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Sample records for fr27au10r medicare program

  1. 78 FR 16614 - Medicare Program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical...

    Science.gov (United States)

    2013-03-18

    ... Medicare Program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical Insurance (Part B... in Hospitals''. Medicare Program Medicare Hospital Insurance (Part A) and Medicare Supplementary... following the denial of a Part A inpatient hospital claim by a Medicare review contractor on the basis that...

  2. Can health promotion programs save Medicare money?

    Science.gov (United States)

    Goetzel, Ron Z; Shechter, David; Ozminkowski, Ronald J; Stapleton, David C; Lapin, Pauline J; McGinnis, J Michael; Gordon, Catherine R; Breslow, Lester

    2007-01-01

    The impact of an aging population on escalating US healthcare costs is influenced largely by the prevalence of chronic disease in this population. Consequently, preventing or postponing disease onset among the elderly has become a crucial public health issue. Fortunately, much of the total burden of disease is attributable to conditions that are preventable. In this paper, we address whether well-designed health promotion programs can prevent illness, reduce disability, and improve the quality of life. Furthermore, we assess evidence that these programs have the potential to reduce healthcare utilization and related expenditures for the Medicare program. We hypothesize that seniors who reduce their modifiable health risks can forestall disability, reduce healthcare utilization, and save Medicare money. We end with a discussion of a new Senior Risk Reduction Demonstration, which will be initiated by the Centers for Medicare and Medicaid Services in 2007, to test whether risk reduction programs developed in the private sector can achieve health improvements among seniors and a positive return on investment for the Medicare program. PMID:18044084

  3. Medicare Beneficiary Knowledge of the Part D Program

    Data.gov (United States)

    U.S. Department of Health & Human Services — Medicare Beneficiary Knowledge of the Part D Program and Its Relationship with Voluntary Enrollment According to findings appearing in Medicare Beneficiary Knowledge...

  4. Medicare Beneficiary Knowledge of the Part D Program

    Data.gov (United States)

    U.S. Department of Health & Human Services — Medicare Beneficiary Knowledge of the Part D Program and Its Relationship with Voluntary Enrollment According to findings appearing in Medicare Beneficiary...

  5. Medicare Part D Program Analysis

    Data.gov (United States)

    U.S. Department of Health & Human Services — This page contains information on Part D program analysis performed by CMS. These reports will also be used to better identify, evaluate and measure the effects of...

  6. 76 FR 68011 - Medicare Program; Advanced Payment Model

    Science.gov (United States)

    2011-11-02

    ... November 2, 2011 Part IV Department of Health and Human Services Centers for Medicare & Medicaid Services..., November 2, 2011 / Notices#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid... continuous improvement for Medicare, Medicaid, and Children's Health Insurance Program (CHIP) beneficiaries...

  7. 76 FR 19655 - Medicare Program; Waiver Designs in Connection With the Medicare Shared Savings Program and the...

    Science.gov (United States)

    2011-04-07

    ... Medicare and Medicaid Innovation (Innovation Center) ``to test innovative payment and service delivery.... 76, No. 67 / Thursday, April 7, 2011 / Notices#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Office of the Inspector General RIN 0938-ZB05 Medicare Program...

  8. 77 FR 35917 - Medicare Program; Medicare Secondary Payer and “Future Medicals”

    Science.gov (United States)

    2012-06-15

    ... Program; Medicare Secondary Payer and ``Future Medicals'' AGENCY: Centers for Medicare & Medicaid Services... rulemaking solicits comment on standardized options that we are considering making available to beneficiaries... (including self-insurance), no-fault insurance, and workers' compensation when future medical care is...

  9. 75 FR 81885 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Correcting Amendment

    Science.gov (United States)

    2010-12-29

    ... Programs; Electronic Health Record Incentive Program; Correcting Amendment AGENCY: Centers for Medicare...; Electronic Health Record Incentive Program'' that appeared in the July 28, 2010 Federal Register. DATES... 44314) the final rule entitled ``Medicare and Medicaid Programs; Electronic Health Record Incentive...

  10. 78 FR 12427 - Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare...

    Science.gov (United States)

    2013-02-22

    ... the payment remittance of section 1857(4)(e)(A) of the Act is designed to encourage the provision of... overwhelming majority of those offering Medicare products). Third, aligning the commercial and Medicare... Care for the Elderly) organizations, the proposed MLR requirements set forth in this rule generally...

