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, 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...

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...

42 CFR 422.502 - Evaluation and determination procedures.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

42 CFR 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...

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 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...

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...

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 422.521 - 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 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...

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 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...

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...

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 422.320 - 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 422.311 - 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 422.316 - 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...

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 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 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 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...

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...

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, 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 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...

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...

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 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...

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 422.156 - 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...

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, 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 422.2274 - 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...

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...

42 CFR 417.452 - Liability of Medicare enrollees.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

42 CFR 422.158 - 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...

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 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...

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...

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...

42 CFR 423.171 - 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) VOLUNTARY MEDICARE... organization, including the— (i) Size and composition of accreditation survey teams for each type of plan... activities with appropriate licensing bodies and ombudsmen programs. (7) A description of the organization's...

42 CFR 423.171 - 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) VOLUNTARY MEDICARE... organization, including the— (i) Size and composition of accreditation survey teams for each type of plan... activities with appropriate licensing bodies and ombudsmen programs. (7) A description of the organization's...

42 CFR 423.171 - 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) VOLUNTARY MEDICARE... organization, including the— (i) Size and composition of accreditation survey teams for each type of plan... activities with appropriate licensing bodies and ombudsmen programs. (7) A description of the organization's...

42 CFR 422.400 - State licensure requirement.

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 § 422.400 State licensure requirement. Except in the case of a PSO granted a waiver under subpart H of this part, each MA organization must— (a) Be licensed under State law...

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...

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, 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...

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, 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 422.220 - 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...

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...

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.

42 CFR 422.455 - Special rules for MA Regional Plans.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Special rules for MA Regional Plans. 422.455... SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Special Rules for MA Regional Plans § 422.455 Special rules for MA Regional Plans. (a) Coverage of entire MA region. The service area...

42 CFR 422.455 - Special rules for MA Regional Plans.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Special rules for MA Regional Plans. 422.455... SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Special Rules for MA Regional Plans § 422.455 Special rules for MA Regional Plans. (a) Coverage of entire MA region. The service area...

42 CFR 422.455 - Special rules for MA Regional Plans.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Special rules for MA Regional Plans. 422.455... SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Special Rules for MA Regional Plans § 422.455 Special rules for MA Regional Plans. (a) Coverage of entire MA region. The service area...

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...

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...

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 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 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...

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 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...

42 CFR 423.566 - Coverage determinations.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Coverage determinations. 423.566 Section 423.566... (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Grievances, Coverage Determinations, Redeterminations, and Reconsiderations § 423.566 Coverage determinations. (a) Responsibilities of...

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...

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...

42 CFR 417.911 - Definitions.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Definitions. 417.911 Section 417.911 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE...

42 CFR 417.911 - Definitions.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Definitions. 417.911 Section 417.911 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE...

42 CFR 417.911 - Definitions.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Definitions. 417.911 Section 417.911 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE...

42 CFR 421.120 - Performance criteria.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Performance criteria. 421.120 Section 421.120... (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE CONTRACTING Intermediaries § 421.120 Performance criteria. (a) Application of performance criteria. As part of the intermediary evaluations authorized by...

42 CFR 421.120 - Performance criteria.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Performance criteria. 421.120 Section 421.120... (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE CONTRACTING Intermediaries § 421.120 Performance criteria. (a) Application of performance criteria. As part of the intermediary evaluations authorized by...

42 CFR 421.120 - Performance criteria.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Performance criteria. 421.120 Section 421.120... (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE CONTRACTING Intermediaries § 421.120 Performance criteria. (a) Application of performance criteria. As part of the intermediary evaluations authorized by...

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...

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.

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...

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...

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

PubMed

Thomas, Cindy Parks; Sussman, Jeffrey

2007-05-30

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

42 CFR 421.122 - Performance standards.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Performance standards. 421.122 Section 421.122... (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE CONTRACTING Intermediaries § 421.122 Performance standards. (a) Development of standards. In addition to the performance criteria (§ 421.120), CMS develops...

42 CFR 421.122 - Performance standards.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Performance standards. 421.122 Section 421.122... (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE CONTRACTING Intermediaries § 421.122 Performance standards. (a) Development of standards. In addition to the performance criteria (§ 421.120), CMS develops...

42 CFR 421.122 - Performance standards.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Performance standards. 421.122 Section 421.122... (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE CONTRACTING Intermediaries § 421.122 Performance standards. (a) Development of standards. In addition to the performance criteria (§ 421.120), CMS develops...

42 CFR 418.114 - Condition of participation: Personnel qualifications.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Condition of participation: Personnel qualifications. 418.114 Section 418.114 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE Conditions of...

42 CFR 418.114 - Condition of participation: Personnel qualifications.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Condition of participation: Personnel qualifications. 418.114 Section 418.114 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE Conditions of...

42 CFR 418.114 - Condition of participation: Personnel qualifications.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Condition of participation: Personnel qualifications. 418.114 Section 418.114 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE Conditions of...

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 423.156 - 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...

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...

42 CFR 417.461 - Disenrollment by the enrollee.

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 § 417.461 Disenrollment...

42 CFR 417.101 - Health benefits plan: Basic health services.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Health benefits plan: Basic health services. 417.101 Section 417.101 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE...

42 CFR 417.102 - Health benefits plan: Supplemental health services.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Health benefits plan: Supplemental health services. 417.102 Section 417.102 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS...

42 CFR 417.105 - Payment for supplemental health services.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Payment for supplemental health services. 417.105 Section 417.105 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL...

42 CFR 417.105 - Payment for supplemental health services.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Payment for supplemental health services. 417.105 Section 417.105 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL...

42 CFR 417.101 - Health benefits plan: Basic health services.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Health benefits plan: Basic health services. 417.101 Section 417.101 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE...

42 CFR 417.101 - Health benefits plan: Basic health services.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Health benefits plan: Basic health services. 417.101 Section 417.101 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE...

42 CFR 417.102 - Health benefits plan: Supplemental health services.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Health benefits plan: Supplemental health services. 417.102 Section 417.102 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS...

42 CFR 417.102 - Health benefits plan: Supplemental health services.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Health benefits plan: Supplemental health services. 417.102 Section 417.102 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS...

42 CFR 414.100 - Purpose.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Purpose. 414.100 Section 414.100 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedules for Parenteral and...

42 CFR 414.100 - Purpose.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Purpose. 414.100 Section 414.100 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedules for Parenteral and...

42 CFR 414.100 - Purpose.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Purpose. 414.100 Section 414.100 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedules for Parenteral and...

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

Code of Federal Regulations, 2014 CFR

2014-10-01

... AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG..., national accreditation organization approved by CMS; and (2) The accreditation organization uses the...) Access to covered drugs, as provided under §§ 423.120 and 423.124. (2) Drug utilization management...

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

Code of Federal Regulations, 2013 CFR

2013-10-01

... AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG..., national accreditation organization approved by CMS; and (2) The accreditation organization uses the...) Access to covered drugs, as provided under §§ 423.120 and 423.124. (2) Drug utilization management...

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

Code of Federal Regulations, 2012 CFR

2012-10-01

... AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG..., national accreditation organization approved by CMS; and (2) The accreditation organization uses the...) Access to covered drugs, as provided under §§ 423.120 and 423.124. (2) Drug utilization management...

42 CFR 423.44 - Involuntary disenrollment from Part D coverage.

Code of Federal Regulations, 2012 CFR

2012-10-01

... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT... this section; or (ii) The individual has engaged in disruptive behavior, as specified under paragraph...) Disruptive behavior—(i) Definition. A PDP enrollee is disruptive if his or her behavior substantially impairs...

42 CFR 423.44 - Involuntary disenrollment from Part D coverage.

Code of Federal Regulations, 2013 CFR

2013-10-01

... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT... this section; or (ii) The individual has engaged in disruptive behavior, as specified under paragraph...) Disruptive behavior—(i) Definition. A PDP enrollee is disruptive if his or her behavior substantially impairs...

42 CFR 417.484 - Requirement applicable to related entities.

Code of Federal Regulations, 2012 CFR

2012-10-01

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

42 CFR 417.484 - Requirement applicable to related entities.

Code of Federal Regulations, 2014 CFR

2014-10-01

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

42 CFR 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 417.456 - Refunds to Medicare enrollees.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

42 CFR 417.414 - Qualifying condition: Range of services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Qualifying Conditions for Medicare Contracts § 417.414 Qualifying condition...

42 CFR 417.450 - Effective date of coverage.

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 § 417.450 Effective date...

42 CFR 460.68 - Program integrity.

Code of Federal Regulations, 2014 CFR

2014-10-01

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

42 CFR 460.68 - Program integrity.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

42 CFR 460.68 - Program integrity.

Code of Federal Regulations, 2011 CFR

2011-10-01

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

42 CFR 460.68 - Program integrity.

Code of Federal Regulations, 2013 CFR

2013-10-01

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

42 CFR 460.68 - Program integrity.

Code of Federal Regulations, 2012 CFR

2012-10-01

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

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...

