicare claims data electronically for encounter reporting to the Health Care Financing Administration (HCFA). "Through an integrated team approach, an organization truly can benefit from the economies of scale gained through outsourcing."

42 CFR 455.230 - Eligibility requirements.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

75 FR 14176 - Statement of Organization, Functions, and Delegations of Authority

Federal Register 2010, 2011, 2012, 2013, 2014

2010-03-24

... and on matters that affect other units and levels of government. Contributes to the formulation of... formulation, coordination, integration, implementation, and evaluation of national Medicare program policies... Program Integrity on the identification of program vulnerabilities and implementation of strategies to...

Reforming funding for chronic illness: Medicare-CDM.

PubMed

Swerissen, Hal; Taylor, Michael J

2008-02-01

Chronic diseases are a major challenge for the Australian health care system in terms of both the provision of quality care and expenditure, and these challenges will only increase in the future. Various programs have been instituted under the Medicare system to provide increased funding for chronic care, but essentially these programs still follow the traditional fee-for-service model. This paper proposes a realignment and extension of current Medicare chronic disease management programs into a framework that provides general practitioners and other health professionals with the necessary "tools" for high quality care planning and ongoing management, and incorporating international models of outcome-linked funding. The integration of social support services with the Medicare system is also a necessary step in providing high quality care for patients with complex needs requiring additional support.

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.

42 CFR § 414.1460 - Monitoring and program integrity.

Code of Federal Regulations, 2010 CFR

2017-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Merit-Based Incentive Payment System and Alternative Payment Model Incentive § 414.1460 Monitoring and program integrity. (a) Vetting eligible clinicians prior to payment of the APM Incentive Payment. Prior to...

42 CFR 421.300 - Basis, applicability, and scope.

Code of Federal Regulations, 2010 CFR

2010-10-01

... types of entities eligible to become Medicare integrity program contractors. (2) Identifies the program... organizational conflicts of interest. (5) Prescribes responsibilities. (6) Sets forth limitations on contractor...

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.

42 CFR 1001.1601 - Violations of the limitations on physician charges.

Code of Federal Regulations, 2010 CFR

2010-10-01

... AND HUMAN SERVICES OIG AUTHORITIES PROGRAM INTEGRITY-MEDICARE AND STATE HEALTH CARE PROGRAMS... charges; (iv) Whether the physician has a documented history of criminal, civil or administrative...

42 CFR 455.14 - Preliminary investigation.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

CMS gives the RA program a makeover with more changes in store.

PubMed

2016-03-01

CMS has made changes in the scope of work for the Recovery Auditor program and has proposed a number of other changes to be implemented when new RA contracts are issued. CMS has restricted the number of additional documentation requests, has shortened the "look-back" period for patient status reviews, and announced penalties for RAs with high error rates. The new contracts shorten the time RAs have to complete complex reviews, requires RAs to wait 30 days before referring cases to the Medicare Administrative Contractors, and postpones contingency payments to RAs until after the second level of appeals. The Audit and Appeal Fairness, Integrity, and Reforms in Medicare (AFIRM) bill, introduced in the Senate in December, revamps the appeals process, adding an Ombudsman for Medicare Reviews to assist in resolving complaints by hospitals that have appealed and those considering appeals, and establishes an Appeals Medicare Magistrate program with attorneys who will handle appeals of denials for $1,500 or less.

Looking at CER from Medicare's perspective.

PubMed

Mohr, Penny

2012-05-01

Comparative effectiveness research (CER) is rapidly adding to the amount of data available to health care coverage and payment decision makers. Medicare's decisions have a large effect on coverage and reimbursement policies throughout the health insurance industry and will likely influence the entire U.S. health care system; thus, examining its role in integrating CER into policy is crucial. To describe the potential benefits of CER to support payment and coverage decisions in the Medicare program, limitations on its use,the role of the Centers for Medicare & Medicaid Services (CMS) in improving the infrastructure for CER, and to discuss challenges that must be addressed to integrate CER into CMS's decision-making process. A defining feature of CER is that it provides the type of evidence that will help decision makers, such as patients, clinicians, and payers,make more informed treatment and policy decisions. Because CMS is responsible for more than 47 million elderly and disabled beneficiaries, the way that Medicare uses CER has the potential to have a large impact on public and individual health. Currently many critical payment and coverage decisions within the Medicare program are made on the basis of poor quality evidence, and CER has the potential to greatly improve the quality of decision making. Despite common misconceptions, CMS is not prohibited by law from using CER apart from some reasonable limitations. CMS is,however, required to support the development of the CER infrastructure by making their data more readily available to researchers. While CER has substantial potential to improve the quality of the agency's policy decisions,challenges remain to integrate CER into Medicare's processes. These challenges include statutory ambiguities, lack of sufficient staff and internal resources to take advantage of CER, and the lack of an active voice in setting priorities for CER and study design. Although challenges exist, CER has the potential to greatly enhance CMS's ability to make decisions regarding coverage and payment that will benefit both the agency and their patient population.

Integrated Payment and Delivery Models Offer Opportunities and Challenges for Residential Care Facilities

PubMed Central

Grabowski, David C.; Caudry, Daryl J.; Dean, Katie M.; Stevenson, David G.

2016-01-01

Under health care reform, a series of new financing and delivery models are being piloted to integrate health and long-term care services for older adults. To date, these programs have not encompassed residential care facilities, with most programs focusing on long-term care recipients in the community or the nursing home. Our analyses indicate that individuals living in residential care facilities have similarly high rates of chronic illness and Medicare utilization when compared with similar populations in the community and nursing home. These results suggest the residential care facility population could benefit greatly from models that coordinate health and long-term care. However, few providers have invested in integrated delivery models. Several challenges exist toward greater integration including the private payment of residential care facility services and the fact that residential care facilities do not share in any Medicare savings due to improved coordination of care. PMID:26438740

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-07-22

... Advantage and the Medicare Prescription Drug Benefit Programs; Correction AGENCY: Centers for Medicare... Medicare Advantage and the Medicare Prescription Drug Benefit Programs final rule and does not make... Register titled ``Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and the...

42 CFR 455.16 - Resolution of full investigation.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

42 CFR 455.2 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-06-10

... Medicare Advantage and the Medicare Prescription Drug Benefit Programs; Corrections AGENCY: Centers for... Advantage and the Medicare Prescription Drug Benefit Programs'' which appeared in the April 15, 2010 Federal... and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs...

42 CFR 1001.1801 - Waivers of exclusions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES PROGRAM INTEGRITY-MEDICARE AND STATE HEALTH CARE PROGRAMS Waivers and Effect of Exclusion § 1001... health care program that an exclusion from that program be waived with respect to an individual or entity...

Medicare part D data: major changes on the horizon.

PubMed

Greenwald, Leslie M

2007-10-01

The 3 primary administrative data sets developed by the Centers for Medicare and Medicaid services (CMS) to support the Medicare Part D program implementation represent a valuable source of data for health services researchers. This paper describes the structure of the Medicare Part D program and the related databases, and discusses their utilization for research purposes. The Medicare Part D administrative data include information on plan benefits (integrated into the Health Plan Management System), beneficiary enrollment files, and prescription drug event (PDE) claims-type data. The enrollment data may be of use in investigating the benefits and plan types that appeal to beneficiaries, but their application is limited by the fact that, although individual beneficiaries' enrollment choices are recorded, only summary enrollment data are currently publicly available. PDE data are likely to be of most interest to researchers as they are detailed (including beneficiary identifiers, contract identifiers pharmacy provider information on drugs provided, drug cost, and insurance status), beneficiary-specific (allowing them to be linked to beneficiary characteristics), and an unusual output for a program reimbursed under a capitation-based system. Because PDE data are highly sensitive, only summary data on the number of Part D prescriptions filled are publicly available. Although the data collected in relation to the Medicare Part D program could be applied to many questions of interest to health services researchers, their utility is limited by the sensitive natures of many of these data, making it difficult currently to obtain access for research purposes.

Performance Differences in Year 1 of Pioneer Accountable Care Organizations

PubMed Central

McWilliams, J. Michael; Chernew, Michael E.; Landon, Bruce E.; Schwartz, Aaron L.

2015-01-01

BACKGROUND In 2012, a total of 32 organizations entered the Pioneer accountable care organization (ACO) program, in which providers can share savings with Medicare if spending falls below a financial benchmark. Performance differences associated with characteristics of Pioneer ACOs have not been well described. METHODS In a difference-in-differences analysis of Medicare fee-for-service claims, we compared Medicare spending for beneficiaries attributed to Pioneer ACOs (ACO group) with other beneficiaries (control group) before (2009 through 2011) and after (2012) the start of Pioneer ACO contracts, with adjustment for geographic area and beneficiaries’ sociodemographic and clinical characteristics. We estimated differential changes in spending for several subgroups of ACOs: those with and those without clear financial integration between hospitals and physician groups, those with higher and those with lower baseline spending, and the 13 ACOs that withdrew from the Pioneer program after 2012 and the 19 that did not. RESULTS Adjusted Medicare spending and spending trends were similar in the ACO group and the control group during the precontract period. In 2012, the total adjusted per-beneficiary spending differentially changed in the ACO group as compared with the control group (−$29.2 per quarter, P = 0.007), consistent with a 1.2% savings. Savings were significantly greater for ACOs with baseline spending above the local average, as compared with those with baseline spending below the local average (P = 0.05 for interaction), and for those serving high-spending areas, as compared with those serving low-spending areas (P = 0.04). Savings were similar in ACOs with financial integration between hospitals and physician groups and those without, as well as in ACOs that withdrew from the program and those that did not. CONCLUSIONS Year 1 of the Pioneer ACO program was associated with modest reductions in Medicare spending. Savings were greater for ACOs with higher baseline spending than for those with lower baseline spending and were unrelated to withdrawal from the program. (Funded by the National Institute on Aging and others.) PMID:25875195

Association of Informal Clinical Integration of Physicians With Cardiac Surgery Payments.

PubMed

Funk, Russell J; Owen-Smith, Jason; Kaufman, Samuel A; Nallamothu, Brahmajee K; Hollingsworth, John M

2018-05-01

To reduce inefficiency and waste associated with care fragmentation, many current programs target greater clinical integration among physicians. However, these programs have led to only modest Medicare spending reductions. Most programs focus on formal integration, which often bears little resemblance to actual physician interaction patterns. To examine how physician interaction patterns vary between health systems and to assess whether variation in informal integration is associated with care delivery payments. National Medicare data from January 1, 2008, through December 31, 2011, identified 253 545 Medicare beneficiaries (aged ≥66 years) from 1186 health systems where Medicare beneficiaries underwent coronary artery bypass grafting (CABG) procedures. Interactions were mapped between all physicians who treated these patients-including primary care physicians and surgical and medical specialists-within a health system during their surgical episode. The level of informal integration was measured in these networks of interacting physicians. Multivariate regression models were fitted to evaluate associations between payments for each surgical episode made on a beneficiary's behalf and the level of informal integration in the health system where the patient was treated. The informal integration level of a health system. Price-standardized total surgical episode and component payments. The total 253 545 study participants included 175 520 men (69.2%; mean [SD] age, 74.51 [5.75] years) and 78 024 women (34.3%; 75.67 [5.91] years). One beneficiary of the 253 545 participants did not have sex information. The low level of informal clinical integration included 84 598 patients (33.4%; mean [SD] age, 75.00 [5.93] years); medium level, 84 442 (33.30%; 74.94 [5.87] years); and high level, 84 505 (33.34%; 74.66 [5.72] years) (P < .001). Informal integration levels varied across health systems. After adjusting for patient, health-system, and community factors, higher levels of informal integration were associated with significantly lower total episode and component payments (β coefficients for informal integration were -365.87 [95% CI, -451.08 to -280.67] for total episode payments, -182.63 [-239.80 to -125.46] for index hospitalization, -43.13 [-55.53 to -30.72] for physician services, -74.48 [-103.45 to -45.51] for hospital readmissions, and -62.04 [-88.00 to -36.07] for postacute care; P < .001 for each association). When beneficiaries were treated in health systems with higher informal integration, the greatest savings of lower estimated payments were from hospital readmissions (13.0%) and postacute care services (5.8%). Informal integration is associated with lower spending. Although most programs that seek to promote clinical integration are focused on health systems' formal structures, policy makers may also want to address informal integration.

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

PubMed

Veilleux, Jean Wright

2012-01-01

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

42 CFR 455.17 - Reporting requirements.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

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

Code of Federal Regulations, 2010 CFR

2010-10-01

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

Considering an integrated nephrology care delivery model: six principles for quality.

PubMed

Hamm, L Lee; Hostetter, Thomas H; Shaffer, Rachel N

2013-04-01

In 2012, 27 organizations will initiate participation in the Medicare Shared Savings Program as Accountable Care Organizations. This level of participation reflects the response of Centers for Medicare and Medicaid Services to criticism that the program as outlined in the proposed rule was overly burdensome, prescriptive, and too risky. Centers for Medicare and Medicaid Service made significant changes in the final rule, making the Accountable Care Organization program more attractive to these participants. However, none of these changes addressed the serious concerns raised by subspecialty societies-including the American Society of Nephrology-regarding care of patients with multiple chronic comorbidities and complex and end stage conditions. Virtually all of these concerns remain unaddressed, and consequently, Accountable Care Organizations will require guidance and partnership from the nephrology community to ensure that these patients are identified and receive the individualized care that they require. Although the final rule fell short of addressing the needs of patients with kidney disease, the Centers for Medicare and Medicaid Innovation presents an opportunity to test the potentially beneficial concepts of the Accountable Care Organization program within this patient population. The American Society of Nephrology Accountable Care Organization Task Force developed a set of principles that must be reflected in a possible pilot program or demonstration project of an integrated nephrology care delivery model. These principles include preserving a leadership role for nephrologists, encompassing care for patients with later-stage CKD and kidney transplants as well as ESRD, enabling the participation of a diversity of dialysis provider sizes and types, facilitating research, and establishing monitoring systems to identify and address preferential patient selection or changes in outcomes.

42 CFR 455.20 - Recipient verification procedure.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

42 CFR 455.12 - State plan requirement.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

Improving Refill Adherence in Medicare Patients With Tailored and Interactive Mobile Text Messaging: Pilot Study

PubMed Central

Jeong, Erwin W; Feger, Erin; Noble, Harmony K; Kmiec, Magdalen; Prayaga, Ram S

2018-01-01

Background Nonadherence is a major concern in the management of chronic conditions such as hypertension, cardiovascular disease, and diabetes where patients may discontinue or interrupt their medication for a variety of reasons. Text message reminders have been used to improve adherence. However, few programs or studies have explored the benefits of text messaging with older populations and at scale. In this paper, we present a program design using tailored and interactive text messaging to improve refill rates of partially adherent or nonadherent Medicare members of a large integrated health plan. Objective The aim of this 3-month program was to gain an understanding of whether tailored interactive text message dialogues could be used to improve medication refills in Medicare patients with one or more chronic diseases. Methods We used the mPulse Mobile interactive text messaging solution with partially adherent and nonadherent Medicare patients (ie, over age 65 years or younger with disabilities) of Kaiser Permanente Southern California (KP), a large integrated health plan, and compared refill rates of the text messaging group (n=12,272) to a group of partially adherent or nonadherent Medicare patients at KP who did not receive text messages (nontext messaging group, n=76,068). Both groups were exposed to other forms of refill and adherence outreach including phone calls, secure emails, and robo-calls from December 2016 to February 2017. Results The text messaging group and nontext messaging group were compared using an independent samples t test to test difference in group average of refill rates. There was a significant difference in medication refill rates between the 2 groups, with a 14.07 percentage points higher refill rate in the text messaging group (P<.001). Conclusions The results showed a strong benefit of using this text messaging solution to improve medication refill rates among Medicare patients. These findings also support using interactive text messaging as a cost-effective, convenient, and user-friendly solution for patient engagement. Program outcomes and insights can be used to enhance the design of future text-based solutions to improve health outcomes and promote adherence and long-term behavior change. PMID:29382623

42 CFR 422.310 - Risk adjustment data.

Code of Federal Regulations, 2014 CFR

2014-10-01

... practitioner that would be permitted to bill separately under the original Medicare program, even if they... activities conducted to support program integrity; and (ix) For purposes authorized by other applicable laws... external entities in accordance with the following: (i) Applicable Federal laws; (ii) CMS data sharing...

42 CFR 455.19 - Provider's statement on check.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

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

Code of Federal Regulations, 2010 CFR

2010-10-01

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

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

Code of Federal Regulations, 2010 CFR

2010-10-01

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

42 CFR 1001.2 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false Definitions. 1001.2 Section 1001.2 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES PROGRAM INTEGRITY-MEDICARE AND STATE HEALTH CARE PROGRAMS General Provisions § 1001.2 Definitions. Controlled...

76 FR 63017 - Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-10-11

... to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year 2013 and Other Proposed Changes; Considering Changes to the Conditions of Participation for Long Term Care... to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year 2013...

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

PubMed

2016-11-15

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

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.