  11. Medicare

    Science.gov (United States)

    ... test, item, or service covered? Your Medicare coverage choices What Part A covers What Part B covers What drug plans cover What Medicare health plans cover Preventive & screening services Find suppliers of medical equipment & supplies Find doctors, hospitals, & facilities ...

  12. 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.

    Science.gov (United States)

    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.

  13. 78 FR 71619 - Medicare and Medicaid Programs; Continued Approval of American Osteopathic Association/Healthcare...

    Science.gov (United States)

    2013-11-29

    ... standards to include staff qualification requirements for rehabilitation therapy services. To meet the... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare and Medicaid Programs; Continued... Hospital Accreditation Program AGENCY: Centers for Medicare & Medicaid Services, HHS. ACTION: Final notice...

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

    Science.gov (United States)

    1983-08-18

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

  15. Medicare program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical Insurance (Part B). Notice of CMS ruling.

    Science.gov (United States)

    2013-03-18

    This notice announces a CMS Ruling that establishes a policy that revises the current policy on Part B billing following the denial of a Part A inpatient hospital claim by a Medicare review contractor on the basis that the inpatient admission was determined not reasonable and necessary. This revised policy is intended as an interim measure until CMS can finalize a policy to address the issues raised by the Administrative Law Judge and Medicare Appeals Council decisions going forward. To that end, elsewhere in this issue of the Federal Register, we published a proposed rule entitled, "Medicare Program; Part B Inpatient Billing in Hospitals,'' to propose a permanent policy that would apply on a prospective basis.

  16. 78 FR 31283 - Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare...

    Science.gov (United States)

    2013-05-23

    ... the Act is designed to encourage the provision of value to policyholders by creating incentives for MA... All-Inclusive Care for the Elderly) organizations, we are finalizing that MLR requirements set forth... products. Comment: A few commenters believe that the Medicare MLR requirements should not apply to Part...

  17. 76 FR 21431 - Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit...

    Science.gov (United States)

    2011-04-15

    ... Affordable Care Act 1. Cost Sharing for Specified Services at Original Medicare Levels (Sec. 417.454 and Sec... Good Cause and Reinstatement (Sec. 422.74 and Sec. 423.44) 9. Translated Marketing Materials (Sec. 422... for Multi- Ingredient Drug Compounds; Payment for Multi-Ingredient Drug Compounds (Sec. 423.120) 5...

  18. Medicare FFS Physician Feedback Program Value-Based Payment

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Physician Feedback - Value-Based Modifier Program provides comparative performance information to physicians as one part of Medicares efforts to improve the...

  19. Medicare

    Science.gov (United States)

    ... health insurance plans supplement Medicare and offers some shopping hints for people looking at those plans. To ... are several ways to contact Social Security, including online, by phone, and in person. We’re here ...

  20. 76 FR 50224 - Medicare Program; Accountable Care Organization Accelerated Development Learning Sessions; Center...

    Science.gov (United States)

    2011-08-12

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Accountable Care Organization Accelerated Development Learning Sessions; Center for Medicare and Medicaid Innovation, September 15th and... second Accelerated Development Learning Session (ADLS) hosted by CMS to help Accountable Care...

  1. 77 FR 23193 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 2; Corrections

    Science.gov (United States)

    2012-04-18

    ... Medicare and Medicaid Programs; Electronic Health Record Incentive Program--Stage 2; Corrections AGENCY... Medicaid Programs; Electronic Health Record Incentive Program--Stage 2'' which appeared in the March 7... ``Medicare and Medicaid Programs; Electronic Health Record Incentive Program--Stage 2'' there were a number...

  2. 76 FR 67743 - Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee...

    Science.gov (United States)

    2011-11-02

    ... Medicare or Medicaid programs or Children's Health Insurance Program (CHIP); revalidating their Medicare... Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment..., Medicaid, and Children's Health Insurance Program (CHIP) provider enrollment processes. Specifically, and...

  3. 75 FR 1843 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program

    Science.gov (United States)

    2010-01-13

    ... Medicaid Programs; Electronic Health Record Incentive Program; Proposed Rule #0;#0;Federal Register / Vol... Medicare and Medicaid Programs; Electronic Health Record Incentive Program AGENCY: Centers for Medicare... Medicaid programs that adopt and meaningfully use certified electronic health record (EHR) technology. The...

  4. 78 FR 9457 - Medicare, Medicaid, Children's Health Insurance Programs; Transparency Reports and Reporting of...

    Science.gov (United States)

    2013-02-08

    ... 42 CFR Parts 402 and 403 Medicare, Medicaid, Children's Health Insurance Programs; Transparency..., Medicaid, Children's Health Insurance Programs; Transparency Reports and Reporting of Physician Ownership... medical supplies covered by Medicare, Medicaid or the Children's Health Insurance Program (CHIP) to report...