42 CFR 414.106 - Splints and casts.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Splints and casts. 414.106 Section 414.106 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedules for...

42 CFR 414.102 - General payment rules.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false General payment rules. 414.102 Section 414.102 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedules...

42 CFR 414.102 - General payment rules.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false General payment rules. 414.102 Section 414.102 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedules...

42 CFR 414.102 - General payment rules.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false General payment rules. 414.102 Section 414.102 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedules...

42 CFR 418.108 - Condition of participation: Short-term inpatient care.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Condition of participation: Short-term inpatient care. 418.108 Section 418.108 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE Conditions of...

42 CFR 418.108 - Condition of participation: Short-term inpatient care.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Condition of participation: Short-term inpatient care. 418.108 Section 418.108 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE Conditions of...

42 CFR 418.108 - Condition of participation: Short-term inpatient care.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Condition of participation: Short-term inpatient care. 418.108 Section 418.108 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE Conditions of...

42 CFR 423.1092 - Revision of reopened decision.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

42 CFR 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 423.2262 - Review and distribution of marketing materials.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Part D...) Ad hoc enrollee communication materials. Ad hoc enrollee communication materials may be reviewed by...

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...

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 423.886 - Retiree drug subsidy amounts.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Retiree drug subsidy amounts. 423.886 Section 423... (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Payments to Sponsors of Retiree Prescription Drug Plans § 423.886 Retiree drug subsidy amounts. (a) Amount of subsidy payment. (1...

42 CFR 423.886 - Retiree drug subsidy amounts.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Retiree drug subsidy amounts. 423.886 Section 423... (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Payments to Sponsors of Retiree Prescription Drug Plans § 423.886 Retiree drug subsidy amounts. (a) Amount of subsidy payment. (1...

42 CFR 423.886 - Retiree drug subsidy amounts.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Retiree drug subsidy amounts. 423.886 Section 423... (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Payments to Sponsors of Retiree Prescription Drug Plans § 423.886 Retiree drug subsidy amounts. (a) Amount of subsidy payment. (1...

42 CFR 414.108 - IOLs inserted in a physician's office.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false IOLs inserted in a physician's office. 414.108 Section 414.108 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee...

42 CFR 414.104 - PEN Items and Services.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false PEN Items and Services. 414.104 Section 414.104 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedules...

42 CFR 414.104 - PEN Items and Services.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false PEN Items and Services. 414.104 Section 414.104 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedules...

42 CFR 414.104 - PEN Items and Services.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false PEN Items and Services. 414.104 Section 414.104 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedules...

42 CFR 418.54 - Condition of participation: Initial and comprehensive assessment of the patient.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Condition of participation: Initial and comprehensive assessment of the patient. 418.54 Section 418.54 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE...

42 CFR 418.54 - Condition of participation: Initial and comprehensive assessment of the patient.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Condition of participation: Initial and comprehensive assessment of the patient. 418.54 Section 418.54 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE...

42 CFR 418.54 - Condition of participation: Initial and comprehensive assessment of the patient.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Condition of participation: Initial and comprehensive assessment of the patient. 418.54 Section 418.54 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE...

42 CFR 418.100 - Condition of Participation: Organization and administration of services.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Condition of Participation: Organization and administration of services. 418.100 Section 418.100 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE Conditions of...

42 CFR 418.100 - Condition of Participation: Organization and administration of services.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Condition of Participation: Organization and administration of services. 418.100 Section 418.100 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE Conditions of...

42 CFR 418.100 - Condition of Participation: Organization and administration of services.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Condition of Participation: Organization and administration of services. 418.100 Section 418.100 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE Conditions of...

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...

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 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...

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...

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...

42 CFR 423.586 - Opportunity to submit evidence.

Code of Federal Regulations, 2010 CFR

2010-10-01

... limited by the short timeframe for making a decision. Therefore, the Part D plan sponsor must inform the... (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Grievances, Coverage Determinations...

42 CFR 418.307 - Periodic interim payments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... (CONTINUED) MEDICARE PROGRAM HOSPICE CARE Payment for Hospice Care § 418.307 Periodic interim payments... payments. The biweekly interim payment amount is based on the total estimated Medicare payments for the...

42 CFR 423.420 - Solvency standards for non-licensed entities.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Organization Compliance with State Law and Preemption by Federal Law § 423.420 Solvency standards for non-licensed...

42 CFR 422.372 - Basis for waiver of State licensure.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Provider-Sponsored Organizations § 422.372... authority to conduct business as an MA plan. (b) Basis for waiver of State licensure. Any of the following... engaged in a substantially similar business; or (ii) Required, as a condition of licensure that the...

42 CFR 422.132 - Protection against liability and loss of benefits.

Code of Federal Regulations, 2010 CFR

2010-10-01

... AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Benefits and Beneficiary Protections § 422.132 Protection against liability and loss of benefits. Enrollees of MA organizations are... 42 Public Health 3 2010-10-01 2010-10-01 false Protection against liability and loss of benefits...

42 CFR 420.303 - HHS criteria for requesting books, documents, and records.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false HHS criteria for requesting books, documents, and... HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PROGRAM INTEGRITY: MEDICARE Access to Books, Documents, and Records of Subcontractors § 420.303 HHS criteria for requesting books, documents, and records...

Vertical integration strategies: revenue effects in hospital and Medicare markets.

PubMed

Cody, M

1996-01-01

The purpose of this study was to evaluate the revenue effects of seven vertically integrated strategies on California hospitals. The strategies investigated were managed care contracts, physician affiliations, ambulatory care, ambulatory surgery, home health services, inpatient rehabilitation, and skilled nursing care. The study population included 242 not-for-profit hospitals in continuous operation from 1983 to 1990. Many hospitals developed vertically integrated programs in the 1980s as inpatient utilization fell in response to the Medicare Prospective Payment program. Net revenue rose on average by $2,080 from 1983 to 1990, but fell by $2,421 from the Medicare program. On the whole, the more physicians affiliated with a hospital, the higher the net revenue. However, in the Medicare population, the number of managed care contracts was significant. The pre-hospital strategies generated significant revenue, while the post-hospital strategies did not. In the Medicare program, inpatient rehabilitation significantly reduced revenue.

42 CFR 423.590 - Timeframes and responsibility for making redeterminations.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT... redetermination must be made by a physician with expertise in the field of medicine that is appropriate for the...

42 CFR 423.425 - Licensure does not substitute for or constitute certification.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Organization Compliance with State Law and Preemption by Federal Law § 423.425 Licensure does not substitute...

42 CFR 417.500 - Intermediate sanctions for and civil monetary penalties against HMOs and CMPs.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Intermediate sanctions for and civil monetary penalties against HMOs and CMPs. 417.500 Section 417.500 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH...

42 CFR 417.500 - Intermediate sanctions for and civil monetary penalties against HMOs and CMPs.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Intermediate sanctions for and civil monetary penalties against HMOs and CMPs. 417.500 Section 417.500 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH...

42 CFR 417.500 - Intermediate sanctions for and civil monetary penalties against HMOs and CMPs.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Intermediate sanctions for and civil monetary penalties against HMOs and CMPs. 417.500 Section 417.500 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-08-24

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

42 CFR 421.205 - Termination by the Secretary.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Termination by the Secretary. 421.205 Section 421... (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE CONTRACTING Carriers § 421.205 Termination by the Secretary. (a) Cause for termination. The Secretary may terminate a contract with a carrier at any time if he or...

42 CFR 423.2272 - Licensing of marketing representatives and confirmation of marketing resources.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Licensing of marketing representatives and confirmation of marketing resources. 423.2272 Section 423.2272 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Part D Marketing...

42 CFR 423.415 - Temporary waivers for entities seeking to offer a prescription drug plan in more than one State...

Code of Federal Regulations, 2010 CFR

2010-10-01

... MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Organization Compliance with State Law and Preemption by Federal Law § 423.415 Temporary waivers for entities seeking to offer a prescription drug plan in more...

42 CFR 423.440 - Prohibition of State imposition of premium taxes; relation to State laws.

Code of Federal Regulations, 2010 CFR

2010-10-01

...; relation to State laws. 423.440 Section 423.440 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Organization Compliance with State Law and Preemption by Federal Law § 423.440 Prohibition of...

42 CFR 417.558 - Emergency, urgently needed, and out-of-area services for which the HMO or CMP accepts...

Code of Federal Regulations, 2010 CFR

2010-10-01

... services for which the HMO or CMP accepts responsibility. 417.558 Section 417.558 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Medicare Payment: Cost...

42 CFR 422.455 - Special rules for MA Regional Plans.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Special rules for MA Regional Plans. 422.455... SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Special Rules for MA Regional Plans § 422.455 Special rules for MA Regional Plans. (a) Coverage of entire MA region. The service area for an MA...

42 CFR 422.455 - Special rules for MA Regional Plans.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Special rules for MA Regional Plans. 422.455... SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Special Rules for MA Regional Plans § 422.455 Special rules for MA Regional Plans. (a) Coverage of entire MA region. The service area for an MA...