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

PubMed

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

2017-06-01

As the implementation of the Medicare Access and Children's Health Insurance Program Reauthorization Act begins, many dermatologists who provide Medicare Part B services will be subject to the reporting requirements of the Merit-based Incentive Payment System (MIPS). Clinicians subject to MIPS will receive a composite score based on performance across 4 categories: quality, advancing care information, improvement activities, and cost. Depending on their overall MIPS score, clinicians will be eligible for a positive or negative payment adjustment. Quality will replace the Physician Quality Reporting System and clinicians will report on 6 measures from a list of over 250 options. Advancing care information will replace meaningful use and will assess clinicians on activities related to integration of electronic health record technology into their practice. Improvement activities will require clinicians to attest to completion of activities focused on improvements in care coordination, beneficiary engagement, and patient safety. Finally, cost will be determined automatically from Medicare claims data. In this article, we will provide a detailed review of the Medicare Access and Children's Health Insurance Program Reauthorization Act with a focus on MIPS and briefly discuss the potential implications for dermatologists. Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-12-07

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

42 CFR 1001.102 - Length of exclusion.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 5 2012-10-01 2012-10-01 false Length of exclusion. 1001.102 Section 1001.102 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES PROGRAM INTEGRITY-MEDICARE AND STATE HEALTH CARE PROGRAMS Mandatory Exclusions § 1001.102 Length...

42 CFR 1001.102 - Length of exclusion.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 5 2013-10-01 2013-10-01 false Length of exclusion. 1001.102 Section 1001.102 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES PROGRAM INTEGRITY-MEDICARE AND STATE HEALTH CARE PROGRAMS Mandatory Exclusions § 1001.102 Length...

42 CFR 1001.102 - Length of exclusion.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 5 2011-10-01 2011-10-01 false Length of exclusion. 1001.102 Section 1001.102 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES PROGRAM INTEGRITY-MEDICARE AND STATE HEALTH CARE PROGRAMS Mandatory Exclusions § 1001.102 Length...

42 CFR 1001.102 - Length of exclusion.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false Length of exclusion. 1001.102 Section 1001.102 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES PROGRAM INTEGRITY-MEDICARE AND STATE HEALTH CARE PROGRAMS Mandatory Exclusions § 1001.102 Length...

42 CFR 1001.102 - Length of exclusion.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 5 2014-10-01 2014-10-01 false Length of exclusion. 1001.102 Section 1001.102 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES PROGRAM INTEGRITY-MEDICARE AND STATE HEALTH CARE PROGRAMS Mandatory Exclusions § 1001.102 Length...

42 CFR 1001.952 - Exceptions.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 5 2013-10-01 2013-10-01 false Exceptions. 1001.952 Section 1001.952 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES PROGRAM INTEGRITY-MEDICARE AND STATE HEALTH CARE PROGRAMS Permissive Exclusions § 1001.952 Exceptions. The following payment practices shall not be...

42 CFR 1001.952 - Exceptions.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 5 2012-10-01 2012-10-01 false Exceptions. 1001.952 Section 1001.952 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES PROGRAM INTEGRITY-MEDICARE AND STATE HEALTH CARE PROGRAMS Permissive Exclusions § 1001.952 Exceptions. The following payment practices shall not be...

42 CFR 1001.952 - Exceptions.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 5 2014-10-01 2014-10-01 false Exceptions. 1001.952 Section 1001.952 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES PROGRAM INTEGRITY-MEDICARE AND STATE HEALTH CARE PROGRAMS Permissive Exclusions § 1001.952 Exceptions. The following payment practices shall not be...

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

Code of Federal Regulations, 2010 CFR

2010-10-01

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

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...

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.

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.

76 FR 66931 - Medicare Program: Notice of Two Membership Appointments to the Advisory Panel on Ambulatory...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-10-28

... Administrator) concerning the clinical integrity of the APC groups and their weights. The advice provided by the Panel will be considered as CMS prepares its annual updates of the hospital outpatient prospective... clinical integrity of the Ambulatory Payment Classification (APC) groups and their associated weights. The...

Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2017 Rates; Quality Reporting Requirements for Specific Providers; Graduate Medical Education; Hospital Notification Procedures Applicable to Beneficiaries Receiving Observation Services; Technical Changes Relating to Costs to Organizations and Medicare Cost Reports; Finalization of Interim Final Rules With Comment Period on LTCH PPS Payments for Severe Wounds, Modifications of Limitations on Redesignation by the Medicare Geographic Classification Review Board, and Extensions of Payments to MDHs and Low-Volume Hospitals. Final rule.

PubMed

2016-08-22

We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2017. Some of these changes will implement certain statutory provisions contained in the Pathway for Sustainable Growth Reform Act of 2013, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Notice of Observation Treatment and Implications for Care Eligibility Act of 2015, and other legislation. We also are providing the estimated market basket update to apply to the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2017. We are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2017. In addition, we are making changes relating to direct graduate medical education (GME) and indirect medical education payments; establishing new requirements or revising existing requirements for quality reporting by specific Medicare providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities), including related provisions for eligible hospitals and critical access hospitals (CAHs) participating in the Electronic Health Record Incentive Program; updating policies relating to the Hospital Value-Based Purchasing Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition Reduction Program; implementing statutory provisions that require hospitals and CAHs to furnish notification to Medicare beneficiaries, including Medicare Advantage enrollees, when the beneficiaries receive outpatient observation services for more than 24 hours; announcing the implementation of the Frontier Community Health Integration Project Demonstration; and making technical corrections and changes to regulations relating to costs to related organizations and Medicare cost reports; we are providing notice of the closure of three teaching hospitals and the opportunity to apply for available GME resident slots under section 5506 of the Affordable Care Act. We are finalizing the provisions of interim final rules with comment period that relate to a temporary exception for certain wound care discharges from the application of the site neutral payment rate under the LTCH PPS for certain LTCHs; application of two judicial decisions relating to modifications of limitations on redesignation by the Medicare Geographic Classification Review Board; and legislative extensions of the Medicare-dependent, small rural hospital program and changes to the payment adjustment for low-volume hospitals.

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...

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

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...

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...

Improving Refill Adherence in Medicare Patients With Tailored and Interactive Mobile Text Messaging: Pilot Study.

PubMed

Brar Prayaga, Rena; Jeong, Erwin W; Feger, Erin; Noble, Harmony K; Kmiec, Magdalen; Prayaga, Ram S

2018-01-30

Nonadherence is a major concern in the management of chronic conditions such as hypertension, cardiovascular disease, and diabetes where patients may discontinue or interrupt their medication for a variety of reasons. Text message reminders have been used to improve adherence. However, few programs or studies have explored the benefits of text messaging with older populations and at scale. In this paper, we present a program design using tailored and interactive text messaging to improve refill rates of partially adherent or nonadherent Medicare members of a large integrated health plan. The aim of this 3-month program was to gain an understanding of whether tailored interactive text message dialogues could be used to improve medication refills in Medicare patients with one or more chronic diseases. We used the mPulse Mobile interactive text messaging solution with partially adherent and nonadherent Medicare patients (ie, over age 65 years or younger with disabilities) of Kaiser Permanente Southern California (KP), a large integrated health plan, and compared refill rates of the text messaging group (n=12,272) to a group of partially adherent or nonadherent Medicare patients at KP who did not receive text messages (nontext messaging group, n=76,068). Both groups were exposed to other forms of refill and adherence outreach including phone calls, secure emails, and robo-calls from December 2016 to February 2017. The text messaging group and nontext messaging group were compared using an independent samples t test to test difference in group average of refill rates. There was a significant difference in medication refill rates between the 2 groups, with a 14.07 percentage points higher refill rate in the text messaging group (P<.001). The results showed a strong benefit of using this text messaging solution to improve medication refill rates among Medicare patients. These findings also support using interactive text messaging as a cost-effective, convenient, and user-friendly solution for patient engagement. Program outcomes and insights can be used to enhance the design of future text-based solutions to improve health outcomes and promote adherence and long-term behavior change. ©Rena Brar Prayaga, Erwin W Jeong, Erin Feger, Harmony K Noble, Magdalen Kmiec, Ram S Prayaga. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 30.01.2018.

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-08-20

...] Medicare Program; Request for Nominations for Members for the Medicare Evidence Development & Coverage... notice announces the request for nominations for membership on the Medicare Evidence Development... Centers for Medicare & Medicaid Services (CMS) concerning the adequacy of scientific evidence available to...

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...

77 FR 16841 - Medicare Program; Solicitation for Proposals for the Medicare Graduate Nurse Education...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-22

...] Medicare Program; Solicitation for Proposals for the Medicare Graduate Nurse Education Demonstration... informs interested parties of an opportunity to apply to participate in the Medicare Graduate Nurse... advanced practice registered nurses (APRNs) in order to meet the health care needs of the growing Medicare...

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...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-22

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

76 FR 37120 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-24

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-12-02

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

42 CFR 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. ...

A taxonomy of hospitals participating in Medicare accountable care organizations.

PubMed

Bazzoli, Gloria J; Harless, David W; Chukmaitov, Askar S

2017-03-03

Medicare was an early innovator of accountable care organizations (ACOs), establishing the Medicare Shared Savings Program (MSSP) and Pioneer programs in 2012-2013. Existing research has documented that ACOs bring together an array of health providers with hospitals serving as important participants. Hospitals vary markedly in their service structure and organizational capabilities, and thus, one would expect hospital ACO participants to vary in these regards. Our research identifies hospital subgroups that share certain capabilities and competencies. Such research, in conjunction with existing ACO research, provides deeper understanding of the structure and operation of these organizations. Given that Medicare was an initiator of the ACO concept, our findings provide a baseline to track the evolution of ACO hospitals over time. Hierarchical clustering methods are used in separate analyses of MSSP and Pioneer ACO hospitals. Hospitals participating in ACOs with 2012-2013 start dates are identified through multiple sources. Study data come from the Centers for Medicare and Medicaid Services, American Hospital Association, and Health Information and Management Systems Society. Five-cluster solutions were developed separately for the MSSP and Pioneer hospital samples. Both the MSSP and Pioneer taxonomies had several clusters with high levels of health information technology capabilities. Also distinct clusters with strong physician linkages were present. We examined Pioneer ACO hospitals that subsequently left the program and found that they commonly had low levels of ambulatory care services or health information technology. Distinct subgroups of hospitals exist in both the MSSP and Pioneer programs, suggesting that individual hospitals serve different roles within an ACO. Health information technology and physician linkages appear to be particularly important features in ACO hospitals. ACOs need to consider not only geographic and service mix when selecting hospital participants but also their vertical integration features and management competencies.

Quality Of End-Of-Life Care Is Higher In The VA Compared To Care Paid For By Traditional Medicare.

PubMed

Gidwani-Marszowski, Risha; Needleman, Jack; Mor, Vincent; Faricy-Anderson, Katherine; Boothroyd, Derek B; Hsin, Gary; Wagner, Todd H; Lorenz, Karl A; Patel, Manali I; Joyce, Vilija R; Murrell, Samantha S; Ramchandran, Kavitha; Asch, Steven M

2018-01-01

Congressional and Veterans Affairs (VA) leaders have recommended the VA become more of a purchaser than a provider of health care. Fee-for-service Medicare provides an example of how purchased care differs from the VA's directly provided care. Using established indicators of overly intensive end-of-life care, we compared the quality of care provided through the two systems to veterans dying of cancer in fiscal years 2010-14. The Medicare-reliant veterans were significantly more likely to receive high-intensity care, in the form of chemotherapy, hospital stays, admission to the intensive care unit, more days spent in the hospital, and death in the hospital. However, they were significantly less likely than VA-reliant patients to have multiple emergency department visits. Higher-intensity end-of-life care may be driven by financial incentives present in fee-for-service Medicare but not in the VA's integrated system. To avoid putting VA-reliant veterans at risk of receiving lower-quality care, VA care-purchasing programs should develop coordination and quality monitoring programs to guard against overly intensive end-of-life care.

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...

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.

Medicare managed care. How physicians can make it better.

PubMed

Roggin, G M

1997-12-01

The federal government is attempting to control anticipated, increased Medicare health care costs by providing the senior population with incentives to encourage their movement into managed care programs. For-profit corporate HMOs that currently dominate the managed care arena are coming under increased competitive pressure at a time when their perception of profiteering is undergoing increased public scrutiny. If physicians are to take advantage of this window of opportunity and successfully enter the Medicare managed care marketplace, they must identify the major deficiencies existing in the current model, and fashion a new product that divests itself of the profit orientation of current corporate HMOs. A nonprofit version of a highly integrated, multispecialty provider service organization (PSO) provides an appropriate model to effectively compete with the corporate HMO. The ideal physician-controlled managed care model must: develop a responsive policy board structure; create practice guidelines that decrease variation in physician practice; achieve an appropriate balance between primary and specialty medical care; and adopt a quality-assurance program that effectively addresses both process and outcome data.

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...

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...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-11-15

...-through devices, brachytherapy sources, intraoperative radiation therapy (IORT), brachytherapy composite... Modulated Radiation Therapy I/OCE Integrated Outpatient Code Editor IOL Intraocular lens IOM Institute of Medicine IORT Intraoperative radiation treatment IPF Inpatient Psychiatric Facility IPPS [Hospital...

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

Code of Federal Regulations, 2010 CFR

2010-10-01

... services to a MIP contractor is not in violation of any criminal law or civilly liable under any law of the United States or of any State (or political subdivision thereof) by reason of the performance of any duty...

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...

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...

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.

Insights from a pilot program to integrate medical and social services.

PubMed

Meiners, Mark R; Mokler, Pamela M; Kasunic, Mary Lynn; Hawthornthwaite, Scott; Foster, Susan; Scheer, David; Maldonado, Anna Maria

2014-01-01

This study examines lessons learned from the design, implementation, and early results of an integrated managed care pilot program linking member benefits of a Medicare-Medicaid health care plan with community services and supports. The health plan's average monthly costs for members receiving an assessment and services declined by an economically meaningful, statistically significant amount in the postintervention period relative to the preintervention period compared with those who did not accept an assessment or services. The results along with the lesson learned from the pilot are viewed by the parties as supportive of further program development.

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...

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

Code of Federal Regulations, 2010 CFR

2010-10-01

... for improving Medicare program efficiency and to reward suggesters for monetary savings. 420.410... Program Efficiency and to Reward Suggesters for Monetary Savings § 420.410 Establishment of a program to collect suggestions for improving Medicare program efficiency and to reward suggesters for monetary...

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

Code of Federal Regulations, 2011 CFR

2011-10-01

... for improving Medicare program efficiency and to reward suggesters for monetary savings. 420.410... Program Efficiency and to Reward Suggesters for Monetary Savings § 420.410 Establishment of a program to collect suggestions for improving Medicare program efficiency and to reward suggesters for monetary...

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...

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.

How the center for Medicare and Medicaid innovation should test accountable care organizations.

PubMed

Shortell, Stephen M; Casalino, Lawrence P; Fisher, Elliott S

2010-07-01

The Patient Protection and Affordable Care Act establishes a national voluntary program for accountable care organizations (ACOs) by January 2012 under the auspices of the Centers for Medicare and Medicaid Services (CMS). The act also creates a Center for Medicare and Medicaid Innovation in the CMS. We propose that the CMS allow flexibility and tiers in ACOs based on their specific circumstances, such as the degree to which they are or are not fully integrated systems. Further, we propose that the CMS assume responsibility for ACO provisions and develop an ordered system for learning how to create and sustain ACOs. Key steps would include setting specific performance goals, developing skills and tools that facilitate change, establishing measurement and accountability mechanisms, and supporting leadership development.

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...

Translation of a dementia caregiver intervention for delivery in homecare as a reimbursable Medicare service: outcomes and lessons learned.

PubMed

Gitlin, Laura N; Jacobs, Mimi; Earland, Tracey Vause

2010-12-01

families of dementia patients receiving skilled homecare do not receive supportive services. We evaluated whether a proven intervention, Environmental Skill-building Program (ESP), which reduces caregiver burden and enhances skills managing patient functioning, can be integrated into homecare practices of occupational therapists (OTs) and reimbursed through Medicare Part B. a 2-year translational project with a homecare practice was conducted. Five translational activities included refining ESP, site preparation, therapist training, establishing referral mechanisms, and evaluating outcomes using Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM). of 30 OTs approached for participation, 23 (77%) agreed, 22 (96%) completed training, and 21 (95.5%) used ESP and intended to continue use. Of 69 eligible caregivers, 41 (59%) agreed to participate averaging 4.7 sessions. Of 20 returned caregiver surveys, enhancements were reported in all targeted areas of knowledge and skills. Fidelity monitoring revealed inconsistency in therapists use of problem solving, yet caregiver enactment of ESP strategies was high. ESP sessions integrated within patient-directed therapy were reimbursed by Medicare Part B. RE-AIM indicators suggest moderate translational success. As ESP was reimbursed through Medicare B, its delivery may be sustainable and meet the needs of family caregivers of dementia patients receiving therapies at home.

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...

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...

Cognition, Health Literacy, and Actual and Perceived Medicare Knowledge Among Inner-City Medicare Beneficiaries.