  5. 75 FR 44313 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program

    Science.gov (United States)

    2010-07-28

    .... Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Final Rule #0;#0;Federal... RIN 0938-AP78 Medicare and Medicaid Programs; Electronic Health Record Incentive Program AGENCY... meaningful use of certified electronic health record (EHR) technology. This final rule specifies--the initial...

  6. 75 FR 71189 - Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug...

    Science.gov (United States)

    2010-11-22

    ... Chronic Care Improvement Program CCS Certified Coding Specialist CHIP Children's Health Insurance Programs... Provider Organization PPS Prospective Payment System P&T Pharmacy & Therapeutics QIO Quality Improvement... member materials, including enrollment, communications, grievance and appeals, and quality assurance. b...

  7. 77 FR 53967 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 2

    Science.gov (United States)

    2012-09-04

    ... & Medicaid Services 42 CFR Parts 412, 413, and 495 Medicare and Medicaid Programs; Electronic Health Record... Certification Criteria for Electronic Health Record Technology, 2014 Edition; Revisions to the Permanent... Programs; Electronic Health Record Incentive Program--Stage 2 AGENCY: Centers for Medicare & Medicaid...

  8. Medicare Program: Changes to the Medicare Claims and Entitlement, Medicare Advantage Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures. Final rule.

    Science.gov (United States)

    2017-01-17

    This final rule revises the procedures that the Department of Health and Human Services (HHS) follows at the Administrative Law Judge (ALJ) level for appeals of payment and coverage determinations for items and services furnished to Medicare beneficiaries, enrollees in Medicare Advantage (MA) and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as well as appeals of Medicare beneficiary enrollment and entitlement determinations, and certain Medicare premium appeals. In addition, this final rule revises procedures that the Department of Health and Human Services follows at the Centers for Medicare & Medicaid Services (CMS) and the Medicare Appeals Council (Council) levels of appeal for certain matters affecting the ALJ level.

  9. 75 FR 19677 - Medicare Program; Policy and Technical Changes to the Medicare Advantage and the Medicare...

    Science.gov (United States)

    2010-04-15

    .... Transition Process in Cases of Acquisitions and Mergers (Sec. 422.256 and Sec. 423.272) 3. Non-renewing Low... QRS Quality Review Study PACE Programs of All Inclusive Care for the Elderly RADV Risk Adjustment Data... Needs Plan SPAP State Pharmaceutical Assistance Programs SSI Supplemental Security Income TrOOP True...

  10. 78 FR 25013 - Medicare Program; Requirements for the Medicare Incentive Reward Program and Provider Enrollment

    Science.gov (United States)

    2013-04-29

    ... at least $50,000 deemed currently not collectible (CNC) by CMS during 2005 and 2006.\\9\\ The OIG found... own CNC debt to Medicare.\\11\\ The OIG also found that most of the reviewed DMEPOS suppliers...

  11. 77 FR 34326 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Science.gov (United States)

    2012-06-11

    ... Assistance Program No. 93.773, Medicare--Hospital Insurance; and Program No. 93.774, Medicare-- Supplementary... 0938-AR12 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident...

  12. 78 FR 61197 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Science.gov (United States)

    2013-10-03

    ... Program No. 93.773, Medicare--Hospital Insurance; and Program No. 93.774, Medicare-- Supplementary Medical...-AR53 and 0938-AR73 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2014 Rates; Quality...

  13. 77 FR 13697 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 2

    Science.gov (United States)

    2012-03-07

    ... 42 CFR Parts 412, 413, and 495 Medicare and Medicaid Programs; Electronic Health Record Incentive... CFR Parts 412, 413, and 495 RIN 0938-AQ84 Medicare and Medicaid Programs; Electronic Health Record... Medicaid electronic health record (EHR) incentive payments. In addition, it would specify payment...

  14. Medicare program; Medicare Advantage and prescription drug benefit programs: negotiated pricing and remaining revisions. Final rule with comment period.

    Science.gov (United States)

    2009-01-12

    This rule contains final regulations governing the Medicare Advantage (MA) program (Part C) and prescription drug benefit program (Part D), and interim final regulations governing certain aspects of the Retiree Drug Subsidy (RDS) Program, and reflecting new statutory definitions relating to Special Needs Plans under Part C. The final regulations revising the Part C and Part D regulations include provisions regarding medical savings account (MSA) plans, cost-sharing for dual eligible enrollees in the MA program, the prescription drug payment and novation processes in the Part D program, and the enrollment and appeals processes for both programs. This final rule with comment period also responds to public comments on the May 16, 2008 proposed rule and takes into account statutory revisions contained in the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA).