78 FR 27485 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-05-10

... Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment... [CMS-1599-P] RIN 0938-AR53 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute... capital-related costs of acute care hospitals to implement changes arising from our continuing experience...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-09-28

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

42 CFR 424.124 - Conditions for payment for physician services and ambulance services.

Code of Federal Regulations, 2010 CFR

2010-10-01

..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Special... connection with covered inpatient hospital services; and (2) They meet the conditions set forth in paragraphs...

42 CFR 424.124 - Conditions for payment for physician services and ambulance services.

Code of Federal Regulations, 2011 CFR

2011-10-01

..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Special... connection with covered inpatient hospital services; and (2) They meet the conditions set forth in paragraphs...

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.

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

PubMed

2012-11-15

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

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).

42 CFR 418.308 - Limitation on the amount of hospice payments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... total Medicare payment to a hospice for care furnished during a cap period is limited by the hospice cap... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HOSPICE CARE Payment for Hospice Care § 418.308 Limitation...

42 CFR 422.4 - Types of MA plans.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Types of MA plans. 422.4 Section 422.4 Public...) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM General Provisions § 422.4 Types of MA plans. (a) General rule. An MA plan may be a coordinated care plan, a combination of an MA MSA plan and a...

42 CFR 422.4 - Types of MA plans.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Types of MA plans. 422.4 Section 422.4 Public...) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM General Provisions § 422.4 Types of MA plans. (a) General rule. An MA plan may be a coordinated care plan, a combination of an MA MSA plan and a...

42 CFR 422.4 - Types of MA plans.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Types of MA plans. 422.4 Section 422.4 Public...) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM General Provisions § 422.4 Types of MA plans. (a) General rule. An MA plan may be a coordinated care plan, a combination of an MA MSA plan and a...

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

42 CFR 423.2260 - Definitions concerning marketing materials.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Part D..., physicians or other providers). (v) Membership communication materials such as membership rules, subscriber... communications materials, meaning informational materials that— (i) Are targeted to current enrollees; (ii) Are...

Medicare program; prohibition of midyear benefit enhancements for Medicare Advantage organizations. Final rule.

PubMed

2008-07-28

This final rule prohibits Medicare Advantage (MA) organizations, including organizations offering MA plans to employer and union group health plan sponsors, from making midyear changes to nonprescription drug benefits, premiums, and cost-sharing submitted in their approved bids for a given contract year. This final rule also clarifies that MA organizations offering certain kinds of plans restricted to employer and union group health plan sponsors and not open to general enrollment may continue to offer benefit enhancements as they do currently, through means other than midyear benefit enhancements (MYBEs). Programs of all-inclusive care for elderly (PACE) are not subject to the provisions of this final rule and may continue to offer enhanced benefits as specified in our guidance for PACE plans.

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.

42 CFR 414.806 - Penalties associated with the failure to submit timely and accurate ASP data.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Penalties associated with the failure to submit timely and accurate ASP data. 414.806 Section 414.806 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES...

42 CFR 414.806 - Penalties associated with the failure to submit timely and accurate ASP data.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Penalties associated with the failure to submit timely and accurate ASP data. 414.806 Section 414.806 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES...

42 CFR 414.806 - Penalties associated with the failure to submit timely and accurate ASP data.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Penalties associated with the failure to submit timely and accurate ASP data. 414.806 Section 414.806 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES...

Disenrollment from Medicare HMOs.

PubMed

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

2001-01-01

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

42 CFR 417.911 - Definitions.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Definitions. 417.911 Section 417.911 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS...

42 CFR 417.911 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Definitions. 417.911 Section 417.911 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS...

42 CFR 423.566 - Coverage determinations.

Code of Federal Regulations, 2010 CFR

2010-10-01

... (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Grievances, Coverage Determinations... sponsor. Each Part D plan sponsor must have a procedure for making timely coverage determinations in accordance with the requirements of this subpart regarding the prescription drug benefits an enrollee is...

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.

42 CFR 418.114 - Condition of participation: Personnel qualifications.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Condition of participation: Personnel qualifications. 418.114 Section 418.114 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HOSPICE CARE Conditions of participation...

42 CFR 414.914 - Terms of contract.

Code of Federal Regulations, 2010 CFR

2010-10-01

... disabled, the hearing impaired, and Spanish-speaking inquirers in all customer service operations. (9) Meet... Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Payment for Drugs and Biologicals...

42 CFR 423.760 - Determinations regarding the amount of civil money penalties and assessment imposed by CMS.

Code of Federal Regulations, 2010 CFR

2010-10-01

... & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE... Part D sponsor; (5) The history of prior offenses by the Part D sponsor or principals of the Part D...

42 CFR 421.122 - Performance standards.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Performance standards. 421.122 Section 421.122... (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Intermediaries § 421.122 Performance standards. (a) Development of standards. In addition to the performance criteria (§ 421.120), CMS develops detailed...

42 CFR 417.408 - Contract application process.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Contract application process. 417.408 Section 417... (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Qualifying Conditions for Medicare Contracts § 417.408 Contract application process. (a...

42 CFR 417.424 - Denial of enrollment.

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 § 417.424 Denial of... complying with any of the other contract qualifying conditions set forth in subpart J of this part; (3...

42 CFR 417.548 - Provider services through arrangements.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Provider services through arrangements. 417.548 Section 417.548 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND...

42 CFR 421.212 - Railroad Retirement Board contracts.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Railroad Retirement Board contracts. 421.212... SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Carriers § 421.212 Railroad Retirement Board contracts. In accordance with this subpart C, the Railroad Retirement Board contracts with DMEPOS regional...

42 CFR 421.100 - Intermediary functions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Intermediary functions. 421.100 Section 421.100... (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Intermediaries § 421.100 Intermediary functions. An agreement between CMS and an intermediary specifies the functions to be performed by the intermediary. (a...

42 CFR 417.102 - Health benefits plan: Supplemental health services.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Health benefits plan: Supplemental health services. 417.102 Section 417.102 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL...

42 CFR 417.105 - Payment for supplemental health services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Payment for supplemental health services. 417.105 Section 417.105 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND...

42 CFR 417.102 - Health benefits plan: Supplemental health services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Health benefits plan: Supplemental health services. 417.102 Section 417.102 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL...

42 CFR 414.504 - [Reserved

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false [Reserved] 414.504 Section 414.504 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Payment for New Clinical Diagnostic...

42 CFR 414.100 - Purpose.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Purpose. 414.100 Section 414.100 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedules for Parenteral and Enteral...

42 CFR 414.100 - Purpose.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Purpose. 414.100 Section 414.100 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedules for Parenteral and Enteral...

42 CFR 418.104 - Condition of participation: Clinical records.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Condition of participation: Clinical records. 418.104 Section 418.104 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HOSPICE CARE Conditions of participation: Organizational...

42 CFR 418.104 - Condition of participation: Clinical records.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Condition of participation: Clinical records. 418.104 Section 418.104 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HOSPICE CARE Conditions of participation: Organizational...

42 CFR 418.102 - Condition of participation: Medical director.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Condition of participation: Medical director. 418.102 Section 418.102 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HOSPICE CARE Conditions of participation: Organizational...

42 CFR 418.102 - Condition of participation: Medical director.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Condition of participation: Medical director. 418.102 Section 418.102 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HOSPICE CARE Conditions of participation: Organizational...

42 CFR 421.120 - Performance criteria.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Performance criteria. 421.120 Section 421.120... (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Intermediaries § 421.120 Performance criteria. (a) Application of performance criteria. As part of the intermediary evaluations authorized by section 1816(f) of...

42 CFR 421.120 - Performance criteria.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Performance criteria. 421.120 Section 421.120... (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Intermediaries § 421.120 Performance criteria. (a) Application of performance criteria. As part of the intermediary evaluations authorized by section 1816(f) of...

42 CFR 417.406 - Application and determination.

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 § 417.406 Application and determination. (a... forth in § 417.407. (2) If an entity no longer meets those requirements, CMS terminates the contract of...

42 CFR 417.413 - Qualifying condition: Operating experience and enrollment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Qualifying Conditions for Medicare Contracts § 417.413..., as appropriate. (b) Standard: Enrollment and operating experience for HMOs or CMPs to contract on a...

42 CFR 417.402 - Effective date of initial regulations.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Qualifying Conditions for Medicare Contracts § 417.402 Effective date of... implementing regulations. (b) No new cost plan contracts are accepted by CMS. CMS will, however, accept and...

42 CFR 418.78 - Conditions of participation-Volunteers.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Conditions of participation-Volunteers. 418.78 Section 418.78 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HOSPICE CARE Conditions of Participation: Patient Care Non-Core...

42 CFR 423.2276 - 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. 423.2276 Section... SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Part D Marketing Requirements § 423.2276 Employer group retiree marketing. Part D sponsors may develop marketing materials...

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.

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 414.918 - Assignment.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Assignment. 414.918 Section 414.918 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Payment for Drugs and Biologicals Under Part...