PubMed

Sivakumar, Haran; Hanoch, Yaniv; Barnes, Andrew J; Federman, Alex D

2016-01-01

Poor Medicare knowledge is associated with worse health outcomes, especially in low-income patients. We examined the association of health literacy and cognition with actual and perceived Medicare knowledge in a sample of inner-city older adults. We conducted a cross-sectional analysis of data on 336 adults ages 65 years and older with Medicare coverage recruited from senior centers and low-income housing facilities in Manhattan, New York. Actual Medicare knowledge was determined by a summary score of 9 true/false questions about the Medicare program and perceived Medicare knowledge with a single item. Validated measures were used to assess health literacy and general cognition. Among respondents, 63.1% had high actual Medicare knowledge, and 36.0% believed that they knew what they needed to know about Medicare. Actual and perceived Medicare knowledge were poorly correlated (r = -.01, p > .05). In multivariable models, low health literacy was significantly associated with actual Medicare knowledge (β = -8.30, SE = 2.71, p < .01) but not perceived Medicare knowledge (β = 0.37, SE = 0.22, p = .09). Individuals with low health literacy were more likely to perceive their Medicare knowledge as adequate when actual Medicare knowledge was low (adjusted odds ratio = 3.30, 95% confidence interval [1.20, 9.05], p < .05). These results show that older adults with low health literacy are more likely to have poor understanding of the Medicare program and yet more likely to believe that their understanding of the program is adequate. This combination of factors may place them at increased risk for poor access to information about the Medicare program and diminish their ability to make fully informed choices.

75 FR 67751 - Medicare Program: Community-Based Care Transitions Program (CCTP) Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-03

...] Medicare Program: Community-Based Care Transitions Program (CCTP) Meeting AGENCY: Centers for Medicare... guidance and ask questions about the upcoming Community-based Care Transitions Program. The meeting is open... registration information will be posted on the CMS Care Transitions Web site at http://www.cms.gov/DemoProjects...

Financial performance in the social health maintenance organization, 1985-88

PubMed Central

Leutz, Walter; Malone, Joelyn; Kistner, Marlin; O'Bar, Tim; Ripley, Jeanne M.; Sandhaus, Martin

1990-01-01

Since early 1985, four social health maintenance organizations have delivered integrated health and long-term care services to Medicare beneficiaries under congressionally mandated waivers that included shared public-program risk for losses. Three of four sites had substantial losses in the first 3 years, primarily because of slow enrollment and resultant high marketing and administrative costs. After assuming full risk, two of the three showed surpluses in 1988. Service and management costs for expanded long-term care were similar across sites and were affordable within the framework of Medicare and Medicaid reimbursement and private premiums. PMID:10113466

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...

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...

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

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...

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.

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...

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...

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...

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...

Delivery System Integration and Health Care Spending and Quality for Medicare Beneficiaries

PubMed Central

McWilliams, J. Michael; Chernew, Michael E.; Zaslavsky, Alan M.; Hamed, Pasha; Landon, Bruce E.

2013-01-01

Background The Medicare accountable care organization (ACO) programs rely on delivery system integration and provider risk sharing to lower spending while improving quality of care. Methods Using 2009 Medicare claims and linked American Medical Association Group Practice data, we assigned 4.29 million beneficiaries to provider groups based on primary care use. We categorized group size according to eligibility thresholds for the Shared Savings (≥5,000 assigned beneficiaries) and Pioneer (≥15,000) ACO programs and distinguished hospital-based from independent groups. We compared spending and quality of care between larger and smaller provider groups and examined how size-related differences varied by 2 factors considered central to ACO performance: group primary care orientation (measured by the primary care share of large groups’ specialty mix) and provider risk sharing (measured by county health maintenance organization penetration and its relationship to financial risk accepted by different group types for managed care patients). Spending and quality of care measures included total medical spending, spending by type of service, 5 process measures of quality, and 30-day readmissions, all adjusted for sociodemographic and clinical characteristics. Results Compared with smaller groups, larger hospital-based groups had higher total per-beneficiary spending in 2009 (mean difference: +$849), higher 30-day readmission rates (+1.3% percentage points), and similar performance on 4 of 5 process measures of quality. In contrast, larger independent physician groups performed better than smaller groups on all process measures and exhibited significantly lower per-beneficiary spending in counties where risk sharing by these groups was more common (−$426). Among all groups sufficiently large to participate in ACO programs, a strong primary care orientation was associated with lower spending, fewer readmissions, and better quality of diabetes care. Conclusions Spending was lower and quality of care better for Medicare beneficiaries served by larger independent physician groups with strong primary care orientations in environments where providers accepted greater risk. PMID:23780467

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-05-31

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-04-11

... the Support of the Senior Medicare Patrol (SMP) Program ACTION: Notice of intent to provide expansion... funds for the support of the Senior Medicare Patrol (SMP) Program. This additional funding opportunity... program capacity to recruit, train, and support the SMP volunteer network. In addition, this funding...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-04-23

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

42 CFR 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...

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 423.800 - 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 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 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 effect of integration of hospitals and post-acute care providers on Medicare payment and patient outcomes.

PubMed

Konetzka, R Tamara; Stuart, Elizabeth A; Werner, Rachel M

2018-02-07

In this paper we examine empirically the effect of integration on Medicare payment and rehospitalization. We use 2005-2013 data on Medicare beneficiaries receiving post-acute care (PAC) in the U.S. to examine integration between hospitals and the two most common post-acute care settings: skilled nursing facilities (SNFs) and home health agencies (HHA), using two measures of integration-formal vertical integration and informal integration representing preferential relationships between providers without formal relationships. Our identification strategy is twofold. First, we use longitudinal models with a fixed effect for each hospital-PAC pair in a market to test how changes in integration impact patient outcomes. Second, we use an instrumental variable approach to account for patient selection into integrated providers. We find that vertical integration between hospitals and SNFs increases Medicare payments and reduces rehospitalization rates. However, vertical integration between hospitals and HHAs has little effect, nor does informal integration between hospitals and either PAC setting. Copyright © 2018 The Author(s). Published by Elsevier B.V. All rights reserved.

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...

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...

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...

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 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 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...

An Analysis of Medicare's Incentive Payment Program for Physicians in Health Professional Shortage Areas

ERIC Educational Resources Information Center

Chan, Leighton; Hart, L. Gary; Ricketts III, Thomas C.; Beaver, Shelli K.

2004-01-01

Medicare's Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat Medicare patients in rural and urban areas where there is a shortage of generalist physicians. Purpose: To examine the experience of Alaska, Idaho, North Carolina, South Carolina, and Washington with the MIP program. We determined the program's…

Medicare+Choice: what lies ahead?

PubMed

Layne, R Jeffrey

2002-03-01

Health plans have continued to exit the Medicare+Choice program in recent years, despite efforts of Congress and the Centers for Medicare and Medicaid Services (CMS) to reform the program. Congress and CMS therefore stand poised to make additional, substantial reforms to the program. CMS has proposed to consolidate its oversight of the program, extend the due date for Medicare+Choice plans to file their adjusted community rate proposals, revise risk-adjustment processes, streamline the marketing review process, enhance quality-improvement requirements, institute results based performance assessment audits, coordinate policy changes to coincide with contracting cycles, expand its fall advertising campaign for the program, provide better employer-based Medicare options for beneficiaries, and take steps to minimize beneficiary costs. Congressional leaders have proposed various legislative remedies to improve the program, including creation of an entirely new pricing structure for the program based on a competitive bidding process.

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).

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

Medicare program; additional extension of the payment adjustment for low-volume hospitals and the Medicare-dependent hospital (MDH) program under the hospital Inpatient Prospective Payment Systems (IPPS) for acute care hospitals for fiscal year 2014. Extension of a payment adjustment and a program.

PubMed

2014-06-17

This document announces changes to the payment adjustment for low-volume hospitals and to the Medicare-dependent hospital (MDH) program under the hospital inpatient prospective payment systems (IPPS) for the second half of FY 2014 (April 1, 2014 through September 30, 2014) in accordance with sections 105 and 106, respectively, of the Protecting Access to Medicare Act of 2014 (PAMA).

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.

Expanding physician education in health care fraud and program integrity.

PubMed

Agrawal, Shantanu; Tarzy, Bruce; Hunt, Lauren; Taitsman, Julie; Budetti, Peter

2013-08-01

Program integrity (PI) spans the entire spectrum of improper payments from fraud to abuse, errors, and waste in the health care system. Few physicians will perpetrate fraud or abuse during their careers, but nearly all will contribute to the remaining spectrum of improper payments, making preventive education in this area vital. Despite the enormous impact that PI issues have on government-sponsored and private insurance programs, physicians receive little formal education in this area. Physicians' lack of awareness of PI issues not only makes them more likely to submit inappropriate claims, generate orders that other providers and suppliers will use to submit inappropriate claims, and document improperly in the medical record but also more likely to become victims of fraud schemes themselves.In this article, the authors provide an overview of the current state of PI issues in general, and fraud in particular, as well as a description of the state of formal education for practicing physicians, residents, and fellows. Building on the lessons from pilot programs conducted by the Centers for Medicare and Medicaid Services and partner organizations, the authors then propose a model PI education curriculum to be implemented nationwide for physicians at all levels. They recommend that various stakeholder organizations take part in the development and implementation process to ensure that all perspectives are included. Educating physicians is an essential step in establishing a broader culture of compliance and improved integrity in the health care system, extending beyond Medicare and Medicaid.

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...

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 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...

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...

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.

77 FR 29033 - Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital Conditions of...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-05-16

... organizational structure, whereby multi- hospital systems have integrated their governing body functions to... based on nationally recognized and evidence-based guidelines and recommendations. Verbal Orders: We have..., Outpatient services ($300 million). Our estimates were based on input from stakeholders as well as on our own...

42 CFR 418.56 - Condition of participation: Interdisciplinary group, care planning, and coordination of services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HOSPICE CARE... level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice... communication and integration, in accordance with the hospice's own policies and procedures, to— (1) Ensure that...

75 FR 81138 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-27

... [CMS-1510-CN2] RIN 0938-AP88 Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011; Changes in Certification Requirements for Home Health Agencies and Hospices AGENCY... ``Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011; Changes in...

78 FR 39730 - Medicare Program; Notification of Closure of Teaching Hospitals and Opportunity To Apply for...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-07-02

..., Medicare--Hospital Insurance; and Program No. 93.774, Medicare-- Supplementary Medical Insurance Program.... SUMMARY: This document corrects a typographical error that appeared in the notice published in the Federal... typographical error that is identified and corrected in the Correction of Errors section below. II. Summary of...

Disease management for chronically ill beneficiaries in traditional Medicare.

PubMed

Bott, David M; Kapp, Mary C; Johnson, Lorraine B; Magno, Linda M

2009-01-01

We summarize the Centers for Medicare and Medicaid Services' (CMS's) experience with disease management (DM) in fee-for-service Medicare. Since 1999, the CMS has conducted seven DM demonstrations involving some 300,000 beneficiaries in thirty-five programs. Programs include provider-based, third-party, and hybrid models. Reducing costs sufficient to cover program fees has proved particularly challenging. Final evaluations on twenty programs found three with evidence of quality improvement at or near budget-neutrality, net of fees. Interim monitoring covering at least twenty-one months on the remaining fifteen programs suggests that four are close to covering their fees. Characteristics of the traditional Medicare program present a challenge to these DM models.

The Spillover Effects of Medicare Managed Care: Medicare Advantage and Hospital Utilization

PubMed Central

Baicker, Katherine; Chernew, Michael; Robbins, Jacob

2013-01-01

More than a quarter of Medicare beneficiaries are enrolled in Medicare Advantage, which was created in large part to improve the efficiency of health care delivery by promoting competition among private managed care plans. This paper explores the spillover effects of the Medicare Advantage program on the traditional Medicare program and other patients, taking advantage of changes in Medicare Advantage payment policy to isolate exogenous increases in Medicare Advantage enrollment and trace out the effects of greater managed care penetration on hospital utilization and spending throughout the health care system. We find that when more seniors enroll in Medicare managed care, hospital costs decline for all seniors and for commercially insured younger populations. Greater managed care penetration is not associated with fewer hospitalizations, but is associated with lower costs and shorter stays per hospitalization. These spillovers are substantial – offsetting more than 10% of increased payments to Medicare Advantage plans. PMID:24308880

Seizing opportunities under the Affordable Care Act for transforming the mental and behavioral health system.

PubMed

Mechanic, David

2012-02-01

The Affordable Care Act, along with Medicaid expansions, offers the opportunity to redesign the nation's highly flawed mental health system. It promotes new programs and tools, such as health homes, interdisciplinary care teams, the broadening of the Medicaid Home and Community-Based Services option, co-location of physical health and behavioral services, and collaborative care. Provisions of the act offer extraordinary opportunities, for instance, to insure many more people, reimburse previously unreimbursed services, integrate care using new information technology tools and treatment teams, confront complex chronic comorbidities, and adopt underused evidence-based interventions. The Centers for Medicare and Medicaid Services and its Center for Medicare and Medicaid Innovation should work intensively with the states to implement these new programs and other arrangements and begin to fulfill the many unmet promises of community mental health care.

Public financing of the Medicare program will make its uniform structure increasingly costly to sustain.

PubMed

Baicker, Katherine; Shepard, Mark; Skinner, Jonathan

2013-05-01

The US Medicare program consumes an ever-rising share of the federal budget. Although this public spending can produce health and social benefits, raising taxes to finance it comes at the cost of slower economic growth. In this article we describe a model incorporating the benefits of public programs and the cost of tax financing. The model implies that the "one-size-fits-all" Medicare program, with everyone covered by the same insurance policy, will be increasingly difficult to sustain. We show that a Medicare program with guaranteed basic benefits and the option to purchase additional coverage could lead to more unequal health spending but slower growth in taxation, greater overall well-being, and more rapid growth of gross domestic product. Our framework highlights the key trade-offs between Medicare spending and economic prosperity.

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...

Medicare and Medicaid programs; hospital conditions of participation; provider agreements and supplier approval--HCFA. Proposed rule.

PubMed

1997-12-19

This proposed rule would revise the requirements that hospitals must meet to participate in the Medicare and Medicaid programs. The revised requirements focus on patients care and the outcomes of that care, reflect a cross-functional view of patient treatment, encourage flexibility in meeting quality standards, and eliminate unnecessary procedural requirements. These changes are necessary to reflect advances in patient care delivery and quality assessment practices since the requirements were last revised in 1986. They are also an integral part of the Administration's efforts to achieve broad-based improvements in the quality of care furnished through Federal programs and in the measurement of that care, while at the same time reducing procedural burdens on providers. In addition, in an effort to increase the number of organ donations, we are proposing changes in the interaction between hospitals and organ procurement organizations. The proposed rule also would specify that HCFA may terminate the participation agreement of a hospital, skilled nursing facility, home health agency, or other provider if the provider refuses to allow access to its facilities, or examination of its operations or records, by or on behalf of HCFA, as necessary to verify that it is complying with the Medicare law and regulations and the terms of its provider agreement.

Integrated Payment And Delivery Models Offer Opportunities And Challenges For Residential Care Facilities.

PubMed

Grabowski, David C; Caudry, Daryl J; Dean, Katie M; Stevenson, David G

2015-10-01

Under health care reform, new financing and delivery models are being piloted to integrate health and long-term care services for older adults. Programs using these models generally have not included residential care facilities. Instead, most of them have focused on long-term care recipients in the community or the nursing home. Our analyses indicate that individuals living in residential care facilities have similarly high rates of chronic illness and Medicare utilization when compared with matched individuals in the community and nursing home, and rates of functional dependency that fall between those of their counterparts in the other two settings. These results suggest that the residential care facility population could benefit greatly from models that coordinated health and long-term care services. However, few providers have invested in the infrastructure needed to support integrated delivery models. Challenges to greater care integration include the private-pay basis for residential care facility services, which precludes shared savings from reduced Medicare costs, and residents' preference for living in a home-like, noninstitutional environment. Project HOPE—The People-to-People Health Foundation, Inc.

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

PubMed

Hallam, K; Gardner, J

1999-11-08

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

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.

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...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-07-09

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

The Impact Of Medicare ACOs On Improving Integration And Coordination Of Physical And Behavioral Health Care.

PubMed

Fullerton, Catherine A; Henke, Rachel M; Crable, Erika L; Hohlbauch, Andriana; Cummings, Nicholas

2016-07-01

The accountable care organization (ACO) model holds the promise of reducing costs and improving the quality of care by realigning payment incentives to focus on health outcomes instead of service volume. One key to managing the total cost of care is improving care coordination for and treatment of people with behavioral health disorders. We examined qualitative data from ninety organizations participating in Medicare ACO demonstration programs from 2012 through 2015 to determine whether and how they focused on behavioral health care. These ACOs had mixed degrees of engagement in improving behavioral health care for their populations. The biggest challenges included a lack of behavioral health care providers, data availability, and sustainable financing models. Nonetheless, we found substantial interest in integrating behavioral health care into primary care across a majority of the ACOs. Project HOPE—The People-to-People Health Foundation, Inc.

76 FR 21431 - Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-04-15

...This final rule makes revisions to the Medicare Advantage (MA) program (Part C) and Prescription Drug Benefit Program (Part D) to implement provisions specified in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act) (ACA) and make other changes to the regulations based on our experience in the administration of the Part C and Part D programs. These latter revisions clarify various program participation requirements; make changes to strengthen beneficiary protections; strengthen our ability to identify strong applicants for Part C and Part D program participation and remove consistently poor performers; and make other clarifications and technical changes.