  15. Medicare program; establishing additional Medicare durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) supplier enrollment safeguards. Final rule.

    Science.gov (United States)

    2010-08-27

    This final rule will clarify, expand, and add to the existing enrollment requirements that Durable Medical Equipment and Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers must meet to establish and maintain billing privileges in the Medicare program.

  16. 76 FR 33305 - Medicare Program; Accelerated Development Sessions for Accountable Care Organizations-June 20, 21...

    Science.gov (United States)

    2011-06-08

    ... ``Medicare Program; Accelerated Development Sessions for Accountable Care Organizations--June 20, 21, and 22... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Accelerated Development Sessions for Accountable Care Organizations--June 20, 21, and 22, 2011; Corrections AGENCY: Centers for...

  17. 75 FR 70165 - Medicare Program; Request for Information Regarding Accountable Care Organizations and the...

    Science.gov (United States)

    2010-11-17

    ... Information Regarding Accountable Care Organizations and the Medicare Shared Saving Program AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Request for information. SUMMARY: This document... accountable care organizations (ACOs) participating in the Medicare program under section 3021 or 3022 of the...

  18. 75 FR 70013 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Science.gov (United States)

    2010-11-16

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services RIN 0938-AP89 Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2011; Correction AGENCY: Centers for..., ``Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2011.''...

  19. 76 FR 33306 - Medicare Program; Pioneer Accountable Care Organization Model, Request for Applications; Correction

    Science.gov (United States)

    2011-06-08

    ... Care Organization Model: Request for Applications.'' FOR FURTHER INFORMATION CONTACT: Maria Alexander... http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care-models/pioneer-aco... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Pioneer Accountable...

  20. CMS Medicare and Medicaid EHR Incentive Program, Electronic Health Record Products Used for Attestation

    Data.gov (United States)

    U.S. Department of Health & Human Services — Data set merges information about the Centers for Medicare and Medicaid Services, Medicare and Medicaid EHR Incentive Programs attestations with the Office of the...

  1. 75 FR 49215 - Medicare Program; End-Stage Renal Disease Quality Incentive Program

    Science.gov (United States)

    2010-08-12

    ... Renal Disease Quality Incentive Program AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS...) for Medicare outpatient end-stage renal disease (ESRD) dialysis providers and facilities with payment... Erythropoiesis stimulating agent ESRD End stage renal disease FDA Food and Drug Administration Kt/V A measure...

  2. 77 FR 38837 - Medicare Program; Meeting of the Medicare Economic Index Technical Advisory Panel

    Science.gov (United States)

    2012-06-29

    ... Auditorium of the Centers for Medicare & Medicaid Services (CMS), 7500 Security Boulevard, Baltimore, MD... Economic Index Technical Advisory Panel AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION... Medicare & Medicaid Services, Office of the Actuary, Mail stop N3-02-02, 7500 Security Boulevard,...

  3. 78 FR 75304 - Medicare Program; Medicare Secondary Payer and Certain Civil Money Penalties

    Science.gov (United States)

    2013-12-11

    ... includes, in part, authority for Medicare to impose CMPs against GHPs responsible reporting entities which...)'' taken by an entity to identify a Medicare beneficiary for the purposes of reporting under section 1862(b... or may not be imposed for failure to comply with Medicare Secondary Payer reporting requirements...

  4. 76 FR 66931 - Medicare Program; Accountable Care Organization Accelerated Development Learning Sessions; Center...

    Science.gov (United States)

    2011-10-28

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Accountable Care Organization Accelerated Development Learning Sessions; Center for Medicare and Medicaid Innovation November 17 and 18... third and final Accelerated Development Learning Session (ADLS) hosted by CMS to help Accountable Care...

  5. Claims and Appeals (Medicare)

    Science.gov (United States)

    ... get about Medicare Lost/incorrect Medicare card Report fraud & abuse File a complaint Identity theft: protect yourself ... from a Medicare provider. Contact your State Health Insurance Assistance Program (SHIP) for local, personalized Medicare counseling. ...

  6. 77 FR 31361 - Medicare and Medicaid Programs; Application by American Osteopathic Association/Healthcare...