42 CFR 414.910 - Bidding process.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Bidding process. 414.910 Section 414.910 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Payment for Drugs and Biologicals...

42 CFR 414.920 - Judicial review.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Judicial review. 414.920 Section 414.920 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Payment for Drugs and Biologicals...

42 CFR 414.920 - Judicial review.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Judicial review. 414.920 Section 414.920 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Payment for Drugs and Biologicals...

42 CFR 414.918 - Assignment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Assignment. 414.918 Section 414.918 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Payment for Drugs and Biologicals Under Part...

42 CFR 414.910 - Bidding process.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Bidding process. 414.910 Section 414.910 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Payment for Drugs and Biologicals...

42 CFR 417.101 - Health benefits plan: Basic health services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Health benefits plan: Basic health services. 417.101 Section 417.101 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS...

42 CFR 417.101 - Health benefits plan: Basic health services.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Health benefits plan: Basic health services. 417.101 Section 417.101 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS...

42 CFR 417.478 - Requirements of other laws and regulations.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Requirements of other laws and regulations. 417.478... SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Medicare Contract Requirements § 417.478 Requirements of other laws and...

42 CFR 414.102 - General payment rules.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false General payment rules. 414.102 Section 414.102 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedules for...

42 CFR 414.102 - General payment rules.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false General payment rules. 414.102 Section 414.102 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedules for...

42 CFR 418.108 - Condition of participation: Short-term inpatient care.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Condition of participation: Short-term inpatient care. 418.108 Section 418.108 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HOSPICE CARE Conditions of participation...

42 CFR 414.912 - Conflicts of interest

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Conflicts of interest 414.912 Section 414.912 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Payment for Drugs and...

42 CFR 414.912 - Conflicts of interest

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Conflicts of interest 414.912 Section 414.912 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Payment for Drugs and...

42 CFR 418.108 - Condition of participation: Short-term inpatient care.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Condition of participation: Short-term inpatient care. 418.108 Section 418.108 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HOSPICE CARE Conditions of participation...

42 CFR 417.423 - Special rules: ESRD and hospice patients.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Special rules: ESRD and hospice patients. 417.423 Section 417.423 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND...

42 CFR 417.520 - Effect on HMO and CMP contracts.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 417.520 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND... these provisions, references to “M+C organizations” must be read as references to “HMOs and CMPs”. (c...

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

Code of Federal Regulations, 2011 CFR

2011-10-01

... AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Cost..., national accreditation organization approved by CMS; and (2) The accreditation organization uses the...) Access to covered drugs, as provided under §§ 423.120 and 423.124. (2) Drug utilization management...

42 CFR 423.44 - Involuntary disenrollment from Part D coverage.

Code of Federal Regulations, 2011 CFR

2011-10-01

... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Eligibility and...) The individual has engaged in disruptive behavior, as specified under paragraph (d)(2) of this section...) Disruptive behavior—(i) Definition. A PDP enrollee is disruptive if his or her behavior substantially impairs...

42 CFR 423.2046 - Notice of an ALJ decision.

Code of Federal Regulations, 2010 CFR

2010-10-01

... making the determination; (2) The procedures for obtaining additional information concerning the decision... 42 Public Health 3 2010-10-01 2010-10-01 false Notice of an ALJ decision. 423.2046 Section 423... (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Reopening, ALJ Hearings, MAC review...

42 CFR 417.585 - Special rules: Hospice care.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Special rules: Hospice care. 417.585 Section 417... (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Medicare Payment: Risk Basis § 417.585 Special rules: Hospice care. (a) No payment is made...

42 CFR 414.620 - Publication of the ambulance fee schedule.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Section 414.620 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedule for Ambulance Services § 414.620 Publication of the ambulance fee schedule. Changes in payment rates resulting...

42 CFR 414.707 - Basis of payment.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Basis of payment. 414.707 Section 414.707 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Payment for Drugs and Biologicals...

42 CFR 414.707 - Basis of payment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Basis of payment. 414.707 Section 414.707 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Payment for Drugs and Biologicals...

42 CFR 414.104 - PEN Items and Services.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false PEN Items and Services. 414.104 Section 414.104 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedules for...

42 CFR 414.104 - PEN Items and Services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false PEN Items and Services. 414.104 Section 414.104 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedules for...

42 CFR 423.171 - 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 VOLUNTARY MEDICARE PRESCRIPTION DRUG...) Size and composition of accreditation survey teams for each type of plan reviewed as part of the... policies and procedures regarding coordination of these activities with appropriate licensing bodies and...

42 CFR 415.174 - Exception: Evaluation and management services furnished in certain centers.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Exception: Evaluation and management services furnished in certain centers. 415.174 Section 415.174 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM SERVICES FURNISHED BY PHYSICIANS IN...

42 CFR 415.172 - Physician fee schedule payment for services of teaching physicians.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Physician fee schedule payment for services of teaching physicians. 415.172 Section 415.172 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM SERVICES FURNISHED BY PHYSICIANS IN...

42 CFR 421.110 - Requirements for approval of an agreement.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Intermediaries § 421.110 Requirements for... regulatory authorities of the State or States in which it, or any subcontractor performing some or all of its... only providers located in a single State; (5) Has acted in good faith to achieve effective cooperation...

42 CFR 419.20 - Hospitals subject to the hospital outpatient prospective payment system.

Code of Federal Regulations, 2010 CFR

2010-10-01

... prospective payment system. 419.20 Section 419.20 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL... Outpatient Prospective Payment System § 419.20 Hospitals subject to the hospital outpatient prospective...

42 CFR 489.1 - Statutory basis.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 5 2014-10-01 2014-10-01 false Statutory basis. 489.1 Section 489.1 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS... regulations for the administration of the Medicare program. (b) Although section 1866 of the Act speaks only...

42 CFR 489.1 - Statutory basis.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 5 2013-10-01 2013-10-01 false Statutory basis. 489.1 Section 489.1 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS... regulations for the administration of the Medicare program. (b) Although section 1866 of the Act speaks only...

42 CFR 489.1 - Statutory basis.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 5 2012-10-01 2012-10-01 false Statutory basis. 489.1 Section 489.1 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS... regulations for the administration of the Medicare program. (b) Although section 1866 of the Act speaks only...

42 CFR 423.2020 - Time and place for a hearing before an ALJ.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Reopening, ALJ...-teleconferencing technology is available to conduct the appearance. (2) The ALJ may also offer to conduct a hearing...-teleconferencing technology is not available; or (ii) Special or extraordinary circumstances exist. (c) Notice of...

42 CFR 417.420 - Basic rules on enrollment and entitlement.

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 § 417.420... HMO or CMP that has in effect a contract with CMS under subpart L of this part. (b) Entitlement. If a...

42 CFR 417.458 - Recoupment of uncollected deductible and coinsurance amounts.

Code of Federal Regulations, 2010 CFR

2010-10-01

..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS... Medicare Contract § 417.458 Recoupment of uncollected deductible and coinsurance amounts. An HMO or CMP... previous contract period except in the following circumstances: (a) The HMO or CMP failed to collect the...

42 CFR 417.422 - Eligibility to enroll in an HMO or CMP.

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 § 417.422... entered into a contract under subpart L of this part; (d) During an enrollment period of the HMO or CMP...

42 CFR 414.90 - Physician Quality Reporting System.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Physician Quality Reporting System. 414.90 Section 414.90 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Physicians and Other...

42 CFR 423.410 - Waiver of certain requirements to expand choice.

Code of Federal Regulations, 2010 CFR

2010-10-01

... AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Organization Compliance with State Law and Preemption by Federal Law § 423.410 Waiver of certain requirements... than those required by Federal Law. The application by a State of any grounds other than those required...

42 CFR 416.40 - Condition for coverage-Compliance with State licensure law.

Code of Federal Regulations, 2010 CFR

2010-10-01

... licensure law. 416.40 Section 416.40 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM AMBULATORY SURGICAL SERVICES Specific Conditions for Coverage § 416.40 Condition for coverage—Compliance with State licensure law. The ASC must comply...

42 CFR 423.2000 - Hearing before an ALJ: general rule.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Reopening, ALJ Hearings... subject to the restrictions in § 423.2018, examine the evidence used in making the determination under... conducts a de novo review and issues a decision based on the hearing record. (e) If an enrollee waives his...

42 CFR 423.1986 - Good cause for reopening.

Code of Federal Regulations, 2010 CFR

2010-10-01

... the time of the determination or decision; and (ii) May result in a different conclusion; or (2) The evidence that was considered in making the determination or decision clearly shows on its face that an... (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Reopening, ALJ Hearings, MAC review...

42 CFR 489.1 - Statutory basis.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false Statutory basis. 489.1 Section 489.1 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS... regulations for the administration of the Medicare program. (b) Although section 1866 of the Act speaks only...

42 CFR 489.1 - Statutory basis.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 5 2011-10-01 2011-10-01 false Statutory basis. 489.1 Section 489.1 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS... regulations for the administration of the Medicare program. (b) Although section 1866 of the Act speaks only...