Public Financing Of The Medicare Program Will Make Its Uniform Structure Increasingly Costly To Sustain

PubMed Central

Baicker, Katherine; Shepard, Mark; Skinner, Jonathan

2013-01-01

The US Medicare program consumes an ever-rising share of the federal budget. Although this public spending can produce health and social benefits, raising taxes to finance it comes at the cost of slower economic growth. In this article we describe a model incorporating the benefits of public programs and the cost of tax financing. The model implies that the “one-size-fits-all” Medicare program, with everyone covered by the same insurance policy, will be increasingly difficult to sustain. We show that a Medicare program with guaranteed basic benefits and the option to purchase additional coverage could lead to more unequal health spending but slower growth in taxation, greater overall well-being, and more rapid growth of gross domestic product. Our framework highlights the key trade-offs between Medicare spending and economic prosperity. PMID:23650321

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 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 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 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 423.508 - 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...

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 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 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...

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...

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 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...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-17

..., phone 1-800-743-3951. I. Background The Affordable Care Act seeks to improve the quality of health care services and to lower health care costs by encouraging providers to create integrated health care delivery... incentives for health care providers to enhance health care quality and lower costs. One important delivery...

Translation of a Dementia Caregiver Intervention for Delivery in Homecare as a Reimbursable Medicare Service: Outcomes and Lessons Learned

ERIC Educational Resources Information Center

Gitlin, Laura N.; Jacobs, Mimi; Earland, Tracey Vause

2010-01-01

Purpose: Families of dementia patients receiving skilled homecare do not receive supportive services. We evaluated whether a proven intervention, Environmental Skill-building Program (ESP), which reduces caregiver burden and enhances skills managing patient functioning, can be integrated into homecare practices of occupational therapists (OTs) and…

78 FR 37031 - Patient Protection and Affordable Care Act; Program Integrity: Exchange, SHOP, Premium...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-06-19

... Vol. 78 Wednesday, No. 118 June 19, 2013 Part III Department of Health and Human Services 45 CFR... HUMAN SERVICES 45 CFR Parts 144, 147, 153, 155, and 156 [CMS-9957-P] RIN 0938-AR82 Patient Protection... Standards AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Proposed rule. SUMMARY: This...

Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Policy Changes and Fiscal Year 2016 Rates; Revisions of Quality Reporting Requirements for Specific Providers, Including Changes Related to the Electronic Health Record Incentive Program; Extensions of the Medicare-Dependent, Small Rural Hospital Program and the Low-Volume Payment Adjustment for Hospitals. Final rule; interim final rule with comment period.

PubMed

2015-08-17

We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2016. Some of these changes implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act), the Pathway for Sustainable Growth Reform(SGR) Act of 2013, the Protecting Access to Medicare Act of 2014, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Medicare Access and CHIP Reauthorization Act of 2015, and other legislation. We also are addressing the update of the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2016.As an interim final rule with comment period, we are implementing the statutory extensions of the Medicare dependent,small rural hospital (MDH)Program and changes to the payment adjustment for low-volume hospitals under the IPPS.We also are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2016 and implementing certain statutory changes to the LTCH PPS under the Affordable Care Act and the Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013 and the Protecting Access to Medicare Act of 2014.In addition, we are establishing new requirements or revising existing requirements for quality reporting by specific providers (acute care hospitals,PPS-exempt cancer hospitals, and LTCHs) that are participating in Medicare, including related provisions for eligible hospitals and critical access hospitals participating in the Medicare Electronic Health Record (EHR)Incentive Program. We also are updating policies relating to the Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program.

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.

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.

What can the past of pay-for-performance tell us about the future of Value-Based Purchasing in Medicare?

PubMed

Ryan, Andrew M; Damberg, Cheryl L

2013-06-01

The Medicare program has implemented pay-for-performance (P4P), or Value-Based Purchasing, for inpatient care and for Medicare Advantage plans, and plans to implement a program for physicians in 2015. In this paper, we review evidence on the effectiveness of P4P and identify design criteria deemed to be best practice in P4P. We then assess the extent to which Medicare's existing and planned Value-Based Purchasing programs align with these best practices. Of the seven identified best practices in P4P program design, the Hospital Value-Based Purchasing program is strongly aligned with two of the best practices, moderately aligned with three, weakly aligned with one, and has unclear alignment with one best practice. The Physician Value-Based Purchasing Modifier is strongly aligned with two of the best practices, moderately aligned with one, weakly aligned with three, and has unclear alignment with one of the best practices. The Medicare Advantage Quality Bonus Program is strongly aligned with four of the best practices, moderately aligned with two, and weakly aligned with one of the best practices. We identify enduring gaps in P4P literature as it relates to Medicare's plans for Value-Based Purchasing and discuss important issues in the future of these implementations in Medicare. Copyright © 2013 Elsevier Inc. All rights reserved.

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 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...

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...

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...

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...

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

Canadian Medicare: prognosis guarded.

PubMed

Naylor, C D; Fooks, C; Williams, J I

1995-08-01

Beset by unprecedented fiscal pressures, Canadian medicare has reached a crossroads. The authors review the impact of recent cuts in federal transfer payments on provincial health care programs and offer seven suggestions to policymakers trying to accommodate these reductions. (1) Go slowly: public health care spending is no longer rising and few provinces have the necessary systems in place to manage major reductions. (2) Target reductions, rewarding quality and efficiency instead of making across-the-board cuts. (3) Replace blame with praise:give health care professionals and institutions credit for their contributions. (4) Learn from the successful programs and policies already in place across the country. (5) Foster horizontal and vertical integration of services. (6) Promote physician leadership by rewarding efforts to promote the efficient use of resources. (7) Monitor the effects of cutbacks: physician groups should cooperate with government in maintaining a national "report card" on services, costs and the health status of Canadians.

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...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-26

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-23

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

75 FR 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...

42 CFR 422.220 - Exclusion of services furnished under a private contract.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Exclusion of services furnished under a private contract. 422.220 Section 422.220 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Relationships With...

42 CFR 422.214 - Special rules for services furnished by noncontract providers.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Special rules for services furnished by noncontract providers. 422.214 Section 422.214 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Relationships With...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-09-23

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

Delivery system integration and health care spending and quality for Medicare beneficiaries.

PubMed

McWilliams, J Michael; Chernew, Michael E; Zaslavsky, Alan M; Hamed, Pasha; Landon, Bruce E

2013-08-12

The Medicare accountable care organization (ACO) programs rely on delivery system integration and health care provider risk sharing to lower spending while improving quality of care. To compare spending and quality between larger and smaller provider groups and examine how size-related differences vary by 2 factors considered central to ACO performance: group primary care orientation and financial risk sharing by health care providers. Using 2009 Medicare claims and linked American Medical Association Group Practice data, we assigned 4.29 million beneficiaries to health care provider groups based on primary care use. We categorized group size according to eligibility thresholds for the Shared Savings (≥5000 assigned beneficiaries) and Pioneer (≥15,000) ACO programs and distinguished hospital-based from independent groups. We assessed the primary care orientation of larger groups' specialty mix and used health maintenance organization market penetration and data from the Community Tracking Study to measure the extent of financial risk accepted by different types of provider groups in different areas for managed care patients. We estimated linear regression models comparing spending and quality between larger and smaller health care provider groups, allowing size-related differences to vary by measures of group primary care orientation and risk sharing. Spending and quality measures included total medical spending, spending by type of service, 5 process measures of quality, and 30-day readmissions, all adjusted for sociodemographic and clinical characteristics. Compared with smaller groups, larger hospital-based groups had higher total per-beneficiary spending in 2009 (mean difference, +$849), higher 30-day readmission rates (+1.3 percentage points), and similar performance on 4 of 5 process measures of quality. In contrast, larger independent physician groups performed better than smaller groups on all process measures and exhibited significantly lower per-beneficiary spending in counties where risk sharing by these groups was more common (-$426). Among all groups sufficiently large to participate in ACO programs, a strong primary care orientation was associated with lower spending, fewer readmissions, and better quality of diabetes care. Spending was lower and quality of care better for Medicare beneficiaries served by larger independent physician groups with strong primary care orientations in environments where health care providers accepted greater risk.

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...

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...

Value-Based Payment Reform and the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015: A Primer for Plastic Surgeons.

PubMed

Squitieri, Lee; Chung, Kevin C

2017-07-01

In 2015, the U.S. Congress passed the Medicare Access and Children's Health Insurance Program Reauthorization Act, which effectively repealed the Centers for Medicare and Medicaid Services sustainable growth rate formula and established the Centers for Medicare and Medicaid Services Quality Payment Program. The Medicare Access and Children's Health Insurance Program Reauthorization Act represents an unparalleled acceleration toward value-based payment models and a departure from traditional volume-driven fee-for-service reimbursement. The Quality Payment Program includes two paths for provider participation: the Merit-Based Incentive Payment System and Advanced Alternative Payment Models. The Merit-Based Incentive Payment System pathway replaces existing quality reporting programs and adds several new measures to create a composite performance score for each provider (or provider group) that will be used to adjust reimbursed payment. The advanced alternative payment model pathway is available to providers who participate in qualifying Advanced Alternative Payment Models and is associated with an initial 5 percent payment incentive. The first performance period for the Merit-Based Incentive Payment System opens January 1, 2017, and closes on December 31, 2017, and is associated with payment adjustments in January of 2019. The Centers for Medicare and Medicaid Services estimates that the majority of providers will begin participation in 2017 through the Merit-Based Incentive Payment System pathway, but aims to have 50 percent of payments tied to quality or value through Advanced Alternative Payment Models by 2018. In this article, the authors describe key components of the Medicare Access and Children's Health Insurance Program Reauthorization Act to providers navigating through the Quality Payment Program and discuss how plastic surgeons may optimize their performance in this new value-based payment program.

Payment policy and the growth of Medicare Advantage.

PubMed

Zarabozo, Carlos; Harrison, Scott

2009-01-01

This paper reviews recent trends in Medicare Advantage, examining program costs, access to plans, enrollment, plan bids, and benchmarks. We find that current policy has favored the growth of particular types of plans. Bid data show that plans are paid, on average, 113 percent of what expenditures would have been under the traditional Medicare program. Although some of the plan payments are used to finance extra benefits for enrollees, paying plans at higher than fee-for-service levels could affect the sustainability of the Medicare program and result in increased costs for all taxpayers and beneficiaries.

Medicare program; offset of Medicare payments to individuals to collect past-due obligations arising from breach of scholarship and loan contracts--HCFA. Final rule.

PubMed

1992-05-04

This final rule sets forth the procedures to be followed for collection of past-due amounts owed by individuals who breached contracts under certain scholarship and loan programs. The programs that would be affected are the National Health Service Corps Scholarship, the Physician Shortage Area Scholarship, and the Health Education Assistance Loan. These procedures would apply to those individuals who breached contracts under the scholarship and loan programs and who-- Accept Medicare assignment for services; Are employed by or affiliated with a provider, Health Maintenance Organization, or Competitive Medical Plan that receives Medicare payment for services; or Are members of a group practice that receives Medicare payment for services. This regulation implements section 1892 of the Social Security Act, as added by section 4052 of the Omnibus Budget Reconciliation Act of 1987.

Will Catholic hospitals survive without government reimbursements?

PubMed

Archer, David L

2017-02-01

This brief essay will begin to address the feasibility of operating a Catholic healthcare system without reimbursement from government healthcare programs such as Medicare and Medicaid. This question stems from the recent ACA/HHS "Nondiscrimination in Health Programs and Activities" final rule. Summary : The average hospital in the United States receives 40-50 percent of its net revenues from governmental sources. Participation in Medicare is contingent upon the hospital having a Medicare provider agreement. Participation in other governmental programs (Medicaid) as well as most commercial insurance is also contingent upon that agreement. Hospitals, including "Catholic" hospitals, cannot survive without a Medicare provider agreement. That agreement may be terminated for non-compliance with Medicare and other governmental regulations such as the recent ACA/HHS "Nondiscrimination in Health Programs and Activities" final rule, which could require "Catholic" hospitals to provide services which violate moral principals of the Church.

Ostomy Home Skills Program

MedlinePlus Videos and Cool Tools

... My OR EHR Incentive Program Global Codes and Data Collection Patient Opioid Use New Medicare Card Project Medicare ... self-care checklist Evaluation (Complete the Ostomy Patient Survey . We need your opinion!) Program outcomes The ACS ...

42 CFR 422.156 - Compliance deemed on the basis of accreditation.

Code of Federal Regulations, 2010 CFR

2010-10-01

... AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Quality Improvement § 422...) through (3) of this chapter for MA organizations that offer prescription drug benefit programs. (c...

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.

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.

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.

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...

76 FR 78281 - Medicare Program; First Semi-Annual Meeting of the Advisory Panel on Hospital Outpatient Payment...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-12-16

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-1586-N] Medicare Program; First Semi-Annual Meeting of the Advisory Panel on Hospital Outpatient Payment (HOP--Formerly Known as the Advisory Panel on Ambulatory Payment Classification Groups--APC Panel)--February 27...

75 FR 14905 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-October Through December 2009

Federal Register 2010, 2011, 2012, 2013, 2014

2010-03-26

... stent facilities. Included in this notice is a list of the American College of Cardiology's National... 21244-1850, or you can call (410) 786-6962. Questions concerning Medicare-approved carotid stent... 20 of the CFR. Addendum VIII includes listings of Medicare-approved carotid stent facilities. All...

75 FR 58789 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-April Through June 2010

Federal Register 2010, 2011, 2012, 2013, 2014

2010-09-24

...- approved carotid stent facilities. Included in this notice is a list of the American College of Cardiology... 21244-1850, or you can call (410) 786-6962. Questions concerning Medicare-approved carotid stent... listings of Medicare-approved carotid stent facilities. All facilities listed meet CMS standards for...

78 FR 48688 - Medicare Program; Comprehensive ESRD Care Initiative; Extension of the Submission Deadlines for...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-09

... quality of care for this population, while lowering total per-capita expenditures under the Medicare program. We anticipate that the Comprehensive ESRD Care Model would result in improved health outcomes for... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-5506-N3...

42 CFR 425.204 - Content of the application.

Code of Federal Regulations, 2014 CFR

2014-10-01

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

42 CFR 422.105 - Special rules for self-referral and point of service option.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Special rules for self-referral and point of service option. 422.105 Section 422.105 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Benefits and...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-12

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

42 CFR 422.2 - Definitions.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Definitions. 422.2 Section 422.2 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM General Provisions § 422.2 Definitions. As used in this part— Arrangement means a written agreement between an MA...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-01-22

... * * * on the coverage options provided under [Medicare Advantage] in order to promote an active, informed..., National Hispanic Council on Aging; Stephen L. Fera, Vice President, Social Mission Programs, Independence Blue Cross; Clayton Fong, President and Chief Executive Officer, National Asian Pacific Center on Aging...

The Federal Employees Health Benefits Program: A Model for Competition in Rural America?

ERIC Educational Resources Information Center

Mueller, Keith J.; McBride, Timothy D.; Andrews, Courtney; Fraser, Roslyn; Xu, Liyan

2005-01-01

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) created the Medicare Advantage (MA) program, which promotes the entry of private Preferred Provider Organization (PPO) plans into regions that have not previously had Medicare managed care plans. The assumption that a competitive environment will develop is based on…

42 CFR 422.158 - Procedures for approval of accreditation as a basis for deeming compliance.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Procedures for approval of accreditation as a basis for deeming compliance. 422.158 Section 422.158 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Quality...

42 CFR 413.87 - Payments for Medicare+Choice nursing and allied health education programs.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 2 2013-10-01 2013-10-01 false Payments for Medicare+Choice nursing and allied... NURSING FACILITIES Specific Categories of Costs § 413.87 Payments for Medicare+Choice nursing and allied... reimbursement for approved nursing and allied health education programs and the methodology for determining the...

42 CFR 413.87 - Payments for Medicare+Choice nursing and allied health education programs.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 2 2011-10-01 2011-10-01 false Payments for Medicare+Choice nursing and allied... NURSING FACILITIES Specific Categories of Costs § 413.87 Payments for Medicare+Choice nursing and allied... reimbursement for approved nursing and allied health education programs and the methodology for determining the...

42 CFR 413.87 - Payments for Medicare+Choice nursing and allied health education programs.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 2 2014-10-01 2014-10-01 false Payments for Medicare+Choice nursing and allied... NURSING FACILITIES Specific Categories of Costs § 413.87 Payments for Medicare+Choice nursing and allied... reimbursement for approved nursing and allied health education programs and the methodology for determining the...

42 CFR 413.87 - Payments for Medicare+Choice nursing and allied health education programs.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 2 2012-10-01 2012-10-01 false Payments for Medicare+Choice nursing and allied... NURSING FACILITIES Specific Categories of Costs § 413.87 Payments for Medicare+Choice nursing and allied... reimbursement for approved nursing and allied health education programs and the methodology for determining the...

42 CFR 413.87 - Payments for Medicare+Choice nursing and allied health education programs.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Payments for Medicare+Choice nursing and allied... NURSING FACILITIES Specific Categories of Costs § 413.87 Payments for Medicare+Choice nursing and allied... reimbursement for approved nursing and allied health education programs and the methodology for determining the...