    Science.gov (United States)

    2012-05-25

    ...-Approval of its Ambulatory Surgery Center (ASC) Accreditation Program AGENCY: Centers for Medicare and...--Ambulatory surgery center Insurance Program; and No. 93.774, Medicare--Supplementary Medical Insurance... Program (AOA/HFAP) for continued recognition as a national accrediting organization for ambulatory...

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

    Science.gov (United States)

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

    2004-01-01

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

  8. 76 FR 59134 - Medicare and Medicaid Programs; Approval of the Joint Commission's Continued Deeming Authority...

    Science.gov (United States)

    2011-09-23

    ...). (Catalog of Federal Domestic Assistance Program No. 93.773, Medicare--Hospital Insurance; and Program No... Joint Commission's Continued Deeming Authority for Critical Access Hospitals AGENCY: Centers for... critical access hospitals (CAHs) seeking to participate in the Medicare or Medicaid programs. DATES...

  9. Measuring Coding Intensity in the Medicare Advantage Program

    Data.gov (United States)

    U.S. Department of Health & Human Services — In 2004, Medicare implemented a risk-adjustment system that pays Medicare Advantage (MA) plans based on diagnoses reported for their enrollees, giving the plans an...

  10. Measuring Coding Intensity in the Medicare Advantage Program

    Data.gov (United States)

    U.S. Department of Health & Human Services — In 2004, Medicare implemented a risk-adjustment system that pays Medicare Advantage (MA) plans based on diagnoses reported for their enrollees, giving the plans an...

  11. 76 FR 16422 - Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee...

    Science.gov (United States)

    2011-03-23

    ... Health Insurance Programs; Provider Enrollment Application Fee Amount for 2011 AGENCY: Centers for... with comment period entitled: ``Medicare, Medicaid, and Children's Health Insurance Programs... Health Insurance Program (CHIP) provider enrollment processes. Specifically, and as stated in 42 CFR 424...

  12. 77 FR 71423 - Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee...

    Science.gov (United States)

    2012-11-30

    ... or Medicaid program or the Children's Health Insurance Program (CHIP); revalidating their Medicare... Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND...

  13. 75 FR 58203 - Medicare, Medicaid, and Children's Health Insurance Programs; Additional Screening Requirements...

    Science.gov (United States)

    2010-09-23

    .... Medicare, Medicaid, and Children's Health Insurance Programs; Additional Screening Requirements... Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment... requirement for participation as a provider of health care services under a Federal health care program that...

  14. 76 FR 15105 - Medicare and Medicaid Programs; Civil Money Penalties for Nursing Homes

    Science.gov (United States)

    2011-03-18

    ... Services 42 CFR Part 488 Medicare and Medicaid Programs; Civil Money Penalties for Nursing Homes; Final... and Medicaid Programs; Civil Money Penalties for Nursing Homes AGENCY: Centers for Medicare & Medicaid... nursing homes are not in compliance with Federal participation requirements in accordance with...

  15. 76 FR 19527 - Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations

    Science.gov (United States)

    2011-04-07

    ... Plans and Integration of Community Resources 11. ACO Marketing Guidelines 12. Program Integrity... systems and public reporting should rely on a mix of standards, processes, outcomes, and patient...

  16. Impact of Medicare Shared Savings Program Accountable Care Organizations at Screening Mammography: A Retrospective Cohort Study.

    Science.gov (United States)

    Narayan, Anand K; Harvey, Susan C; Durand, Daniel J

    2017-02-01

    Purpose To evaluate the impact of accountable care organizations (ACOs) on use of screening mammography in the Medicare Shared Savings Program (MSSP), the largest value-based reimbursement program in U.S.

  17. 77 FR 51542 - Medicare Program; Solicitation of Two Nominations to the Advisory Panel on Hospital Outpatient...

    Science.gov (United States)

    2012-08-24

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Solicitation of Two... Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice solicits nominations for two new members to the Advisory Panel on Hospital Outpatient Payment (HOP, the Panel). There will be two vacancies on the Panel...

  18. 75 FR 70831 - Medicare and Medicaid Programs: Changes to the Hospital and Critical Access Hospital Conditions...

    Science.gov (United States)

    2010-11-19

    ... and Medicaid Programs: Changes to the Hospital and Critical Access Hospital Conditions of... for hospitals and critical access hospitals (CAHs) to provide visitation rights to Medicare and Medicaid patients. Specifically, Medicare- and Medicaid-participating hospitals and CAHs will be required...

  19. 76 FR 28195 - Medicare Program; Hospice Wage Index for Fiscal Year 2012

    Science.gov (United States)

    2011-05-16

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part 418 RIN 0938-AQ31 Medicare Program; Hospice Wage Index for Fiscal Year 2012 Correction In proposed rule document 2011-10689 appearing on...