42 CFR 417.412 - Qualifying condition: Administration and management.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Qualifying condition: Administration and management. 417.412 Section 417.412 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS...

42 CFR 423.886 - Retiree drug subsidy amounts.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Retiree drug subsidy amounts. 423.886 Section 423... (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Payments to Sponsors of Retiree Prescription Drug Plans § 423.886 Retiree drug subsidy amounts. (a) Amount of subsidy payment. (1) For each...

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

42 CFR 460.168 - Reinstatement in other Medicare and Medicaid programs.

Code of Federal Regulations, 2011 CFR

2011-10-01

... HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Participant Enrollment and Disenrollment § 460.168...

42 CFR 460.168 - Reinstatement in other Medicare and Medicaid programs.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Participant Enrollment and Disenrollment § 460.168...

42 CFR 417.937 - Loan and loan guarantee provisions.

Code of Federal Regulations, 2014 CFR

2014-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL.... Principal repayment during the first 60 months of operation could be deferred with payment of interest only...

42 CFR 417.937 - Loan and loan guarantee provisions.

Code of Federal Regulations, 2012 CFR

2012-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL.... Principal repayment during the first 60 months of operation could be deferred with payment of interest only...

42 CFR 417.937 - Loan and loan guarantee provisions.

Code of Federal Regulations, 2013 CFR

2013-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL.... Principal repayment during the first 60 months of operation could be deferred with payment of interest only...

42 CFR § 414.1310 - Applicability.

Code of Federal Regulations, 2010 CFR

2017-10-01

... (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Merit-Based Incentive Payment System and Alternative Payment Model Incentive § 414.1310 Applicability. (a) Program Implementation. Except as specified in paragraph (b) of this section, MIPS applies to payments for items and...

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.

42 CFR 417.500 - Intermediate sanctions for and civil monetary penalties against HMOs and CMPs.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Intermediate sanctions for and civil monetary penalties against HMOs and CMPs. 417.500 Section 417.500 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE...

42 CFR 423.1074 - Right to request Departmental Appeals Board review of Administrative Law Judge's decision or...

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Right to request Departmental Appeals Board review of Administrative Law Judge's decision or dismissal. 423.1074 Section 423.1074 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM...

42 CFR 423.1074 - Right to request Departmental Appeals Board review of Administrative Law Judge's decision or...

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Right to request Departmental Appeals Board review of Administrative Law Judge's decision or dismissal. 423.1074 Section 423.1074 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM...

42 CFR 417.500 - Intermediate sanctions for and civil monetary penalties against HMOs and CMPs.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Intermediate sanctions for and civil monetary penalties against HMOs and CMPs. 417.500 Section 417.500 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE...

42 CFR 423.1074 - Right to request Departmental Appeals Board review of Administrative Law Judge's decision or...

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Right to request Departmental Appeals Board review of Administrative Law Judge's decision or dismissal. 423.1074 Section 423.1074 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM...

42 CFR 423.782 - Cost-sharing subsidy.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Cost-sharing subsidy. 423.782 Section 423.782... (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Premiums and Cost-Sharing Subsidies... cents. (c) When the out-of-pocket cost for a covered Part D drug under a Part D sponsor's plan benefit...

42 CFR 414.58 - Payment of charges for physician services to patients in providers.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Payment of charges for physician services to patients in providers. 414.58 Section 414.58 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER...

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

Federal Register 2010, 2011, 2012, 2013, 2014

2010-05-04

... Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment... operating and capital-related costs of acute care hospitals to implement changes arising from our continuing... changes to the amounts and factors used to determine the rates for Medicare acute care hospital inpatient...

42 CFR 417.444 - Special rules for certain enrollees of risk HMOs and CMPs.

Code of Federal Regulations, 2010 CFR

2010-10-01

... OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS... Medicare Contract § 417.444 Special rules for certain enrollees of risk HMOs and CMPs. (a) Applicability...: (1) On February 1, 1985, was enrolled— (i) In an HMO or CMP that had in effect a cost contract...

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.

42 CFR § 414.1325 - Data submission requirements.

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 § 414.1325 Data submission...

42 CFR § 414.1395 - Public reporting.

Code of Federal Regulations, 2010 CFR

2017-10-01

... (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Merit-Based Incentive Payment System and Alternative Payment Model Incentive § 414.1395 Public reporting. (a) Public...

42 CFR § 414.1390 - Data validation and auditing.

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 § 414.1390 Data validation...

Medicare program; changes to the Medicare claims appeal procedures; continuation of effectiveness and extension of timeline for publication of final rule. Interim final rule with comment period; continuation of effectiveness and extension of timeline for publication of final rule.

PubMed

2009-02-27

This notice announces the continuation of effectiveness of a Medicare interim final rule with comment period and the extension of the timeline for publication of the final rule. This notice is issued in accordance with section 1871(a)(3)(C) of the Social Security Act (the Act), which allows an interim final rule to remain in effect after the expiration of the timeline specified in section 1871(a)(3)(B) of the Act (the "regular timeline") or, if applicable, at the end of each succeeding 1-year extension to the regular timeline, if prior to the expiration of the timeline, the Secretary publishes in the Federal Register a notice of continuation and explains why the regular timeline or any subsequent extension was not complied with.

42 CFR § 414.1400 - Third party data submission.

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 § 414.1400 Third party data...

42 CFR § 414.1365 - Subcategories for the improvement activities performance category.

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...

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.

42 CFR 455.236 - Renewal of a contract.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

42 CFR 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...

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 § 414.1335 - Data submission criteria for the quality performance category.

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...

42 CFR 455.232 - Medicaid integrity audit program contractor functions.

Code of Federal Regulations, 2012 CFR

2012-10-01

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

42 CFR 455.232 - Medicaid integrity audit program contractor functions.

Code of Federal Regulations, 2014 CFR

2014-10-01

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

42 CFR 455.232 - Medicaid integrity audit program contractor functions.

Code of Federal Regulations, 2011 CFR

2011-10-01

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

42 CFR 455.232 - Medicaid integrity audit program contractor functions.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

42 CFR 457.618 - Ten percent limit on certain Children's Health Insurance Program expenditures.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Insurance Program expenditures. 457.618 Section 457.618 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STATE CHILDREN'S HEALTH INSURANCE PROGRAMS... Children's Health Insurance Program expenditures. (a) Expenditures. (1) Primary expenditures are...

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 423.150 - Scope.

Code of Federal Regulations, 2014 CFR

2014-10-01

... PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Cost Control and Quality Improvement... utilization management programs, quality assurance measures and systems, and medication therapy management... organization (QIO) activities. (f) Compliance deemed on the basis of accreditation. (g) Accreditation...

42 CFR 423.150 - Scope.

Code of Federal Regulations, 2012 CFR

2012-10-01

... PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Cost Control and Quality Improvement... utilization management programs, quality assurance measures and systems, and medication therapy management... organization (QIO) activities. (f) Compliance deemed on the basis of accreditation. (g) Accreditation...

42 CFR 423.150 - Scope.

Code of Federal Regulations, 2013 CFR

2013-10-01

... PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Cost Control and Quality Improvement... utilization management programs, quality assurance measures and systems, and medication therapy management... organization (QIO) activities. (f) Compliance deemed on the basis of accreditation. (g) Accreditation...

42 CFR 414.806 - Penalties associated with the failure to submit timely and accurate ASP data.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Penalties associated with the failure to submit timely and accurate ASP data. 414.806 Section 414.806 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Submission of...

42 CFR 414.806 - Penalties associated with the failure to submit timely and accurate ASP data.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Penalties associated with the failure to submit timely and accurate ASP data. 414.806 Section 414.806 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Submission of...

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.

Society for Health Psychology (APA Division 38) and Society of Behavioral Medicine joint position statement on the Medicare Diabetes Prevention Program.

PubMed

Fitzpatrick, Stephanie L; Wilson, Dawn K; Pagoto, Sherry L

2017-06-01

Beginning in January 2018, the Centers for Medicare and Medicaid Services (CMS) plans to cover the Diabetes Prevention Program (DPP), also referred to as Medicare DPP. The American Psychological Association Society for Health Psychology (SfHP) and the Society for Behavioral Medicine (SBM) reviewed the proposed plan. SfHP and SBM are in support of the CMS decision to cover DPP for Medicare beneficiaries but have a significant concern that aspects of the proposal will limit the public health impact. Concerns include the emphasis on weight outcomes to determine continued coverage and the lack of details regarding requirements for coaches. SfHP and SBM are in strong support of modifications to the proposal that would remove the minimum weight loss stipulation to determine coverage and to specify type and qualifications of "coaches."

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

PubMed

Shrank, William

2013-04-01

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

The Medicare Hospital Readmissions Reduction Program: potential unintended consequences for hospitals serving vulnerable populations.