A Direct Experience in a New Accountable Care Organization: Results, Challenges, and the Role of the Neurosurgeon.

PubMed

Kim, Dong H; Lloyd, Christopher; Fernandez, Douglas K; Spielman, Amanda; Bradshaw, David

2017-04-01

The passage of the Affordable Care Act saw the creation of Accountable Care Organizations (ACOs), a new approach to healthcare delivery moving from fee-for-service toward population health. This paper presents a case study of the Memorial Hermann ACO (MHACO), launched in response to the Medicare Shared Savings Program, with goals to align physician and hospital incentives, practice evidence-based medicine, develop care coordination, and increase efficiency. Building blocks included an affiliated primary care network, a clinical integration program (involving shared electronic medical record platforms and quality data reporting), and significant investments in information technology. Presented is the approach taken to form MHACO; the management structure, technology developed, and a 2-year experience. Incorporated in July 2012, the MHACO involved 22 000 Medicare patients. In 2015, Centers for Medicare and Medicaid Services released data showing a composite quality score between 80 and 85 (from a maximum 100) and nearly $53 million in total savings (or 11% of expected expenditure), making MHACO one of the most successful nationally.1 In fewer than 5 years, almost 500 ACOs have developed, and by some estimates, a quarter of Medicare patients are currently enrolled in an ACO. Although ACOs to date have focused on primary care, the future will increasingly involve specialists. At Memorial Hermann, neurosurgeons took an early role in forming collaborative partnerships with the hospital, and started programs that served as precursors to the ACO model. This paper ends with an overview of ACO development, likely changes going forward, and a discussion of the role of specialists in general, and of neurosurgeons in particular. Copyright © 2016 by the Congress of Neurological Surgeons.

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

PubMed

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

2016-12-01

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

42 CFR 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...

Applying Resource Based Relative Value Scales (RBRVS) to the Champus Program

DTIC Science & Technology

1990-12-01

fee for the related service .[Ref. 6:p. 7] F. EFFECTS OF RBRVS When a Medicare fee schedule is fully implemented, several Important...reimbursement rates increase would be attracted to CHAMPUS. In analyzing the impact of a resource based fee schedule on the Medicare program, the PPRC...procedures performed by physicians into components of work, training costs, and practice costs. The Medicare program is planning to implement a fee

42 CFR 423.159 - Electronic prescription drug program.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Electronic prescription drug program. 423.159... SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Cost Control and Quality Improvement Requirements § 423.159 Electronic prescription drug program. (a) Definitions...

42 CFR 423.159 - Electronic prescription drug program.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Electronic prescription drug program. 423.159... SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Cost Control and Quality Improvement Requirements § 423.159 Electronic prescription drug program. (a) Definitions...

42 CFR 423.159 - Electronic prescription drug program.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Electronic prescription drug program. 423.159... SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Cost Control and Quality Improvement Requirements § 423.159 Electronic prescription drug program. (a) Definitions...

PACE and the Medicare+Choice risk-adjusted payment model.

PubMed

Temkin-Greener, H; Meiners, M R; Gruenberg, L

2001-01-01

This paper investigates the impact of the Medicare principal inpatient diagnostic cost group (PIP-DCG) payment model on the Program of All-Inclusive Care for the Elderly (PACE). Currently, more than 6,000 Medicare beneficiaries who are nursing home certifiable receive care from PACE, a program poised for expansion under the Balanced Budget Act of 1997. Overall, our analysis suggests that the application of the PIP-DCG model to the PACE program would reduce Medicare payments to PACE, on average, by 38%. The PIP-DCG payment model bases its risk adjustment on inpatient diagnoses and does not capture adequately the risk of caring for a population with functional impairments.

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 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...

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.

42 CFR 405.809 - Opportunity to submit evidence.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 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 Program § 405.809 Opportunity to submit...

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

Code of Federal Regulations, 2010 CFR

2010-10-01

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

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...

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

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.

42 CFR 422.152 - Quality improvement program.

Code of Federal Regulations, 2011 CFR

2011-10-01

..., quality of life indicators, depression scales, or chronic disease outcomes). (iii) Staff implementation of... 42 Public Health 3 2011-10-01 2011-10-01 false Quality improvement program. 422.152 Section 422... (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Quality Improvement § 422.152 Quality improvement...

42 CFR 422.152 - Quality improvement program.

Code of Federal Regulations, 2010 CFR

2010-10-01

..., psychosocial, or clinical domains (for example, quality of life indicators, depression scales, or chronic... 42 Public Health 3 2010-10-01 2010-10-01 false Quality improvement program. 422.152 Section 422... (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Quality Improvement § 422.152 Quality improvement...

42 CFR 422.152 - Quality improvement program.

Code of Federal Regulations, 2014 CFR

2014-10-01

..., quality of life indicators, depression scales, or chronic disease outcomes). (iii) Staff implementation of... 42 Public Health 3 2014-10-01 2014-10-01 false Quality improvement program. 422.152 Section 422... (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Quality Improvement § 422.152 Quality...

42 CFR 422.152 - Quality improvement program.

Code of Federal Regulations, 2012 CFR

2012-10-01

..., quality of life indicators, depression scales, or chronic disease outcomes). (iii) Staff implementation of... 42 Public Health 3 2012-10-01 2012-10-01 false Quality improvement program. 422.152 Section 422... (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Quality Improvement § 422.152 Quality...

42 CFR 422.152 - Quality improvement program.

Code of Federal Regulations, 2013 CFR

2013-10-01

..., quality of life indicators, depression scales, or chronic disease outcomes). (iii) Staff implementation of... 42 Public Health 3 2013-10-01 2013-10-01 false Quality improvement program. 422.152 Section 422... (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Quality Improvement § 422.152 Quality...

42 CFR 423.159 - Electronic prescription drug program.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Electronic prescription drug program. 423.159... SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Cost Control and Quality Improvement Requirements § 423.159 Electronic prescription drug program. (a) Definitions. For purposes of this...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-09-28

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

Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials.

PubMed

Peikes, Deborah; Chen, Arnold; Schore, Jennifer; Brown, Randall

2009-02-11

Medicare expenditures of patients with chronic illnesses might be reduced through improvements in care, patient adherence, and communication. To determine whether care coordination programs reduced hospitalizations and Medicare expenditures and improved quality of care for chronically ill Medicare beneficiaries. Eligible fee-for-service Medicare patients (primarily with congestive heart failure, coronary artery disease, and diabetes) who volunteered to participate between April 2002 and June 2005 in 15 care coordination programs (each received a negotiated monthly fee per patient from Medicare) were randomly assigned to treatment or control (usual care) status. Hospitalizations, costs, and some quality-of-care outcomes were measured with claims data for 18 309 patients (n = 178 to 2657 per program) from patients' enrollment through June 2006. A patient survey 7 to 12 months after enrollment provided additional quality-of-care measures. Nurses provided patient education and monitoring (mostly via telephone) to improve adherence and ability to communicate with physicians. Patients were contacted twice per month on average; frequency varied widely. Hospitalizations, monthly Medicare expenditures, patient-reported and care process indicators. Thirteen of the 15 programs showed no significant (P<.05) differences in hospitalizations; however, Mercy had 0.168 fewer hospitalizations per person per year (90% confidence interval [CI], -0.283 to -0.054; 17% less than the control group mean, P=.02) and Charlestown had 0.118 more hospitalizations per person per year (90% CI, 0.025-0.210; 19% more than the control group mean, P=.04). None of the 15 programs generated net savings. Treatment group members in 3 programs (Health Quality Partners [HQP], Georgetown, Mercy) had monthly Medicare expenditures less than the control group by 9% to 14% (-$84; 90% CI, -$171 to $4; P=.12; -$358; 90% CI, -$934 to $218; P=.31; and -$112; 90% CI, -$231 to $8; P=.12; respectively). Savings offset fees for HQP and Georgetown but not for Mercy; Georgetown was too small to be sustainable. These programs had favorable effects on none of the adherence measures and only a few of many quality of care indicators examined. Viable care coordination programs without a strong transitional care component are unlikely to yield net Medicare savings. Programs with substantial in-person contact that target moderate to severe patients can be cost-neutral and improve some aspects of care. clinicaltrials.gov Identifier: NCT00627029.

42 CFR 417.418 - Qualifying condition: Quality assurance program.

Code of Federal Regulations, 2010 CFR

2010-10-01

... AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Qualifying Conditions for Medicare Contracts § 417.418...

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.

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

PubMed

O'Brien, Ellen; Hoadley, Jack

2008-04-01

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

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.

Effects of a Community-Based Fall Management Program on Medicare Cost Savings.

PubMed

Ghimire, Ekta; Colligan, Erin M; Howell, Benjamin; Perlroth, Daniella; Marrufo, Grecia; Rusev, Emil; Packard, Michael

2015-12-01

Fall-related injuries and health risks associated with reduced mobility or physical inactivity account for significant costs to the U.S. healthcare system. The widely disseminated lay-led A Matter of Balance (MOB) program aims to help older adults reduce their risk of falling and associated activity limitations. This study examined effects of MOB participation on health service utilization and costs for Medicare beneficiaries, as a part of a larger effort to understand the value of community-based prevention and wellness programs for Medicare. A controlled retrospective cohort study was conducted in 2012-2013, using 2007-2011 MOB program data and 2006-2013 Medicare data. It investigated program effects on falls and fall-related fractures, and health service utilization and costs (standardized to 2012 dollars), of 6,136 Medicare beneficiaries enrolled in MOB from 2007 through 2011. A difference-in-differences analysis was employed to compare outcomes of MOB participants with matched controls. MOB participation was associated with total medical cost savings of $938 per person (95% CI=$379, $1,498) at 1 year. Savings per person amounted to $517 (95% CI=$265, $769) for unplanned hospitalizations; $81 for home health care (95% CI=$20, $141); and $234 (95% CI=$55, $413) for skilled nursing facility care. Changes in the incidence of falls or fall-related fractures were not detected, suggesting that cost savings accrue through other mechanisms. This study suggests that MOB and similar prevention programs have the potential to reduce Medicare costs. Further research accounting for program delivery costs would help inform the development of Medicare-covered preventive benefits. Copyright © 2015 American Journal of Preventive Medicine. All rights reserved.

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.

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

PubMed

2010-04-23

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

Medicare program; competitive acquisition for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) and other issues. Final rule.

PubMed

2007-04-10

This final rule establishes competitive bidding programs for certain Medicare Part B covered items of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) throughout the United States in accordance with sections 1847(a) and (b) of the Social Security Act. These competitive bidding programs, which will be phased in over several years, utilize bids submitted by DMEPOS suppliers to establish applicable payment amounts under Medicare Part B.

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.

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...

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

PubMed

Dorn, Stan; Shang, Baoping

2012-02-01

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

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...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-04-15

... Care and Network-Based Private Fee-for-Service Plans Under Part C (Sec. 422.112) 7. Deemable Program... Cost by HMO/CMP Cost Contractors and Health Care Prepayment Plans (HCPPs) (Sec. 417.564) 4. Calculation... and Other Technical Changes 1. Application of Subpart M to Health Care Prepayment Plans (Sec. 417.840...

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

PubMed

2014-11-06

This final rule will update and make revisions to the End-Stage Renal Disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2015. This rule also finalizes requirements for the ESRD quality incentive program (QIP), including for payment years (PYs) 2017 and 2018. This rule will also make a technical correction to remove outdated terms and definitions. In addition, this final rule sets forth the methodology for adjusting Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) fee schedule payment amounts using information from the Medicare DMEPOS Competitive Bidding Program (CBP); makes alternative payment rules for certain DME under the Medicare DMEPOS CBP; clarifies the statutory Medicare hearing aid coverage exclusion and specifies devices not subject to the hearing aid exclusion; will not update the definition of minimal self-adjustment; clarifies the Change of Ownership (CHOW) and provides for an exception to the current requirements; revises the appeal provisions for termination of a CBP contract, including the beneficiary notification requirement under the Medicare DMEPOS CBP, and makes a technical change to the regulation related to the conditions for awarding contracts for furnishing infusion drugs under the Medicare DMEPOS CBP.

Integrated care organizations: Medicare financing for care at home.

PubMed

Davis, Karen; Willink, Amber; Schoen, Cathy

2016-11-01

As the boomer population ages, there is a growing need for integrated care organizations (ICOs) that can integrate both medical care and long-term services and supports in the home. This paper presents a policy proposal to support the creation of ICOs, redesign care, and provide financing for home- and community-based services (HCBS), with the goal of enhancing financial protection for beneficiaries, coordinating care, and preventing costly hospital and nursing home use. This study used the 2012 Medicare Current Beneficiary Survey (MCBS) Cost and Use File, inflated to 2016 figures, to describe the characteristics of Medicare beneficiaries and their healthcare utilization and spending. The costs of covering up to 20 hours of personal care services a week were estimated using MCBS population counts, participation assumptions based on the literature, and financing design parameters. A targeted HCBS benefit could be added to Medicare and financed with income-related cost sharing ranging from 5% to 50%, a premium paid by Medicare beneficiaries of approximately $42 a month, and payroll taxes estimated at around 0.4% of earnings on employers and employees. Adoption of an HCBS benefit in Medicare would improve financial protection for beneficiaries with physical and/or cognitive impairment and provide the financing for health organizations to better integrate medical and social services. ICOs and delivery models of care emphasizing care at home would improve accessibility of care and avoid costly institutionalization; additionally, it would also reduce beneficiary reliance on Medicaid.

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

PubMed

2016-11-14

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

Leveraging Administrative Data for Program Evaluations: A Method for Linking Data Sets Without Unique Identifiers.

PubMed

Lorden, Andrea L; Radcliff, Tiffany A; Jiang, Luohua; Horel, Scott A; Smith, Matthew L; Lorig, Kate; Howell, Benjamin L; Whitelaw, Nancy; Ory, Marcia

2016-06-01

In community-based wellness programs, Social Security Numbers (SSNs) are rarely collected to encourage participation and protect participant privacy. One measure of program effectiveness includes changes in health care utilization. For the 65 and over population, health care utilization is captured in Medicare administrative claims data. Therefore, methods as described in this article for linking participant information to administrative data are useful for program evaluations where unique identifiers such as SSN are not available. Following fuzzy matching methodologies, participant information from the National Study of the Chronic Disease Self-Management Program was linked to Medicare administrative data. Linking variables included participant name, date of birth, gender, address, and ZIP code. Seventy-eight percent of participants were linked to their Medicare claims data. Linking program participant information to Medicare administrative data where unique identifiers are not available provides researchers with the ability to leverage claims data to better understand program effects. © The Author(s) 2014.

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 ...

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.

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-03-03

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-30

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

Benefits and costs of intensive lifestyle modification programs for symptomatic coronary disease in Medicare beneficiaries.

PubMed

Zeng, Wu; Stason, William B; Fournier, Stephen; Razavi, Moaven; Ritter, Grant; Strickler, Gail K; Bhalotra, Sarita M; Shepard, Donald S

2013-05-01

This study reports outcomes of a Medicare-sponsored demonstration of two intensive lifestyle modification programs (LMPs) in patients with symptomatic coronary heart disease: the Cardiac Wellness Program of the Benson-Henry Mind Body Institute (MBMI) and the Dr Dean Ornish Program for Reversing Heart Disease® (Ornish). This multisite demonstration, conducted between 2000 and 2008, enrolled Medicare beneficiaries who had had an acute myocardial infarction or a cardiac procedure within the preceding 12 months or had stable angina pectoris. Health and economic outcomes are compared with matched controls who had received either traditional or no cardiac rehabilitation following similar cardiac events. Each program included a 1-year active intervention of exercise, diet, small-group support, and stress reduction. Medicare claims were used to examine 3-year outcomes. The analysis includes 461 elderly, fee-for-service, Medicare participants and 1,795 controls. Cardiac and non-cardiac hospitalization rates were lower in participants than controls in each program and were statistically significant in MBMI (P < .01). Program costs of $3,801 and $4,441 per participant for the MBMI and Ornish Programs, respectively, were offset by reduced health care costs yielding non-significant three-year net savings per participant of about $3,500 in MBMI and $1,000 in Ornish. A trend towards lower mortality compared with controls was observed in MBMI participants (P = .07). Intensive, year-long LMPs reduced hospitalization rates and suggest reduced Medicare costs in elderly beneficiaries with symptomatic coronary heart disease. Copyright © 2013 Mosby, Inc. All rights reserved.

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...

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…

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...

Medicare's chronic care improvement pilot program: what is its potential?

PubMed

Super, Nora

2004-05-10

This paper describes the voluntary chronic care improvement program under traditional fee-for-service Medicare as authorized by the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 (Public Law 108-173; section 721). This brief analyzes the emerging issues raised by this new program, including which chronic conditions and regional areas will be targeted, the types of entities that may participate, the physician's role in care management, and the adoption and use of health information technology and evidence-based clinical guidelines.

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.

The competitive acquisition program for drugs and biologicals.