  20. 76 FR 44010 - Medicare Program; Hospice Wage Index for Fiscal Year 2012; Correction

    Science.gov (United States)

    2011-07-22

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services RIN 0938-AQ31 Medicare Program; Hospice Wage... appeared in the notice of CMS ruling published in the Federal Register on May 9, 2011 entitled ``Hospice... (76 FR 26731) was incorrectly titled as ``Hospice Wage Index for Fiscal Year 2012''. We note that...

  1. 77 FR 53204 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Science.gov (United States)

    2012-08-31

    ... can be covered under the Medicare statute. This meeting will focus on the use of ventricular assist... Register (63 FR 68780). This notice announces the Wednesday, November 14, 2012, public meeting of the... for your arrival at the CMS complex or you will be notified that the seating capacity has been...

  2. 78 FR 78802 - Medicare Program; Right of Appeal for Medicare Secondary Payer Determination Relating to...

    Science.gov (United States)

    2013-12-27

    ... administrative appeal rights or judicial review. CMS' recovery contractor addresses any dispute raised by the... applicable plan but does not provide formal administrative appeal rights. The RFA requires agencies to...; Right of Appeal for Medicare Secondary Payer Determination Relating to Liability Insurance...

  3. 77 FR 29647 - Medicare Program; Solicitation for Proposals for the Medicare Graduate Nurse Education...

    Science.gov (United States)

    2012-05-18

    ... specified. Section 5509(e)(5) of the Affordable Care Act defines an ``eligible hospital'' to mean a hospital (as defined in section 1861(e) of the Social Security Act (the Act) (42 U.S.C. 1395x)) or a critical..., Center for Medicare & Medicaid Innovation, Attention: Alexandre Laberge, Mail Stop: WB-06-05, 7500...

  4. 78 FR 57800 - Medicare Program; Obtaining Final Medicare Secondary Payer Conditional Payment Amounts via Web...

    Science.gov (United States)

    2013-09-20

    ... From the Federal Register Online via the Government Publishing Office ] DEPARTMENT OF HEALTH AND...; Obtaining Final Medicare Secondary Payer Conditional Payment Amounts via Web Portal AGENCY: Centers for... the beneficiary to access CMS' MSP conditional payment amounts and claims detail information via...

  5. Medicare program; appeals of CMS or CMS contractor determinations when a provider or supplier fails to meet the requirements for Medicare billing privileges. Final rule.

    Science.gov (United States)

    2008-06-27

    This final rule implements a number of regulatory provisions that are applicable to all providers and suppliers, including durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers. This final rule establishes appeals processes for all providers and suppliers whose enrollment, reenrollment or revalidation application for Medicare billing privileges is denied and whose Medicare billing privileges are revoked. It also establishes timeframes for deciding enrollment appeals by an Administrative Law Judge (ALJ) within the Department of Health and Human Services (DHHS) or the Departmental Appeals Board (DAB), or Board, within the DHHS; and processing timeframes for CMS' Medicare fee-for-service (FFS) contractors. In addition, this final rule allows Medicare FFS contractors to revoke Medicare billing privileges when a provider or supplier submits a claim or claims for services that could not have been furnished to a beneficiary. This final rule also specifies that a Medicare contractor may establish a Medicare enrollment bar for any provider or supplier whose billing privileges have been revoked. Lastly, the final rule requires that all providers and suppliers receive Medicare payments by electronic funds transfer (EFT) if the provider or supplier, is submitting an initial enrollment application to Medicare, changing their enrollment information, revalidating or re-enrolling in the Medicare program.

  6. Individualizing Medicare.

    Science.gov (United States)

    Chollet, D J

    1999-05-01

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

  7. 42 CFR 421.304 - Medicare integrity program contractor functions.

    Science.gov (United States)

    2010-10-01

    ... services for which Medicare payment may be made either directly or indirectly. (b) Auditing, settling and... and benefit quality assurance issues. (e) Developing, and periodically updating, a list of items of...

  8. 77 FR 70446 - Medicare and Medicaid Programs; Approval of the American Association for Accreditation of...

    Science.gov (United States)

    2012-11-26

    ... American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) for Continuing CMS Approval of Its Ambulatory Surgical Center Accreditation Program AGENCY: Centers for Medicare & Medicaid... Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) for continued recognition as...

  9. 75 FR 32480 - Funding Opportunity: Affordable Care Act Medicare Beneficiary Outreach and Assistance Program...