PubMed

Gu, Qian; Koenig, Lane; Faerberg, Jennifer; Steinberg, Caroline Rossi; Vaz, Christopher; Wheatley, Mary P

2014-06-01

To explore the impact of the Hospital Readmissions Reduction Program (HRRP) on hospitals serving vulnerable populations. Medicare inpatient claims to calculate condition-specific readmission rates. Medicare cost reports and other sources to determine a hospital's share of duals, profit margin, and characteristics. Regression analyses and projections were used to estimate risk-adjusted readmission rates and financial penalties under the HRRP. Findings were compared across groups of hospitals, determined based on their share of duals, to assess differential impacts of the HRRP. Both patient dual-eligible status and a hospital's dual-eligible share of Medicare discharges have a positive impact on risk-adjusted hospital readmission rates. Under current Centers for Medicare and Medicaid Service methodology, which does not adjust for socioeconomic status, high-dual hospitals are more likely to have excess readmissions than low-dual hospitals. As a result, HRRP penalties will disproportionately fall on high-dual hospitals, which are more likely to have negative all-payer margins, raising concerns of unintended consequences of the program for vulnerable populations. Policies to reduce hospital readmissions must balance the need to ensure continued access to quality care for vulnerable populations. © Health Research and Educational Trust.

The Medicare Hospital Readmissions Reduction Program: Potential Unintended Consequences for Hospitals Serving Vulnerable Populations

PubMed Central

Gu, Qian; Koenig, Lane; Faerberg, Jennifer; Steinberg, Caroline Rossi; Vaz, Christopher; Wheatley, Mary P

2014-01-01

Objective To explore the impact of the Hospital Readmissions Reduction Program (HRRP) on hospitals serving vulnerable populations. Data Sources/Study Setting Medicare inpatient claims to calculate condition-specific readmission rates. Medicare cost reports and other sources to determine a hospital's share of duals, profit margin, and characteristics. Study Design Regression analyses and projections were used to estimate risk-adjusted readmission rates and financial penalties under the HRRP. Findings were compared across groups of hospitals, determined based on their share of duals, to assess differential impacts of the HRRP. Principal Findings Both patient dual-eligible status and a hospital's dual-eligible share of Medicare discharges have a positive impact on risk-adjusted hospital readmission rates. Under current Centers for Medicare and Medicaid Service methodology, which does not adjust for socioeconomic status, high-dual hospitals are more likely to have excess readmissions than low-dual hospitals. As a result, HRRP penalties will disproportionately fall on high-dual hospitals, which are more likely to have negative all-payer margins, raising concerns of unintended consequences of the program for vulnerable populations. Conclusions Policies to reduce hospital readmissions must balance the need to ensure continued access to quality care for vulnerable populations. PMID:24417309

42 CFR 456.234 - Subsequent continued stay review dates.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Subsequent continued stay review dates. 456.234 Section 456.234 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Mental Hospitals...

42 CFR 456.232 - Evaluation criteria for continued stay.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Evaluation criteria for continued stay. 456.232 Section 456.232 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Mental Hospitals...

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 455.230 - Eligibility requirements.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

42 CFR 455.2 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

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.

Determinants of success in Shared Savings Programs: An analysis of ACO and market characteristics.

PubMed

Ouayogodé, Mariétou H; Colla, Carrie H; Lewis, Valerie A

2017-03-01

Medicare's Accountable Care Organization (ACO) programs introduced shared savings to traditional Medicare, which allow providers who reduce health care costs for their patients to retain a percentage of the savings they generate. To examine ACO and market factors associated with superior financial performance in Medicare ACO programs. We obtained financial performance data from the Centers for Medicare and Medicaid Services (CMS); we derived market-level characteristics from Medicare claims; and we collected ACO characteristics from the National Survey of ACOs for 215 ACOs. We examined the association between ACO financial performance and ACO provider composition, leadership structure, beneficiary characteristics, risk bearing experience, quality and process improvement capabilities, physician performance management, market competition, CMS-assigned financial benchmark, and ACO contract start date. We examined two outcomes from Medicare ACOs' first performance year: savings per Medicare beneficiary and earning shared savings payments (a dichotomous variable). When modeling the ACO ability to save and earn shared savings payments, we estimated positive regression coefficients for a greater proportion of primary care providers in the ACO, more practicing physicians on the governing board, physician leadership, active engagement in reducing hospital re-admissions, a greater proportion of disabled Medicare beneficiaries assigned to the ACO, financial incentives offered to physicians, a larger financial benchmark, and greater ACO market penetration. No characteristic of organizational structure was significantly associated with both outcomes of savings per beneficiary and likelihood of achieving shared savings. ACO prior experience with risk-bearing contracts was positively correlated with savings and significantly increased the likelihood of receiving shared savings payments. In the first year, performance is quite heterogeneous, yet organizational structure does not consistently predict performance. Organizations with large financial benchmarks at baseline have greater opportunities to achieve savings. Findings on prior risk bearing suggest that ACOs learn over time under risk-bearing contracts. Given the lack of predictive power for organizational characteristics, CMS should continue to encourage diversity in organizational structures for ACO participants, and provide alternative funding and risk bearing mechanisms to continue to allow a diverse group of organizations to participate. III. Copyright © 2016 Elsevier Inc. All rights reserved.

42 CFR 417.165 - Reapplication for qualification.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Continued Regulation of Federally Qualified Health Maintenance Organizations... CMS for purposes of section 1310 of the PHS Act may, after completing the corrective action required...

5 CFR 890.909 - End-of-year settlements.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 890.909 Administrative Personnel OFFICE OF PERSONNEL MANAGEMENT (CONTINUED) CIVIL SERVICE REGULATIONS (CONTINUED) FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM Limit on Inpatient Hospital Charges, Physician Charges... in the Medicare payment calculation information to, hospital providers who have received FEHB benefit...

5 CFR 890.909 - End-of-year settlements.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 890.909 Administrative Personnel OFFICE OF PERSONNEL MANAGEMENT (CONTINUED) CIVIL SERVICE REGULATIONS (CONTINUED) FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM Limit on Inpatient Hospital Charges, Physician Charges... in the Medicare payment calculation information to, hospital providers who have received FEHB benefit...

5 CFR 890.909 - End-of-year settlements.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 890.909 Administrative Personnel OFFICE OF PERSONNEL MANAGEMENT (CONTINUED) CIVIL SERVICE REGULATIONS (CONTINUED) FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM Limit on Inpatient Hospital Charges, Physician Charges... in the Medicare payment calculation information to, hospital providers who have received FEHB benefit...

42 CFR 430.60 - Scope.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

77 FR 23722 - Medicare Program; Extension of Certain Wage Index Reclassifications and Special Exceptions for...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-04-20

... Payroll Tax Cut Continuation Act of 2011 (TPTCCA) as amended by section 3001 of the Middle Class Tax... INFORMATION: I. Background On December 23, 2011, the Temporary Payroll Tax Cut Continuation Act (TPTCCA) of...

42 CFR 438.240 - Quality assessment and performance improvement program.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Quality assessment and performance improvement program. 438.240 Section 438.240 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS MANAGED CARE Quality Assessment and...

42 CFR 438.240 - Quality assessment and performance improvement program.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 4 2013-10-01 2013-10-01 false Quality assessment and performance improvement program. 438.240 Section 438.240 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS MANAGED CARE Quality Assessment and...

42 CFR 438.240 - Quality assessment and performance improvement program.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Quality assessment and performance improvement program. 438.240 Section 438.240 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS MANAGED CARE Quality Assessment and...

42 CFR 438.240 - Quality assessment and performance improvement program.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Quality assessment and performance improvement program. 438.240 Section 438.240 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS MANAGED CARE Quality Assessment and...

42 CFR 430.0 - Program description.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Program description. 430.0 Section 430.0 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED... Provisions § 430.0 Program description. Title XIX of the Social Security Act, enacted in 1965, authorizes...

42 CFR 430.0 - Program description.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Program description. 430.0 Section 430.0 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED... Provisions § 430.0 Program description. Title XIX of the Social Security Act, enacted in 1965, authorizes...

The effects of hospice coverage on Medicare expenditures.

PubMed Central

Kidder, D

1992-01-01

This article reports on the findings of a study of the effects of the hospice program on Medicare Part A expenditures during the first three years of the program. The analysis compared treatment costs between hospice beneficiaries and nonbenefit patients with diagnosis of malignant cancer during their last seven months of life. It was estimated that during the first three years of the hospice program, Medicare saved $1.26 for every dollar spent on Part A expenditures. While the methodology included use of data from Medicare claims to adjust for confounding factors, including self-selection bias, our estimated savings might still have been overstated due to persistent selection effects. The extent of savings also varied according to the hospice's organization. Freestanding hospices, in contrast to those affiliated with either a hospital, nursing home, or home health agency, achieved the greatest savings by utilizing home care more extensively. However, we note that payment rates are increasing and the limits on the benefit period are being lifted, making it possible that the savings related to the hospice program found in this study will not continue. Of greater importance may be the long-term access and quality effects engendered by the benefit's preference for home care. PMID:1592605

The effects of hospice coverage on Medicare expenditures.