PubMed

Lace, Daniel A

2006-07-01

Unlike the Medicare Part D program, which has a significant number of participating plans, the new Competitive Acquisition Program (CAP), which was to have started on Jan. 1, 2006, along with Medicare Part D, did not because, in part, of a lack of interest. As a result, the program was delayed until July 1, 2006. This new program separates the physician from the purchase and billing of medications provided in the physician's office. Under CAP, physicians sign with a specialty pharmacy provider that will deliver the medications to the physicians as ordered and then bill Medicare directly. This will alleviate some physician administrative responsibilities. Although it is unlikely that high-volume Medicare Part B medication providers, such as oncologists, will use a CAP provider, it is likely that busy primary care physicians and other specialists not usually involved in providing medications in their offices now may start to take advantage of this valuable service.

42 CFR 422.404 - State premium taxes prohibited.

Code of Federal Regulations, 2012 CFR

2012-10-01

... (CONTINUED) MEDICARE PROGRAM (CONTINUED) 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...

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.

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

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.

42 CFR 460.94 - Required services for Medicare participants.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

42 CFR 460.94 - Required services for Medicare participants.

Code of Federal Regulations, 2011 CFR

2011-10-01

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

42 CFR 460.180 - Medicare payment to PACE organizations.

Code of Federal Regulations, 2011 CFR

2011-10-01

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

42 CFR 422.6 - Cost-sharing in enrollment-related costs.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM General Provisions § 422.6 Cost-sharing in... for the drug benefit). (c) Applicability. The fee assessment also applies to those demonstrations for...

42 CFR 422.68 - Effective dates of coverage and change of coverage.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Eligibility, Election, and... continuity of health benefits coverage. (e) Special election period for individual age 65. For an election of...

20 CFR 418.3005 - Purpose and administration of the program.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 20 Employees' Benefits 2 2010-04-01 2010-04-01 false Purpose and administration of the program. 418.3005 Section 418.3005 Employees' Benefits SOCIAL SECURITY ADMINISTRATION MEDICARE SUBSIDIES... and Human Services has responsibility for administration of the Medicare program, including the new...

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...

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...

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...

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

Code of Federal Regulations, 2010 CFR

2010-10-01

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

76 FR 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...

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.

Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNFs) for FY 2016, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and Staffing Data Collection. Final Rule.

PubMed

2015-08-04

This final rule updates the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2016. In addition, it specifies a SNF all-cause all-condition hospital readmission measure, as well as adopts that measure for a new SNF Value-Based Purchasing (VBP) Program, and includes a discussion of SNF VBP Program policies we are considering for future rulemaking to promote higher quality and more efficient health care for Medicare beneficiaries. Additionally, this final rule will implement a new quality reporting program for SNFs as specified in the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). It also amends the requirements that a long-term care (LTC) facility must meet to qualify to participate as a skilled nursing facility (SNF) in the Medicare program, or a nursing facility (NF) in the Medicaid program, by establishing requirements that implement the provision in the Affordable Care Act regarding the submission of staffing information based on payroll data.

Early Performance of Accountable Care Organizations in Medicare

PubMed Central

McWilliams, J. Michael; Hatfield, Laura A.; Chernew, Michael E.; Landon, Bruce E.; Schwartz, Aaron L.

2016-01-01

BACKGROUND In the Medicare Shared Savings Program (MSSP), accountable care organizations (ACOs) have financial incentives to lower spending and improve quality. We used quasi-experimental methods to assess the early performance of MSSP ACOs. METHODS Using Medicare claims from 2009 through 2013 and a difference-in-differences design, we compared changes in spending and in performance on quality measures from before the start of ACO contracts to after the start of the contracts between beneficiaries served by the 220 ACOs entering the MSSP in mid-2012 (2012 ACO cohort) or January 2013 (2013 ACO cohort) and those served by non-ACO providers (control group), with adjustment for geographic area and beneficiary characteristics. We analyzed the 2012 and 2013 ACO cohorts separately because entry time could reflect the capacity of an ACO to achieve savings. We compared ACO savings according to organizational structure, baseline spending, and concurrent ACO contracting with commercial insurers. RESULTS Adjusted Medicare spending and spending trends were similar in the ACO cohorts and the control group during the precontract period. In 2013, the differential change (i.e., the between-group difference in the change from the precontract period) in total adjusted annual spending was −$144 per beneficiary in the 2012 ACO cohort as compared with the control group (P = 0.02), consistent with a 1.4% savings, but only −$3 per beneficiary in the 2013 ACO cohort as compared with the control group (P = 0.96). Estimated savings were consistently greater in independent primary care groups than in hospital-integrated groups among 2012 and 2013 MSSP entrants (P = 0.005 for interaction). MSSP contracts were associated with improved performance on some quality measures and unchanged performance on others. CONCLUSIONS The first full year of MSSP contracts was associated with early reductions in Medicare spending among 2012 entrants but not among 2013 entrants. Savings were greater in independent primary care groups than in hospital-integrated groups. PMID:27075832

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 ...

Physician Quality Reporting System Program Updates and the Impact on Emergency Medicine Practice.

PubMed

Wiler, Jennifer L; Granovsky, Michael; Cantrill, Stephen V; Newell, Richard; Venkatesh, Arjun K; Schuur, Jeremiah D

2016-03-01

In 2007, the Centers for Medicaid and Medicare Services (CMS) created a novel payment program to create incentives for physician's to focus on quality of care measures and report quality performance for the first time. Initially termed "The Physician Voluntary Reporting Program," various Congressional actions, including the Tax Relief and Health Care Act of 2006 (TRHCA) and Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) further strengthened and ensconced this program, eventually leading to the quality program termed today as the Physician Quality Reporting System (PQRS). As a result of passage of the Affordable Care Act of 2010, the PQRS program has expanded to include both the "traditional PQRS" reporting program and the newer "Value Modifier" program (VM). For the first time, these programs were designed to include pay-for-performance incentives for all physicians providing care to Medicare beneficiaries and to measure the cost of care. The recent passage of the Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act in March of 2015 includes changes to these payment programs that will have an even more profound impact on emergency care providers. We describe the implications of these important federal policy changes for emergency physicians.

Medicare risk contracting: Determinants of market entry

PubMed Central

Porell, Frank W.; Wallack, Stanley S.

1990-01-01

The Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 made it more attractive for health maintenance organizations (HMOs) and other competitive medical plans to enter into risk contracts with Medicare. Since the start of the TEFRA program in April 1985, more than 160 HMOs have had risk contracts with Medicare under the program. An investigation of factors associated with TEFRA risk-market entry at the end of 1986 revealed that high adjusted average per capita cost payment levels, prior Medicare cost-contract experience, and prior Federal qualification were the most important factors distinguishing market entrants from nonentrants. PMID:10113567

77 FR 44255 - Medicare Program; Application by the American Association of Diabetes Educators (AADE) for...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-07-27

...] Medicare Program; Application by the American Association of Diabetes Educators (AADE) for Continued Recognition as a National Accreditation Organization for Accrediting Entities To Furnish Outpatient Diabetes... of Diabetes Educators for continued recognition as a national accreditation program for accrediting...

42 CFR 460.124 - Additional appeal rights under Medicare or Medicaid.

Code of Federal Regulations, 2011 CFR

2011-10-01

... AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Participant Rights § 460.124 Additional appeal rights under Medicare...

42 CFR 460.124 - Additional appeal rights under Medicare or Medicaid.

Code of Federal Regulations, 2010 CFR

2010-10-01

... AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Participant Rights § 460.124 Additional appeal rights under Medicare...

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

Potential epidemiologic, economic, and budgetary impacts of current rates of hepatitis C treatment in medicare and non-medicare populations.

PubMed

Wittenborn, John; Brady, Joanne; Dougherty, Michelle; Rein, David

2017-04-01

We forecast the health and budgetary impact of hepatitis C (HCV) treatment on the Medicare program based on currently observed rates of treatment among Medicare and non-Medicare patients and identify the impact of higher rates of treatment among non-Medicare populations. We developed a computer microsimulation model to conduct an epidemiologic forecast, a budgetary impact analysis, and a cost-effectiveness analysis of the treatment of HCV based on three scenarios: 1) no treatment, 2) continuation of current-treatment rates, and 3) treatment rates among non-Medicare patients increased to match that of Medicare patients. The simulated population is based on National Health and Nutrition Examination Survey data. HCV progression rates and costs were calculated in Surveillance, Epidemiology, and End Results Program Medicare 5% claims data from the Chronic Hepatitis Cohort Study and published literature. We estimate that 13.6% of patients with HCV in the United States are enrolled in Medicare, but 75% will enter Medicare in the next 20 years. Medicare patients were over 5 times as likely to be treated in 2014-2015 as other patients. Medicare paid over $9 billion in treatment costs in both 2015 and 2016 and will total $28.4 billion from 2017-2026. Increasing treatment rates among non-Medicare patients would lead to 234,000 more patients being treated, reduce HCV mortality by 19%, and decrease Medicare costs by $18.6 billion from 2017-2026. We find that treatment remains cost-effective under most assumptions, costing $31,718 per quality adjusted life year gained. Conclusion : Medicare treats a disproportionately large share of HCV patients. Continued low rates of treatment among non-Medicare HCV patients will result in both reduced and deferred treatment, shifting future treatment costs to Medicare while increasing overall medical management costs, morbidity, and mortality. ( Hepatology Communications 2017;1:99-109).

Covenant model of corporate compliance. "Corporate integrity" program meets mission, not just legal, requirements.

PubMed

Tuohey, J F

1998-01-01

Catholic healthcare should establish comprehensive compliance strategies, beyond following Medicare reimbursement laws, that reflect mission and ethics. A covenant model of business ethics--rather than a self-interest emphasis on contracts--can help organizations develop a creed to focus on obligations and trust in their relationships. The corporate integrity program (CIP) of Mercy Health System Oklahoma promotes its mission and interests, educates and motivates its employees, provides assurance of systemwide commitment, and enforces CIP policies and procedures. Mercy's creed, based on its mission statement and core values, articulates responsibilities regarding patients and providers, business partners, society and the environment, and internal relationships. The CIP is carried out through an integrated network of committees, advocacy teams, and an expanded institutional review board. Two documents set standards for how Mercy conducts external affairs and clarify employee codes of conduct.

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.

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.

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.

Opting out of an integrated healthcare system: dual-system use is associated with poorer glycemic control in veterans with diabetes.

PubMed

Helmer, Drew; Sambamoorthi, Usha; Shen, Yujing; Tseng, Chin-Lin; Rajan, Mangala; Tiwari, Anjali; Maney, Miriam; Pogach, Leonard

2008-06-01

To test for an association between quality of care and patient choice to obtain care outside an integrated healthcare delivery system. We used administrative data to define dual-system use (Veterans Health Administration (VHA) and Medicare) in 1999 for VHA users with diabetes over 65 years old. Quality of diabetes care was determined by the last hemoglobin A1c (HA1c) value in 2000. The distance to nearest VHA facility minus the distance to nearest non-federal hospital was the instrumental variable in a two-part regression model which controlled for observed and unobserved factors. In 1999, 57.4% of subjects received care from both VHA and Medicare providers; their mean proportion of visits to Medicare providers was 0.41 (median 0.38). After controlling for observed and unobserved factors, higher proportions of Medicare visits were significantly associated with higher HA1c values; a 40% increase in the proportion of Medicare visits by those who did not use Medicare was associated with a 0.23% point increase in HA1c value. Dual-system use was associated with higher HA1c values, suggesting that veterans who chose to receive care outside the integrated VHA may have worse intermediate clinical outcomes than those who received care exclusively within the system.

The experience of rural independent pharmacies with medicare part D: reports from the field.

PubMed

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

2007-01-01

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 pharmacies, which represent a higher proportion of all retail pharmacies in rural areas, would fare under the new program. This article describes first-hand reports from rural pharmacist-owners about their experiences with Medicare Part D plans in the first 7 months of 2006 in order to gain a more thorough understanding of the challenges faced by rural independent pharmacies as a result of program implementation. A semi-structured interview protocol was utilized in telephone interviews with 22 pharmacist-owners of rural independent pharmacies in 10 states. The rural independent pharmacists interviewed are experiencing major changes in payment, administrative burden, and interaction with patients as a result of the shift of patients into Medicare Part D plans. While administrative burden has greatly increased, payment and clinical interaction have decreased. Actions should be considered that would help rural independent pharmacists adjust to the new circumstances of having Medicare patients mirror, for administrative and payment purposes, commercially insured patients. Long-term modification of existing policies and regulations may be necessary to assure reasonable access to pharmaceuticals for rural populations. Further study is needed to determine how best to target these modifications to essential pharmacies.

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 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...

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 54599 - Medicare Program; Medicare Advantage and Prescription Drug Benefit Programs

Federal Register 2010, 2011, 2012, 2013, 2014

2011-09-01

... pricing, coverage, and payment processes in the Part D program, and requirements governing the marketing.... Camille Brown, (410) 786-0274, Marketing issues. SUPPLEMENTARY INFORMATION: I. Background The Balanced... the Secretary to revise the marketing requirements for Part C and Part D plans in several areas. MIPPA...

42 CFR 495.208 - Avoiding duplicate payment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... PROGRAM Requirements Specific to Medicare Advantage (MA) Organizations § 495.208 Avoiding duplicate payment. (a) Unless a qualifying MA EP is entitled to a maximum payment for a year under the Medicare FFS EHR incentive program, payment for such an individual is only made under the MA EHR incentive program...

42 CFR 495.208 - Avoiding duplicate payment.

Code of Federal Regulations, 2011 CFR

2011-10-01

... PROGRAM Requirements Specific to Medicare Advantage (MA) Organizations § 495.208 Avoiding duplicate payment. (a) Unless a qualifying MA EP is entitled to a maximum payment for a year under the Medicare FFS EHR incentive program, payment for such an individual is only made under the MA EHR incentive program...

42 CFR 495.208 - Avoiding duplicate payment.

Code of Federal Regulations, 2012 CFR

2012-10-01

... PROGRAM Requirements Specific to Medicare Advantage (MA) Organizations § 495.208 Avoiding duplicate payment. (a) Unless a qualifying MA EP is entitled to a maximum payment for a year under the Medicare FFS EHR incentive program, payment for such an individual is only made under the MA EHR incentive program...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-11-27

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-07-13

... Insurance; and Program No. 93.774, Medicare-- Supplementary Medical Insurance Program) Dated: July 7, 2011...), HHS. ACTION: Correction of proposed rule. SUMMARY: This document corrects technical errors that... explanation of publishing such Tables on the Internet), reflect an error in the calculation of the...

77 FR 49799 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-April Through June 2012

Federal Register 2010, 2011, 2012, 2013, 2014

2012-08-17

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

76 FR 68467 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-April Through June 2011

Federal Register 2010, 2011, 2012, 2013, 2014

2011-11-04

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

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...

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

US health policy and prescription drug coverage of FDA-approved medications for the treatment of obesity.

PubMed

Gomez, G; Stanford, F C

2018-03-01

Obesity is now the most prevalent chronic disease in the United States, which amounts to an estimated $147 billion in health care spending annually. The Affordable Care Act (ACA) enacted in 2010 included provisions for private and public health insurance plans that expanded coverage for lifestyle/behavior modification and bariatric surgery for the treatment of obesity. Pharmacotherapy, however, has not been included despite their evidence-based efficacy. We set out to investigate the coverage of Food and Drug Administration-approved medications for obesity within Medicare, Medicaid and ACA-established marketplace health insurance plans. We examined coverage for phentermine, diethylpropion, phendimetrazine, Benzphentamine, Lorcaserin, Phentermine/Topiramate (Qysmia), Liraglutide (Saxenda) and Buproprion/Naltrexone (Contrave) among Medicare, Medicaid and marketplace insurance plans in 34 states. Among 136 marketplace health insurance plans, 11% had some coverage for the specified drugs in only nine states. Medicare policy strictly excludes drug therapy for obesity. Only seven state Medicaid programs have drug coverage. Obesity requires an integrated approach to combat its public health threat. Broader coverage of pharmacotherapy can make a significant contribution to fighting this complex and chronic disease.

Reducing the Deficit: Spending and Revenue Options

DTIC Science & Technology

2011-03-01

the Conservation Reserve Program 25AgricultureOption 6 Reduce the Premium Subsidy in the Crop Insurance Program 26Option 7 Reduce by 20 Percentage...Graduate Students 31Option 11 Change the Interest Rate Structure for Student Loans 32HealthOption 12 Add a “Public Plan” to the Health Insurance Exchanges...Health Episodes Covered by Medicare 48Option 21 Reduce Medicare Costs by Changing the Cost-Sharing Structures for Medicare and Medigap Insurance 49Option

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

ERIC Educational Resources Information Center

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

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

Medicare prescription drug coverage: Consumer information and preferences

PubMed Central

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

2006-01-01

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

Medicare and Medicaid programs: hospital outpatient prospective payment; ambulatory surgical center payment; hospital value-based purchasing program; physician self-referral; and patient notification requirements in provider agreements. Final rule with comment period.