    Science.gov (United States)

    2010-06-08

    ... HUMAN SERVICES Administration on Aging Funding Opportunity: Affordable Care Act Medicare Beneficiary...: Availability of funding opportunity announcement. Funding Opportunity Title/Program Name: Affordable Care Act... Protection and Affordable Care Act of 2010 (Affordable Care Act). Catalog of Federal Domestic......

  10. 75 FR 36785 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-January Through March 2010

    Science.gov (United States)

    2010-06-28

    ...-7017-N2........ Medicare Program; Meeting of the Advisory Panel on Medicare Education; Cancellation of.... Category A refers to experimental IDEs, and Category B refers to non-experimental IDEs. To obtain more... deliver a particular service, or the methods in which data are collected to supplement the delivery of...

  11. 78 FR 31560 - Medicare Program; Public Meeting in Calendar Year 2013 for New Clinical Laboratory Test Payment...

    Science.gov (United States)

    2013-05-24

    ... auditorium of the Centers for Medicare & Medicaid Services (CMS), Central Building, 7500 Security Boulevard... [CMS-1451-N] Medicare Program; Public Meeting in Calendar Year 2013 for New Clinical Laboratory Test Payment Determinations AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION:...

  12. Lessons for the new CMS innovation center from the Medicare health support program.

    Science.gov (United States)

    Barr, Michael S; Foote, Sandra M; Krakauer, Randall; Mattingly, Patrick H

    2010-07-01

    The Patient Protection and Affordable Care Act establishes a new Center for Medicare and Medicaid Innovation in the Centers for Medicare and Medicaid Services (CMS). The center is intended to enhance the CMS's role in promoting much-needed improvements in payment and service delivery. Lessons from the Medicare Health Support Program, a chronic care pilot program that ran between 2005 and 2008, illustrate the value of drawing on experience in planning for the center and future pilot programs. The lessons include the importance of strong leadership; collaboration and flexibility to foster innovation; receptivity of beneficiaries to care management; and the need for timely data on patients' status. The lessons also highlight pitfalls to be avoided in planning future pilot programs, such as flawed strategies for selecting populations to target when testing payment and service delivery reforms.

  13. 76 FR 11782 - Medicare, Medicaid, and Children's Health Insurance Programs; Renewal, Expansion, and Renaming of...

    Science.gov (United States)

    2011-03-03

    ... with or who are eligible for Medicare, Medicaid and the Children's Health Insurance Program (CHIP... Insurance Assistance Programs (SHIPs), health insurance plans, aging, Web health education, e-prescribing... insurance exchanges, and minority health education. We are requesting that all curricula vitae include the...

  14. 78 FR 38594 - Medicare and Medicaid Programs; Requirements for Long Term Care Facilities; Hospice Services

    Science.gov (United States)

    2013-06-27

    ... requirements that an institution will have to meet in order to qualify to participate as a skilled nursing facility (SNF) in the Medicare program, or as a nursing facility (NF) in the Medicaid program. These... sections 1819(b)(2) and 1919(b)(2) of the Act, a skilled nursing facility (SNF) or nursing facility...

  15. 76 FR 33565 - Medicare Program; Availability of Medicare Data for Performance Measurement

    Science.gov (United States)

    2011-06-08

    ... Services, Department of Health and Human Services, Attention: CMS-5059-P, Mail Stop C4-26-05, 7500 Security... rigorous data privacy and security program, including disclosing to CMS in its application any... can participate in this program. c. Data Privacy and Security It is of the utmost importance to...

  16. Medicare program; revisions to the Medicare Advantage and prescription drug benefit programs: clarification of compensation plans. Interim final rule with comment period.

    Science.gov (United States)

    2008-11-14

    This interim final rule with comment period (IFC) revises the regulations governing the Medicare Advantage (MA) program (Part C), and prescription drug benefit program (Part D). This IFC sets forth new requirements governing the marketing of Part C and Part D plans which by statute must be in place at a date specified by the Secretary, but no later than November 15, 2008. The new marketing requirements, which set forth new limits on the compensation that can be paid to agents or brokers with respect to Part C and Part D plans, are based on authority under provisions in the Medicare Improvements for Patients and Providers Act (MIPPA) that became law on July 15, 2008.

  17. 76 FR 21372 - Medicare Program; Solicitation for Proposals for the Medicare Community-Based Care Transitions...