PubMed

Kidder, D

1992-06-01

This article reports on the findings of a study of the effects of the hospice program on Medicare Part A expenditures during the first three years of the program. The analysis compared treatment costs between hospice beneficiaries and nonbenefit patients with diagnosis of malignant cancer during their last seven months of life. It was estimated that during the first three years of the hospice program, Medicare saved $1.26 for every dollar spent on Part A expenditures. While the methodology included use of data from Medicare claims to adjust for confounding factors, including self-selection bias, our estimated savings might still have been overstated due to persistent selection effects. The extent of savings also varied according to the hospice's organization. Freestanding hospices, in contrast to those affiliated with either a hospital, nursing home, or home health agency, achieved the greatest savings by utilizing home care more extensively. However, we note that payment rates are increasing and the limits on the benefit period are being lifted, making it possible that the savings related to the hospice program found in this study will not continue. Of greater importance may be the long-term access and quality effects engendered by the benefit's preference for home care.

42 CFR 430.88 - Evidence.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

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...

42 CFR 417.536 - Cost payment principles.

Code of Federal Regulations, 2012 CFR

2012-10-01

... (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND... of nonpaid workers. The value of services of nonpaid workers of an organization is not an allowable... therapists and other therapists and nonphysician health specialists, the limitations set forth in § 413.106...

42 CFR 456.236 - Continued stay review process.

Code of Federal Regulations, 2012 CFR

2012-10-01

....236 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Mental Hospitals Ur Plan... physician members of the committee, one of whom is knowledgeable in the treatment of mental diseases, review...

42 CFR 456.236 - Continued stay review process.

Code of Federal Regulations, 2014 CFR

2014-10-01

....236 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Mental Hospitals Ur Plan... physician members of the committee, one of whom is knowledgeable in the treatment of mental diseases, review...

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

PubMed

Howard, Larry L

2014-09-01

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

The Evolution of Private Plans in Medicare.

PubMed

Patel, Yash M; Guterman, Stuart

2017-12-01

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

Sustainable growth rate 2013: time for definitive intervention.

PubMed

Hirsch, Joshua A; Rosman, David A; Liu, Raymond W; Ding, Alexander; Manchikanti, Laxmaiah

2013-07-01

Federal healthcare spending has been a subject of intense concern as the US Congress continues to search for ways to reduce the budget deficit. The Congressional Budget Office (CBO) estimated that, even though it is growing more slowly than previously projected, federal spending on Medicare, Medicaid and the State Children's Health Insurance Program (SCHIP) will reach nearly $900 billion in 2013. In 2011 the Medicare program paid $68 billion for physicians and other health professional services, 12% of total Medicare spending. Since 2002 the sustainable growth rate (SGR) correction has called for reductions to physician reimbursements; however, Congress has typically staved off these reductions, although the situation remains precarious for physicians who accept Medicare. The fiscal cliff agreement that came into focus at the end of 2012 averted a 26.5% reduction to physician reimbursements related to the SGR correction. Nonetheless, the threat of these devastating cuts continues to loom. The Administration, Congress and others have devised many options to fix this unsustainable situation. This review explores the historical development of the SGR, touches on elements of the formula itself and outlines current proposals for fixing the SGR problem. A recent CBO estimate reduces the potential cost of a 10-year fix of SGR system to $138 billion. This has provided new hope for resolution of this long-standing issue.

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...

42 CFR 417.832 - Applicability of requirements and procedures.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS... determinations and appeals. (d) The provisions of part 405 dealing with administrative law judge hearings...

Medicare program; hospital outpatient prospective payment system and CY 2007 payment rates; CY 2007 update to the ambulatory surgical center covered procedures list; Medicare administrative contractors; and reporting hospital quality data for FY 2008 inpatient prospective payment system annual payment update program--HCAHPS survey, SCIP, and mortality. Final rule with comment period and final rule.

PubMed

2006-11-24

This final rule with comment period revises the Medicare hospital outpatient prospective payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system, and to implement certain related provisions of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 and the Deficit Reduction Act (DRA) of 2005. In this final rule with comment period, we describe changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These changes are applicable to services furnished on or after January 1, 2007. In addition, this final rule with comment period implements future CY 2009 required reporting on quality measures for hospital outpatient services paid under the prospective payment system. This final rule with comment period revises the current list of procedures that are covered when furnished in a Medicare-approved ambulatory surgical center (ASC), which are applicable to services furnished on or after January 1, 2007. This final rule with comment period revises the emergency medical screening requirements for critical access hospitals (CAHs). This final rule with comment period supports implementation of a restructuring of the contracting entities responsibilities and functions that support the adjudication of Medicare fee-for-service (FFS) claims. This restructuring is directed by section 1874A of the Act, as added by section 911 of the MMA. The prior separate Medicare intermediary and Medicare carrier contracting authorities under Title XVIII of the Act have been replaced with the Medicare Administrative Contractor (MAC) authority. This final rule continues to implement the requirements of the DRA that require that we expand the "starter set" of 10 quality measures that we used in FY 2005 and FY 2006 for the hospital inpatient prospective payment system (IPPS) Reporting Hospital Quality Data for the Annual Payment Update (RHQDAPU) program. We began to adopt expanded measures effective for payments beginning in FY 2007. In this rule, we are finalizing additional quality measures for the expanded set of measures for FY 2008 payment purposes. These measures include the HCAHPS survey, as well as Surgical Care Improvement Project (SCIP, formerly Surgical Infection Prevention (SIP)), and Mortality quality measures.

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...

42 CFR 456.702 - Definitions.

Code of Federal Regulations, 2014 CFR

2014-10-01

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

42 CFR 456.700 - Scope.

Code of Federal Regulations, 2012 CFR

2012-10-01

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

42 CFR 456.702 - Definitions.

Code of Federal Regulations, 2012 CFR

2012-10-01

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

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.

42 CFR 441.11 - Continuation of FFP for institutional services.

Code of Federal Regulations, 2014 CFR

2014-10-01

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

42 CFR 441.11 - Continuation of FFP for institutional services.

Code of Federal Regulations, 2011 CFR

2011-10-01

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

42 CFR 441.11 - Continuation of FFP for institutional services.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

Determinants of Success in Shared Savings Programs: An Analysis of ACO and Market Characteristics

PubMed Central

Colla, Carrie H.; Lewis, Valerie A.

2016-01-01

Background Medicare’s Accountable Care Organization (ACO) programs introduced shared savings to traditional Medicare, which allow providers who reduce health care costs for their patients to retain a percentage of the savings they generate. Objective To examine ACO and market factors associated with superior financial performance in Medicare ACO programs. Methods We obtained financial performance data from the Centers for Medicare and Medicaid Services (CMS); we derived market-level characteristics from Medicare claims; and we collected ACO characteristics from the National Survey of ACOs for 215 ACOs. We examined the association between ACO financial performance and ACO provider composition, leadership structure, beneficiary characteristics, risk bearing experience, quality and process improvement capabilities, physician performance management, market competition, CMS-assigned financial benchmark, and ACO contract start date. We examined two outcomes from Medicare ACOs’ first performance year: savings per Medicare beneficiary and earning shared savings payments (a dichotomous variable). Results When modeling the ACO ability to save and earn shared savings payments, we estimated positive regression coefficients for a greater proportion of primary care providers in the ACO, more practicing physicians on the governing board, physician leadership, active engagement in reducing hospital re-admissions, a greater proportion of disabled Medicare beneficiaries assigned to the ACO, financial incentives offered to physicians, a larger financial benchmark, and greater ACO market penetration. No characteristic of organizational structure was significantly associated with both outcomes of savings per beneficiary and likelihood of achieving shared savings. ACO prior experience with risk-bearing contracts was positively correlated with savings and significantly increased the likelihood of receiving shared savings payments. Conclusions In the first year performance is quite heterogeneous, yet organizational structure does not consistently predict performance. Organizations with large financial benchmarks at baseline have greater opportunities to achieve savings. Findings on prior risk bearing suggest that ACOs learn over time under risk-bearing contracts. Implications Given the lack of predictive power for organizational characteristics, CMS should continue to encourage diversity in organizational structures for ACO participants, and provide alternative funding and risk bearing mechanisms to continue to allow a diverse group of organizations to participate. Level of evidence III PMID:27687917

42 CFR 417.536 - Cost payment principles.

Code of Federal Regulations, 2013 CFR

2013-10-01

... (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND...) Value of services of nonpaid workers. The value of services of nonpaid workers of an organization is not... therapists and other therapists and nonphysician health specialists, the limitations set forth in § 413.106...

42 CFR 417.536 - Cost payment principles.

Code of Federal Regulations, 2014 CFR

2014-10-01

... (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND...) Value of services of nonpaid workers. The value of services of nonpaid workers of an organization is not... therapists and other therapists and nonphysician health specialists, the limitations set forth in § 413.106...

42 CFR 417.937 - Loan and loan guarantee provisions.

Code of Federal Regulations, 2011 CFR

2011-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND.... Principal repayment during the first 60 months of operation could be deferred with payment of interest only...

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.