PubMed

2011-11-30

This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) for CY 2012 to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the OPPS. In addition, this final rule with comment period updates the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this final rule with comment period, we set forth the relative payment weights and payment amounts for services furnished in ASCs, specific HCPCS codes to which these changes apply, and other ratesetting information for the CY 2012 ASC payment system. We are revising the requirements for the Hospital Outpatient Quality Reporting (OQR) Program, adding new requirements for ASC Quality Reporting System, and making additional changes to provisions of the Hospital Inpatient Value-Based Purchasing (VBP) Program. We also are allowing eligible hospitals and CAHs participating in the Medicare Electronic Health Record (EHR) Incentive Program to meet the clinical quality measure reporting requirement of the EHR Incentive Program for payment year 2012 by participating in the 2012 Medicare EHR Incentive Program Electronic Reporting Pilot. Finally, we are making changes to the rules governing the whole hospital and rural provider exceptions to the physician self-referral prohibition for expansion of facility capacity and changes to provider agreement regulations on patient notification requirements.

75 FR 49215 - Medicare Program; End-Stage Renal Disease Quality Incentive Program

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-12

... new feature on http://www.medicare.gov that was modeled after Nursing Home Compare and continues to be... for the three finalized measures. We believe that this is the performance period that best balances...

Health care utilization among Medicare-Medicaid dual eligibles: a count data analysis.

PubMed

Moon, Sangho; Shin, Jaeun

2006-04-05

Medicare-Medicaid dual eligibles are the beneficiaries of both Medicare and Medicaid. Dual eligibles satisfy the eligibility conditions for Medicare benefit. Dual eligibles also qualify for Medicaid because they are aged, blind, or disabled and meet the income and asset requirements for receiving Supplement Security Income (SSI) assistance. The objective of this study is to explore the relationship between dual eligibility and health care utilization among Medicare beneficiaries. The household component of the nationally representative Medical Expenditure Panel Survey (MEPS) 1996-2000 is used for the analysis. Total 8,262 Medicare beneficiaries are selected from the MEPS data. The Medicare beneficiary sample includes individuals who are covered by Medicare and do not have private health insurance during a given year. Zero-inflated negative binomial (ZINB) regression model is used to analyse the count data regarding health care utilization: office-based physician visits, hospital inpatient nights, agency-sponsored home health provider days, and total dental visits. Dual eligibility is positively correlated with the likelihood of using hospital inpatient care and agency-sponsored home health services and the frequency of agency-sponsored home health days. Frequency of dental visits is inversely associated with dual eligibility. With respect to racial differences, dually eligible Afro-Americans use more office-based physician and dental services than white duals. Asian duals use more home health services than white duals at the 5% statistical significance level. The dual eligibility programs seem particularly beneficial to Afro-American duals. Dual eligibility has varied impact on health care utilization across service types. More utilization of home healthcare among dual eligibles appears to be the result of delayed realization of their unmet healthcare needs under the traditional Medicare-only program rather than the result of overutilization in response to the expanded benefits of the dual eligibility program. The dual eligibility program is particularly beneficial to Asian and Afro-American duals in association with the provision of home healthcare and dental benefits.

Medicare Contracting Risk/Medicare Risk Contracting: A Life-Cycle View from Twelve Markets

PubMed Central

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

2003-01-01

Objective To examine the evolution of the Medicare HMO program from 1996 to 2001 in 12 nationally representative urban markets by exploring how the separate and confluent influences of government policy initiatives and health plans' strategic aims and operational experience affected the availability of HMOs to Medicare beneficiaries. Data Source Qualitative data gathered from 12 nationally representative urban communities with more than 200,000 residents each, in tandem with quantitative information from the Centers for Medicare and Medicaid Services and other sources. Study Design Detailed interview protocols, developed as part of the multiyear, multimethod Community Tracking Study of the Center for Studying Health System Change, were used to conduct three rounds of interviews (1996, 1998, and 2000–2001) with health plans and providers in 12 nationally representative urban communities. A special focus during the third round of interviews was on gathering information related to Medicare HMOs' experience in the previous four years. This information was used to build on previous research to develop a longitudinal perspective on health plans' experience in Medicare's HMO program. Principal Findings From 1996 to 2001, the activities and expectations of health plans in local markets underwent a rapid and dramatic transition from enthusiasm for the Medicare HMO product, to abrupt reconsideration of interest corresponding to changes in the Balanced Budget Act of 1997, on to significant retrenchment and disillusionment. Policy developments were important in their own right, but they also interacted with shifts in the strategic aims and operational experiences of health plans that reflect responses to insurance underwriting cycle pressures and pushback from providers. Conclusion The Medicare HMO program went through a substantial reversal of fortune during the study period, raising doubts about whether its downward course can be altered. Market-level analysis reveals that virtually all momentum for the program has been lost and that enrollment is shrinking back to the levels and locations found in the mid-1990s. PMID:12650373

Medicare contracting risk/Medicare risk contracting: a life-cycle view from twelve markets.

PubMed

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

2003-02-01

To examine the evolution of the Medicare HMO program from 1996 to 2001 in 12 nationally representative urban markets by exploring how the separate and confluent influences of government policy initiatives and health plans' strategic aims and operational experience affected the availability of HMOs to Medicare beneficiaries. Qualitative data gathered from 12 nationally representative urban communities with more than 200,000 residents each, in tandem with quantitative information from the Centers for Medicare and Medicaid Services and other sources. Detailed interview protocols, developed as part of the multiyear, multimethod Community Tracking Study of the Center for Studying Health System Change, were used to conduct three rounds of interviews (1996, 1998, and 2000-2001) with health plans and providers in 12 nationally representative urban communities. A special focus during the third round of interviews was on gathering information related to Medicare HMOs' experience in the previous four years. This information was used to build on previous research to develop a longitudinal perspective on health plans' experience in Medicare's HMO program. From 1996 to 2001, the activities and expectations of health plans in local markets underwent a rapid and dramatic transition from enthusiasm for the Medicare HMO product, to abrupt reconsideration of interest corresponding to changes in the Balanced Budget Act of 1997, on to significant retrenchment and disillusionment. Policy developments were important in their own right, but they also interacted with shifts in the strategic aims and operational experiences of health plans that reflect responses to insurance underwriting cycle pressures and pushback from providers. The Medicare HMO program went through a substantial reversal of fortune during the study period, raising doubts about whether its downward course can be altered. Market-level analysis reveals that virtually all momentum for the program has been lost and that enrollment is shrinking back to the levels and locations found in the mid-1990s.

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...

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 and Medicaid fraud and abuse regulations.

PubMed

Liang, F Z; Black, B L

1991-11-01

Specific business arrangements that are protected under legislation and regulations governing parties doing business with Medicare or Medicaid are discussed. Regulations implementing the Medicare and Medicaid Patient Protection Act of 1987 specify practices and activities that are not subject to criminal penalties under the antikickback provisions of the Social Security Act or to exclusion from Medicare or state health-care programs. As of July 29, 1991, all organized health-care settings that receive payments from either Medicare or state health-care programs must comply with these regulations. The final rule sets forth "safe harbors"--exceptions to prohibitions against (1) kickbacks, bribes, rebates, and other illegal activities involving remunerations for patient referrals and (2) inducements to purchase or lease goods paid for by Medicare or state health-care programs. The safe harbors comprise 11 broad categories--investment interests, space rental, equipment rental, personal services and management contracts, purchase of a medical practice, referral services, warranties, discounts, employees, group purchasing organizations, and waiver of deductibles and coinsurance. Implications for pharmacy are discussed. These regulations will affect the purchase of pharmaceuticals by institutional pharmacies. Each institution should review its current practices to determine whether they are within the safe harbors.

Competitive pricing and the challenge of cost control in medicare.

PubMed

Coulam, Robert F; Feldman, Roger D; Dowd, Bryan E

2011-08-01

The Medicare program faces a serious challenge: it must find ways to control costs but must do so through a system of congressional oversight that necessarily limits its choices. We look at one approach to prudent purchasing - competitive pricing - that Medicare has attempted many times and in various ways since the beginning of the program, and in all but one case unsuccessfully due to the politics of provider opposition working through Congress and the courts. We look at some related efforts to change Medicare pricing to explore when the program has been successful in making dramatic changes in how it pays for health care. A set of recommendations emerges for ways to respond to the impediments of law and politics that have obstructed change to more efficient payment methods. Except in unusual cases, competitive pricing threatens too many stakeholders in too many ways for key political actors to support it. But an unusual case may arise in the coming Medicare fiscal crisis, a crisis related in part to the prices Medicare pays. At that point, competitive pricing may look less like a problem and more like a solution coming at a time when the system badly needs one.

Physician Quality Reporting System Program Updates and the Impact on Emergency Medicine Practice

PubMed Central

Wiler, Jennifer L.; Granovsky, Michael; Cantrill, Stephen V.; Newell, Richard; Venkatesh, Arjun K.; Schuur, Jeremiah D.

2016-01-01

In 2007, the Centers for Medicaid and Medicare Services (CMS) created a novel payment program to create incentives for physician’s to focus on quality of care measures and report quality performance for the first time. Initially termed “The Physician Voluntary Reporting Program,” various Congressional actions, including the Tax Relief and Health Care Act of 2006 (TRHCA) and Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) further strengthened and ensconced this program, eventually leading to the quality program termed today as the Physician Quality Reporting System (PQRS). As a result of passage of the Affordable Care Act of 2010, the PQRS program has expanded to include both the “traditional PQRS” reporting program and the newer “Value Modifier” program (VM). For the first time, these programs were designed to include pay-for-performance incentives for all physicians providing care to Medicare beneficiaries and to measure the cost of care. The recent passage of the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act in March of 2015 includes changes to these payment programs that will have an even more profound impact on emergency care providers. We describe the implications of these important federal policy changes for emergency physicians. PMID:26973757

42 CFR § 510.320 - Treatment of incentive programs or add-on payments under existing Medicare payment systems.

Code of Federal Regulations, 2010 CFR

2017-10-01

... INFRASTRUCTURE AND MODEL PROGRAMS COMPREHENSIVE CARE FOR JOINT REPLACEMENT MODEL Pricing and Payment § 510.320 Treatment of incentive programs or add-on payments under existing Medicare payment systems. The CJR model... 42 Public Health 5 2017-10-01 2017-10-01 false Treatment of incentive programs or add-on payments...

42 CFR § 510.320 - Treatment of incentive programs or add-on payments under existing Medicare payment systems.

Code of Federal Regulations, 2010 CFR

2016-10-01

... INFRASTRUCTURE AND MODEL PROGRAMS COMPREHENSIVE CARE FOR JOINT REPLACEMENT MODEL Pricing and Payment § 510.320 Treatment of incentive programs or add-on payments under existing Medicare payment systems. The CJR model... 42 Public Health 5 2016-10-01 2016-10-01 false Treatment of incentive programs or add-on payments...

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-06

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

75 FR 73090 - Medicare Program; Listening Session on Development of Additional Imaging Efficiency Measures for...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-29

... Hospital Outpatient Quality Data Reporting Program AGENCY: Centers for Medicare & Medicaid Services (CMS... Quality Data Reporting Program (HOP QDRP), which is authorized under section 1833(t)(17) of the Social... participate either in person or via teleconference. The meeting is open to the public, but attendance is...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-06

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-05-03

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

75 FR 70013 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-16

... Insurance; and Program No. 93.774, Medicare-- Supplementary Medical Insurance Program) Dated: November 9...: Correction notice. SUMMARY: This document corrects a technical error that appeared in the notice published in... of July 22, 2010 (75 FR 42836), there was a technical error that we are identifying and correcting in...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-09-20

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

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

Code of Federal Regulations, 2010 CFR

2010-10-01

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-12-27

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

42 CFR 422.566 - Organization determinations.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Organization determinations. 422.566 Section 422... (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Grievances, Organization Determinations and Appeals § 422.566 Organization determinations. (a) Responsibilities of the MA organization. Each MA organization...

42 CFR 414.908 - Competitive acquisition program.

Code of Federal Regulations, 2011 CFR

2011-10-01

.... (J) Beneficiary Medicare information/Health insurance (HIC) number. (K) Supplementary insurance... 42 Public Health 3 2011-10-01 2011-10-01 false Competitive acquisition program. 414.908 Section 414.908 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN...

42 CFR 414.908 - Competitive acquisition program.

Code of Federal Regulations, 2010 CFR

2010-10-01

.... (J) Beneficiary Medicare information/Health insurance (HIC) number. (K) Supplementary insurance... 42 Public Health 3 2010-10-01 2010-10-01 false Competitive acquisition program. 414.908 Section 414.908 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN...

The welfare impact of Medicare HMOs.

PubMed

Town, Robert; Liu, Su

2003-01-01

We estimate the welfare associated with the Medicare HMO program, now known as Medicare+Choice (M+C). We find that the creation of the M+C program resulted in approximately $15.6 billion in consumer surplus and $52 billion in profits from 1993 to 2000 (in 2000 dollars). This program most likely generated significant net social welfare. However, we find that consumer surplus is geographically unevenly distributed. Prescription drug coverage accounts for approximately 45% of the estimated consumer surplus for 2000. Consumer surplus increases in the number of plans in a county, and most of the increase in welfare is due to increased premium competition.

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 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 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 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 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 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...

Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Short Inpatient Hospital Stays; Transition for Certain Medicare-Dependent, Small Rural Hospitals Under the Hospital Inpatient Prospective Payment System; Provider Administrative Appeals and Judicial Review. Final rule with comment period; final rule.

PubMed

2015-11-13

This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2016 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this final rule with comment period updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program. Further, this document includes certain finalized policies relating to the hospital inpatient prospective payment system: Changes to the 2-midnight rule under the short inpatient hospital stay policy; and a payment transition for hospitals that lost their status as a Medicare-dependent, small rural hospital (MDH) because they are no longer in a rural area due to the implementation of the new Office of Management and Budget delineations in FY 2015 and have not reclassified from urban to rural before January 1, 2016. In addition, this document contains a final rule that finalizes certain 2015 proposals, and addresses public comments received, relating to the changes in the Medicare regulations governing provider administrative appeals and judicial review relating to appropriate claims in provider cost reports.

The Medicare bundled payment pilot program participation considerations.

PubMed

Pearce, Jonathan W; Harris, John M

2010-09-01

The Medicare bundled payment pilot program is scheduled to begin in January 2013 and will run for five years. The program holds the promise of increased alignment between hospitals and physicians, presenting opportunities for hospital cost reduction and improvements in quality. Nonetheless, the program carries fixed costs and assumption of risks that hospitals need to evaluate as they deliberate over whether to seek to participate in the program.

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.

Impacts of a disease management program for dually eligible beneficiaries.

PubMed

Esposito, Dominick; Brown, Randall; Chen, Arnold; Schore, Jennifer; Shapiro, Rachel

2008-01-01

The LifeMasters Supported SelfCare demonstration program provides disease management (DM) services to Florida Medicare beneficiaries who are also enrolled in Medicaid and have congestive heart failure (CHF), diabetes, or coronary artery disease (CAD). The population-based program provides primarily telephonic patient education and monitoring services. Findings from the randomized, intent-to-treat design over the first 18 months of operations show virtually no overall impacts on hospital or emergency room (ER) use, Medicare expenditures, quality of care, or prescription drug use for the 33,000 enrollees. However, for beneficiaries with CHF who resided in high-cost South Florida counties, the program reduced Medicare expenditures by 9.6 percent.

The PSRO hospital review system.

PubMed

Goran, M J; Roberts, J S; Kellogg, M A; Fielding, J; Jessee, W

1975-04-01

The 1972 Social Security amendments contained the landmark Professional Standards Review Organization (PSRO) provisions as well as several sections upgrading existing utilization review (UR) requirements under Medicare and Medicaid. With issuance of the PSRO Program Manual and the recent publication of the new UR regulations, HEW for the first time has brought Medicare and Medicaid hospital review requirements into conformity and made them compatible with and supportive of the PSRO program. This article defines the PSRO hospital review system, describes how the three major components-concurrent review, medical care evaluation studies, and profile analysis-interrelate and provides examples of each of these components. Under utilization review requirements or PSRO, hospitals will be required to implement an integrated system of review designed to assure appropriate utilization practices and improve the quality of care. These aims are to be accomplished through the application of concepts of peer review, the use of norms, criteria, and standards, the identification of deficiencies in the quality, administration, or appropriateness of health care services, and their correction through linkage with programs of continuing medical education. Although PSROs are initially responsible for review in hospitals, they will likely provide the locus for a community-wide system of peer review for all services provided under National Health Insurance.

76 FR 18766 - Early Retiree Reinsurance Program

Federal Register 2010, 2011, 2012, 2013, 2014

2011-04-05

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

42 CFR 422.102 - Supplemental benefits.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Supplemental benefits. 422.102 Section 422.102... (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Benefits and Beneficiary Protections § 422.102 Supplemental benefits. (a) Mandatory supplemental benefits. (1) Subject to CMS approval, an MA...

42 CFR 422.102 - Supplemental benefits.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Supplemental benefits. 422.102 Section 422.102... (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Benefits and Beneficiary Protections § 422.102 Supplemental benefits. (a) Mandatory supplemental benefits. (1) Subject to CMS approval, an MA...

42 CFR 422.102 - Supplemental benefits.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Supplemental benefits. 422.102 Section 422.102... (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Benefits and Beneficiary Protections § 422.102 Supplemental benefits. (a) Mandatory supplemental benefits. (1) Subject to CMS approval, an MA...