42 CFR 485.58 - Condition of participation: Comprehensive rehabilitation program.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 5 2014-10-01 2014-10-01 false Condition of participation: Comprehensive rehabilitation program. 485.58 Section 485.58 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION CONDITIONS OF PARTICIPATION...

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 456.716 - DUR Board.

Code of Federal Regulations, 2012 CFR

2012-10-01

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

42 CFR 456.716 - DUR Board.

Code of Federal Regulations, 2014 CFR

2014-10-01

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

42 CFR 430.32 - Program reviews.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Program reviews. 430.32 Section 430.32 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED... reviews reveal serious problems with respect to compliance with any Federal requirement, the State must...

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 § 414.1320 - MIPS performance period.

Code of Federal Regulations, 2010 CFR

2017-10-01

... (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Merit-Based Incentive Payment System and Alternative Payment Model Incentive § 414.1320 MIPS performance period. (a) For purposes of the 2019 MIPS payment year, the performance period for all performance categories and...

42 CFR § 414.1415 - Advanced APM criteria.

Code of Federal Regulations, 2010 CFR

2017-10-01

... (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Merit-Based Incentive Payment System and Alternative Payment Model Incentive § 414.1415 Advanced APM criteria. (a) Use... is responsible under an APM. For episode payment models, expected expenditures mean the episode...

42 CFR § 414.1330 - Quality performance category.

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 § 414.1330 Quality... comprise: (1) 60 percent of a MIPS eligible clinician's final score for MIPS payment year 2019. (2) 50...

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.

42 CFR 460.16 - [Reserved

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false [Reserved] 460.16 Section 460.16 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE...

42 CFR 460.66 - Training.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Training. 460.66 Section 460.66 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE...

42 CFR 460.14 - [Reserved

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false [Reserved] 460.14 Section 460.14 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE...

42 CFR 460.114 - Restraints.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Restraints. 460.114 Section 460.114 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.16 - [Reserved

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false [Reserved] 460.16 Section 460.16 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE...

42 CFR 460.66 - Training.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Training. 460.66 Section 460.66 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE...

42 CFR 460.14 - [Reserved

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false [Reserved] 460.14 Section 460.14 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE...

42 CFR 460.10 - Purpose.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Purpose. 460.10 Section 460.10 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE...

42 CFR 460.114 - Restraints.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Restraints. 460.114 Section 460.114 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.10 - Purpose.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Purpose. 460.10 Section 460.10 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE...

42 CFR 489.25 - Special requirements concerning CHAMPUS and CHAMPVA programs.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false Special requirements concerning CHAMPUS and CHAMPVA programs. 489.25 Section 489.25 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION PROVIDER AGREEMENTS AND SUPPLIER...

42 CFR 489.25 - Special requirements concerning CHAMPUS and CHAMPVA programs.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 5 2011-10-01 2011-10-01 false Special requirements concerning CHAMPUS and CHAMPVA programs. 489.25 Section 489.25 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION PROVIDER AGREEMENTS AND SUPPLIER...

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

PubMed

2016-11-04

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

42 CFR 417.594 - Computation of adjusted community rate (ACR).

Code of Federal Regulations, 2012 CFR

2012-10-01

... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE... or CMP develops an aggregate premium for all its enrollees and weights the aggregate by the size of... groups are defined as employee groups or other bodies of subscribers that enroll in the HMO or CMP...

42 CFR 417.594 - Computation of adjusted community rate (ACR).

Code of Federal Regulations, 2014 CFR

2014-10-01

... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE... or CMP develops an aggregate premium for all its enrollees and weights the aggregate by the size of... groups are defined as employee groups or other bodies of subscribers that enroll in the HMO or CMP...

42 CFR 417.594 - Computation of adjusted community rate (ACR).

Code of Federal Regulations, 2013 CFR

2013-10-01

... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE... or CMP develops an aggregate premium for all its enrollees and weights the aggregate by the size of... groups are defined as employee groups or other bodies of subscribers that enroll in the HMO or CMP...

42 CFR § 414.1445 - Identification of other payer advanced APMs.

Code of Federal Regulations, 2010 CFR

2017-10-01

... 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 § 414.1445... determination prior to the QP Performance Period to identify Medicaid Medical Home Models and Medicaid APMs. (b...

42 CFR § 414.1410 - Advanced APM determination.

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 § 414.1410 Advanced APM determination. (a) General. An APM is an Advanced APM for a payment year if CMS determines that it meets the...

42 CFR § 414.1370 - APM scoring standard under MIPS.

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 § 414.1370 APM scoring... Participation List; (3) The APM bases payment on cost/utilization and quality measures; and (4) The APM is not...

42 CFR § 414.1360 - Data submission criteria for the improvement activities performance category.

Code of Federal Regulations, 2010 CFR

2017-10-01

... & MEDICAID SERVICES, 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 § 414.1360 Data submission criteria for the improvement activities performance...

42 CFR § 414.1425 - Qualifying APM participant determination: In general.

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... Score that meets or exceeds the corresponding QP payment amount threshold or QP patient count threshold...

42 CFR § 414.1350 - Cost performance category.

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 § 414.1350 Cost performance... category comprises: (1) 0 percent of a MIPS eligible clinician's final score for MIPS payment year 2019. (2...

42 CFR § 414.1430 - Qualifying APM participant determination: QP and partial QP thresholds.

Code of Federal Regulations, 2010 CFR

2017-10-01

... SERVICES, 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 § 414.1430 Qualifying APM participant determination: QP and partial QP thresholds. (a...

42 CFR § 414.1440 - Qualifying APM participant determination: All-payer combination 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 § 414.1440 Qualifying APM participant determination: All-payer combination option. (a) Payments excluded...

42 CFR § 414.1455 - Limitation on review.

Code of Federal Regulations, 2010 CFR

2017-10-01

... (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Merit-Based Incentive Payment System and Alternative Payment Model Incentive § 414.1455 Limitation on review. There is... of the APM Incentive Payment under § 414.1450, including any estimation as part of such determination. ...

42 CFR § 414.1385 - Targeted review and review limitations.

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 § 414.1385 Targeted review... review of the calculation of the MIPS payment adjustment factor under section 1848(q)(6)(A) of the Act...

42 CFR § 414.1375 - Advancing care information performance category.

Code of Federal Regulations, 2010 CFR

2017-10-01

... 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 § 414.1375... final score for MIPS payment year 2019 and each MIPS payment year thereafter. (b) Reporting for the...

42 CFR § 414.1355 - Improvement activities performance category.

Code of Federal Regulations, 2010 CFR

2017-10-01

... 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 § 414.1355... comprises: (1) 15 percent of a MIPS eligible clinician's final score for MIPS payment year 2019 and for each...

42 CFR § 414.1340 - Data completeness criteria for the quality performance category.

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... that meet the measure's denominator criteria, regardless of payer for MIPS payment year 2019. (2) At...

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...

42 CFR 460.130 - General rule.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false General rule. 460.130 Section 460.130 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.80 - Fiscal soundness.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Fiscal soundness. 460.80 Section 460.80 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.2 - Basis.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Basis. 460.2 Section 460.2 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Basis, Scope...

42 CFR 460.118 - Violation of rights.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Violation of rights. 460.118 Section 460.118 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.92 - Required services.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Required services. 460.92 Section 460.92 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.96 - Excluded services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Excluded services. 460.96 Section 460.96 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.2 - Basis.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Basis. 460.2 Section 460.2 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Basis, Scope...

42 CFR 460.110 - Bill of rights.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Bill of rights. 460.110 Section 460.110 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.74 - Infection control.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Infection control. 460.74 Section 460.74 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.130 - General rule.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false General rule. 460.130 Section 460.130 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.120 - Grievance process.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Grievance process. 460.120 Section 460.120 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.70 - Contracted services.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Contracted services. 460.70 Section 460.70 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.110 - Bill of rights.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Bill of rights. 460.110 Section 460.110 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.4 - Scope and purpose.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Scope and purpose. 460.4 Section 460.4 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.106 - Plan of care.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Plan of care. 460.106 Section 460.106 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE...

42 CFR 460.80 - Fiscal soundness.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Fiscal soundness. 460.80 Section 460.80 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.118 - Violation of rights.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Violation of rights. 460.118 Section 460.118 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.46 - Civil money penalties.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Civil money penalties. 460.46 Section 460.46 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.152 - Enrollment process.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Enrollment process. 460.152 Section 460.152 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.182 - Medicaid payment.

Code of Federal Regulations, 2011 CFR

2011-10-01

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

42 CFR 460.92 - Required services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Required services. 460.92 Section 460.92 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.46 - Civil money penalties.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Civil money penalties. 460.46 Section 460.46 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.100 - Emergency care.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Emergency care. 460.100 Section 460.100 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.70 - Contracted services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Contracted services. 460.70 Section 460.70 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.96 - Excluded services.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Excluded services. 460.96 Section 460.96 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.4 - Scope and purpose.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Scope and purpose. 460.4 Section 460.4 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.186 - PACE premiums.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false PACE premiums. 460.186 Section 460.186 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...