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

PubMed

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

2018-04-01

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

42 CFR 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 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...

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 423.1014 - 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 423.1046 - 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 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...

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-07-18

...This proposed rule would revise the Medicare hospital outpatient prospective payment system (OPPS) to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this proposed rule, we describe the proposed changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the OPPS. These proposed changes would be applicable to services furnished on or after January 1, 2012. In addition, this proposed rule would update the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this proposed rule, we set forth the proposed relative payment weights and payment amounts for services furnished in ASCs, specific HCPCS codes to which these proposed changes would apply, and other proposed ratesetting information for the CY 2012 ASC payment system. These proposed changes would be applicable to services furnished on or after January 1, 2012. We are proposing to revise the requirements for the Hospital Outpatient Quality Reporting (IQR) Program, add new requirements for ASC Quality Reporting System, and make additional changes to provisions of the Hospital Inpatient Value-Based Purchasing (VBP) Program. We also are proposing to allow eligible hospitals and CAHs participating in the Medicare Electronic Health Record (EHR) Incentive Program to meet the clinical quality measure reporting requirement of the EHR Incentive Program for payment year 2012 by participating in the 2012 Medicare EHR Incentive Program Electronic Reporting Pilot. In addition, we are proposing to make changes to the rules governing the whole hospital and rural provider exceptions to the physician self-referral prohibition for expansion of facility capacity and changes to provider agreement regulations on patient notification requirements.

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-10-22

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-04-29

...This proposed rule would revise the Incentive Reward Program provisions in Sec. 420.405 and certain provider enrollment requirements in part 424, subpart P. The most significant of these revisions include: changing the Incentive Reward Program potential reward amount for information on individuals and entities who are or have engaged in acts or omissions which resulted in the imposition of a sanction from 10 percent of the overpayments recovered in the case or $1,000, whichever is less, to 15 percent of the final amount collected applied to the first $66,000,000 for the sanctionable conduct; expanding the instances in which a felony conviction can serve as a basis for denial or revocation of a provider or supplier's enrollment; if certain criteria are met, enabling us to deny enrollment if the enrolling provider, supplier, or owner thereof had an ownership relationship with a previously enrolled provider or supplier that had a Medicare debt; enabling us to revoke Medicare billing privileges if we determine that the provider or supplier has a pattern or practice of submitting claims for services that fail to meet Medicare requirements; and limiting the ability of ambulance suppliers to ``backbill'' for services performed prior to enrollment. We believe this proposed rule would--increase the incentive for individuals to report information on individuals and entities that have or are engaged in sanctionable conduct; improve our ability to detect new fraud schemes; and help us ensure that fraudulent entities and individuals do not enroll in or maintain their enrollment in the Medicare program.

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.

42 CFR 425.700 - General rules.

Code of Federal Regulations, 2014 CFR

2014-10-01

... privacy of individually identifiable health information and comply with the terms of the data use...) MEDICARE PROGRAM (CONTINUED) MEDICARE SHARED SAVINGS PROGRAM Data Sharing With ACOs § 425.700 General rules. (a) CMS shares aggregate reports with the ACO. (b) CMS shares beneficiary identifiable data with ACOs...

42 CFR 422.158 - Procedures for approval of accreditation as a basis for deeming compliance.

Code of Federal Regulations, 2011 CFR

2011-10-01

..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Quality... the accreditation organization, including— (i) The size and composition of accreditation survey teams... and procedures regarding coordination of these activities with appropriate licensing bodies and...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-08-08

...-7205 Ventricular Assist Device (Destination Therapy) Facilities. XIII Medicare-Approved Lung JoAnna...-Approved Ventricular Assist Device (Destination Therapy) Facilities, Addendum XIII: Lung Volume Reduction...-Approved Ventricular Assist Device (Destination Therapy) Facilities (January Through March 2011) Addendum...

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...

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 § 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...

Medicare Advantage Plans Pay Hospitals Less Than Traditional Medicare Pays.

PubMed

Baker, Laurence C; Bundorf, M Kate; Devlin, Aileen M; Kessler, Daniel P

2016-08-01

There is ongoing debate about how prices paid to providers by Medicare Advantage plans compare to prices paid by fee-for-service Medicare. We used data from Medicare and the Health Care Cost Institute to identify the prices paid for hospital services by fee-for-service (FFS) Medicare, Medicare Advantage plans, and commercial insurers in 2009 and 2012. We calculated the average price per admission, and its trend over time, in each of the three types of insurance for fixed baskets of hospital admissions across metropolitan areas. After accounting for differences in hospital networks, geographic areas, and case-mix between Medicare Advantage and FFS Medicare, we found that Medicare Advantage plans paid 5.6 percent less for hospital services than FFS Medicare did. Without taking into account the narrower networks of Medicare Advantage, the program paid 8.0 percent less than FFS Medicare. We also found that the rates paid by commercial plans were much higher than those of either Medicare Advantage or FFS Medicare, and growing. At least some of this difference comes from the much higher prices that commercial plans pay for profitable service lines. Project HOPE—The People-to-People Health Foundation, Inc.

Plan-provider integration, premiums, and quality in the Medicare Advantage market.

PubMed

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

2013-12-01

To investigate how integration between Medicare Advantage plans and health care providers is related to plan premiums and quality ratings. We used public data from the Centers for Medicare and Medicaid Services (CMS) and the Area Resource File and private data from one large insurer. Premiums and quality ratings are from 2009 CMS administrative files and some control variables are historical. We estimated ordinary least-squares models for premiums and plan quality ratings, with state fixed effects and firm random effects. The key independent variable was an indicator of plan-provider integration. With the exception of Medigap premium data, all data were publicly available. We ascertained plan-provider integration through examination of plans' websites and governance documents. We found that integrated plan-providers charge higher premiums, controlling for quality. Such plans also have higher quality ratings. We found no evidence that integration is associated with more generous benefits. Current policy encourages plan-provider integration, although potential effects on health insurance products and markets are uncertain. Policy makers and regulators may want to closely monitor changes in premiums and quality after integration and consider whether quality improvement (if any) justifies premium increases (if they occur). © Health Research and Educational Trust.

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-09-04

...This final rule specifies the Stage 2 criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to qualify for Medicare and/or Medicaid electronic health record (EHR) incentive payments. In addition, it specifies payment adjustments under Medicare for covered professional services and hospital services provided by EPs, eligible hospitals, and CAHs failing to demonstrate meaningful use of certified EHR technology (CEHRT) and other program participation requirements. This final rule revises certain Stage 1 criteria, as finalized in the July 28, 2010 final rule, as well as criteria that apply regardless of Stage.

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...

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...

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 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 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 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...

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...

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 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...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-05-29

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

42 CFR 422.158 - Procedures for approval of accreditation as a basis for deeming compliance.

Code of Federal Regulations, 2012 CFR

2012-10-01

..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM... surveys for the accreditation organization, including— (i) The size and composition of accreditation... policies and procedures regarding coordination of these activities with appropriate licensing bodies and...

42 CFR 422.158 - Procedures for approval of accreditation as a basis for deeming compliance.

Code of Federal Regulations, 2014 CFR

2014-10-01

..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM... surveys for the accreditation organization, including— (i) The size and composition of accreditation... policies and procedures regarding coordination of these activities with appropriate licensing bodies and...

42 CFR 422.158 - Procedures for approval of accreditation as a basis for deeming compliance.

Code of Federal Regulations, 2013 CFR

2013-10-01

..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM... surveys for the accreditation organization, including— (i) The size and composition of accreditation... policies and procedures regarding coordination of these activities with appropriate licensing bodies and...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-22

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-11-05

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

42 CFR 424.502 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... officer, general partner, chairman of the board, or direct owner) to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organization's status in the Medicare program, and to commit the organization to fully abide by the statutes...

The Medicare Health Outcomes Survey program: overview, context, and near-term prospects.

PubMed

Jones, Nathaniel; Jones, Stephanie L; Miller, Nancy A

2004-07-12

In 1996, the Centers for Medicare & Medicaid Services (CMS) initiated the Medicare Health Outcomes Survey (HOS). It is the first national survey to measure the quality of life and functional health status of Medicare beneficiaries enrolled in managed care. The program seeks to gather valid and reliable health status data in Medicare managed care for use in quality improvement activities, public reporting, plan accountability and improving health outcomes based on competition. The context that led to the development of the HOS was formed by the convergence of the following factors: 1) a recognized need to monitor the performance of managed care plans, 2) technical expertise and advancement in the areas of quality measurement and health outcomes assessment, 3) the existence of a tested functional health status assessment tool (SF-36)1, which was valid for an elderly population, 4) CMS leadership, and 5) political interest in quality improvement. Since 1998, there have been six baseline surveys and four follow up surveys. CMS, working with its partners, performs the following tasks as part of the HOS program: 1) Supports the technical/scientific development of the HOS measure, 2) Certifies survey vendors, 3) Collects Health Plan Employer Data and Information Set(HEDIS)2 HOS data, 4) Cleans, scores, and disseminates annual rounds of HOS data, public use files and reports to CMS, Quality Improvement Organizations (QIOs), Medicare+Choice Organizations (M+COs), and other stakeholders, 5) Trains M+COs and QIOs in the use of functional status measures and best practices for improving care, 6) Provides technical assistance to CMS, QIOs, M+COs and other data users, and 7) Conducts analyses using HOS data to support CMS and HHS priorities.CMS has recently sponsored an evaluation of the HOS program, which will provide the information necessary to enhance the future administration of the program. Information collected to date reveals that the HOS program is a valuable tool that provides a rich set of data that is useful for quality monitoring and improvement efforts. To enhance the future of the HOS program, many stakeholders recommend the implementation of incentives to encourage the use of the data, while others identify the need to monitor the health status of plan disenrollees.Overall, the HOS program represents an important vehicle for collecting outcomes data from Medicare beneficiaries. The new Medicare Prescription Drug, Improvement, and Modernization Act (2003) mandates the collection and use of data for outcomes measurement. Consequently, it is important to improve HOS to most effectively meet the mandate.

Medicare Advantage Penetration and Hospital Costs Before and After the Affordable Care Act.

PubMed

Henke, Rachel Mosher; Karaca, Zeynal; Gibson, Teresa B; Cutler, Eli; White, Chapin; Wong, Herbert S

2018-04-01

Research has suggested that growth in the Medicare Advantage (MA) program indirectly benefits the entire 65+-year-old population by reducing overall expenditures and creating spillover effects of patient care practices. Medicare programs and innovations initiated by the Affordable Care Act (ACA) have encouraged practices to adopt models applying to all patient populations, which may influence the continued benefits of MA program growth. This study investigated the relationship between MA program growth and inpatient hospital costs and utilization before and after the ACA. Primary data sources were 2005-2014 Health Care Cost and Utilization Project hospital data and 2004-2013 Centers for Medicare & Medicaid Services enrollment data. County-year-level regression analysis with fixed effects examined the relationship between Medicare managed care penetration and hospital cost per enrollee. We decomposed results into changes in utilization, severity, and severity-adjusted inpatient resource use. Analyses were stratified by whether the admission was urgent or nonurgent. A 10% increase in MA penetration was associated with a 3-percentage point decrease in inpatient cost per Medicare enrollee before the ACA. This effect was more prominent in nonurgent admissions and diminished after the ACA. Results suggest that MA enrollment growth is associated with diminished spillover reductions in hospital admission costs after the ACA. We did not observe a strong relationship between MA enrollment and inpatient days per enrollee. Future research should examine whether spillover effects still are observed in outpatient settings.

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

PubMed Central

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

2012-01-01

Managing competition among health plans that attract different risks has been a challenging policy problem. Within Medicare, the Medicare Advantage (MA) program historically attracted better risks than did Traditional Medicare (TM). This favorable selection resulted in Medicare’s paying more for persons enrolled in MA than if they had been enrolled in TM. We studied whether policies Medicare implemented in the past decade to reduce favorable selection in the MA program succeeded, in particular improved matching of reimbursement with a beneficiary’s expected cost and restricting when beneficiaries could switch from MA to TM. We found they did. Differences in predicted spending between those switching from TM to MA relative to those who remained in TM markedly narrowed, as did adjusted mortality rates. Because insurance exchanges will employ similar policies to combat selection, our results give reason for optimism about managing competition among health plans. PMID:23213145

Medicare Advantage reforms: comparing House and Senate bills.

PubMed

Biles, Brian; Arnold, Grace

2009-12-01

The Medicare Advantage (MA) program, which enables Medicare beneficiaries to enjoy private health plan coverage, is a major element of the current health care reform discussion on Capitol Hill--in large part because payments to MA plans in 2009 are expected to run at least $11 billion more than traditional Medicare would have cost. While the pending Senate and House bills both endeavor to reduce these extra MA payments, their approaches are different. The bills also differ on other aspects of reforming the MA program, such as plans' allowable geographic areas, their risk-adjustment systems and reporting requirements, their potential bonuses for achieving high-quality care and providing good management, and their beneficiary protections. This issue brief compares the above and other provisions in the House and Senate bills, which have a common overall goal to improve the value that Medicare obtains for the dollars it spends

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

PubMed

Glied, Sherry; Zaylor, Abigail

2015-07-01

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-02-18

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

Implications of health reform for retiree health benefits.

PubMed

Fronstin, Paul

2010-01-01

This Issue Brief examines how current health reform legislation being debated in Congress will impact the future of retiree health benefits. In general, the proposals' provisions will have a mixed impact on retiree health benefits: In the short term, the reinsurance provisions would help shore up early retiree coverage and Medicare Part D coverage would become more valuable to retirees. In the longer term, insurance reform combined with new subsidies for individuals enrolling for coverage through insurance exchanges, the maintenance-of-effort provision affecting early retiree benefits, increases to the cost of providing drug benefits to retirees, and enhanced Medicare Part D coverage, would all create significant incentives for employers to drop coverage for early retirees and drug coverage for Medicare-eligible retirees. REINSURANCE PROGRAM FOR EARLY RETIREES: Proposed legislation includes a provision to create a temporary reinsurance program for employers providing health benefits to retirees over age 55 and not yet eligible for Medicare. Given the temporary nature of the program, it is intended to provide employers an incentive to maintain benefits until the health insurance exchange is fully operational. At that point, employers will have less incentive to provide health benefits to early retirees, and retirees will have less need for former employers to maintain a program. MEDICARE DRUG BENEFITS: The House-passed bill would initially reduce the coverage gap (the so-called "doughnut hole") for individuals in the Medicare Part D program by $500 and eliminate it altogether by 2019. The bill currently before the Senate would also reduce the coverage gap by $500, but does not call for eliminating it. Both would also provide a 50 percent discount to brand-name drug coverage in the coverage gap. These provisions increase the value of the Medicare Part D drug program to Medicare-eligible beneficiaries relative to drug benefits provided by employers. TAX TREATMENT OF EMPLOYER SUBSIDIES UNDER MMA: The Medicare Modernization Act provides subsidies to employers that continue to offer prescription drug coverage through a retiree health benefits program. This subsidy is currently not counted as taxable income to the employer receiving it. Both the House and Senate bills would effectively repeal this tax exclusion. This would have two effects: The real cost of providing retiree health benefits to Medicare-eligible retirees would increase, and an employer's FAS 106 liability would increase immediately. The increase in the cost of retiree drug benefits will cause employers to re-evaluate the subsidy, compared with other available options. Moving retirees to Medicare Part D may become even more attractive to employers if the coverage gap is reduced and/or eliminated. POSTRETIREMENT BENEFIT CHANGES: With some exceptions, the House-passed legislation would prohibit employers from changing the benefits offered to retirees and their beneficiaries once a person has retired. This provision could have a number of different effects: More employers may move toward capping their contributions; employers that want to maintain retiree health benefits may react by cutting the health benefits of active workers; employers may eliminate retiree health benefits altogether to avoid being locked into providing a permanent benefit; or they may drop benefits if they think there is no need to provide them.

42 CFR 417.430 - Application procedures.

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 § 417.430 Application...

Evaluation of Student Outcomes after Participating in a Medicare Outreach Program

ERIC Educational Resources Information Center

Hollingsworth, Joshua C.; Teeter, Benjamin S.; Westrick, Salisa C.

2015-01-01

This article describes the development of a service-learning project and analysis of student pharmacists' participation therein. Using a mixed-methods approach, this study analyzed student pharmacists' knowledge and attitudes after volunteering in the inaugural Medicare Outreach Program, a collaboration between the School of Pharmacy and State…

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

Code of Federal Regulations, 2014 CFR

2014-10-01

... the Medicare program. (a) Reasons for revocation. CMS may revoke a currently enrolled provider or... the following reasons: (1) Noncompliance. The provider or supplier is determined not to be in...— (A) Felony crimes against persons, such as murder, rape, assault, and other similar crimes for which...

78 FR 8535 - Medicare Program: Comprehensive End-Stage Renal Disease Care Model Announcement

Federal Register 2010, 2011, 2012, 2013, 2014

2013-02-06

... develop and test innovative health care payment and service delivery models that show promise of reducing program expenditures, while preserving or enhancing the quality of care for Medicare, Medicaid, and... disease (ESRD). This population has complex health care needs, typically with comorbid conditions and...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-09-27

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-04-24

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-10-04

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-08-24

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