    Science.gov (United States)

    2011-04-15

    ..., including consumers. This program creates a source of funding for care transition services that effectively... the responsibilities specified. CBOs may be characterized as physician practices, particularly primary care practices, a corporate entity that has a separate quality improvement organization (QIO) contract...

  18. 77 FR 38067 - Medicare Program; Public Meeting Regarding Inherent Reasonableness of Medicare Fee Schedule...

    Science.gov (United States)

    2012-06-26

    ..., increased facility with that technology, or changes in acquisition, production, or supplier costs. ++ The... amounts for a category of items and services are grossly higher or lower than acquisition or production... equipment (DME) and medical supplies, including diabetic testing supplies. Under these programs,...

  19. 76 FR 28196 - Medicare and Medicaid Programs; Opportunities for Alignment Under Medicaid and Medicare

    Science.gov (United States)

    2011-05-16

    ... generally cover different populations, but an estimated 9.2 million low-income Americans were eligible for... eligible beneficiaries have incomes below the poverty line \\3\\ compared with 8 percent of non-dual eligible... program that is administered by States for certain categories of low-income individuals. Although...

  20. Evaluation of Student Outcomes after Participating in a Medicare Outreach Program

    Science.gov (United States)

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

    2015-01-01

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

  1. 75 FR 39641 - Medicare and Medicaid Programs; Civil Money Penalties for Nursing Homes

    Science.gov (United States)

    2010-07-12

    ... and Medicaid Programs; Civil Money Penalties for Nursing Homes AGENCY: Centers for Medicare & Medicaid... when nursing homes are not in compliance with Federal participation requirements in accordance with the... requirements for these facilities, generally referred to as ``nursing home(s),'' ``facility'' or ``facilities...

  2. 76 FR 42169 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

    Science.gov (United States)

    2011-07-18

    ... Hospital Association AHIMA American Health Information Management Association AHRQ Agency for Healthcare... Administration SCH Sole Community Hospital SDP Single Drug Pricer SI Status Indicator TEP Technical Expert Panel... 42 CFR Parts 410, 411, 416 et al. Medicare and Medicaid Programs: Hospital Outpatient Prospective...

  3. 76 FR 74121 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

    Science.gov (United States)

    2011-11-30

    ... Community Hospital E/M Evaluation and Management EHR Electronic Health Record ESRD End-Stage Renal Disease... Business Administration SCH Sole Community Hospital SDP Single Drug Pricer SI Status Indicator TEP... Services 42 CFR Parts 410, 411, 416 et al. Medicare and Medicaid Programs: Hospital Outpatient Prospective...

  4. 76 FR 22709 - Medicare and Medicaid Programs; Approval of the American Association for Accreditation of...

    Science.gov (United States)

    2011-04-22

    ... therapy and speech language pathology covered services from a provider of services, a clinic, a... pathology services must meet to participate in the Medicare program. Regulations concerning provider... survey and certification of facilities at 42 CFR part 488. Generally, in order to enter into a...

  5. 78 FR 31472 - Medicare and Medicaid Programs; Survey, Certification and Enforcement Procedures; Extension of...

    Science.gov (United States)

    2013-05-24

    ..., Attention: CMS-3255-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850. 4. By hand or... & Medicaid Services 42 CFR Parts 488 and 489 [CMS-3255-N] Medicare and Medicaid Programs; Survey... Services (CMS), HHS. ACTION: Proposed rule; extension of the comment period. SUMMARY: This notice...

  6. 42 CFR 424.530 - Denial of enrollment in the Medicare program.

    Science.gov (United States)

    2010-10-01

    ..., supplier, an owner, managing employee, an authorized or delegated official, medical director, supervising.... (a) Reasons for denial. CMS may deny a provider's or supplier's enrollment in the Medicare program for the following reasons: (1) Compliance. The provider or supplier at any time is found not to be...

  7. Report to the Congress on Nursing and Other Nonphysician Health Professions Educational Programs Reimbursed under Medicare.

    Science.gov (United States)

    Health Resources and Services Administration (DHHS/PHS), Rockville, MD. Bureau of Health Professions.

    This report provides information on approved educational activities for nursing and other nonphysician health professions for which reimbursement is made to hospitals under the Medicare program. Information was summarized from an examination of existing data and a special study of the variations that exist in hospital educational activities. The…

  8. 77 FR 37678 - Medicare and Medicaid Programs; Application From American Association for Accreditation of...

    Science.gov (United States)

    2012-06-22

    ... Ambulatory Surgery Facilities Accreditation Program AGENCY: Centers for Medicare and Medicaid Services, HHS... continued recognition as a national accrediting organization for ambulatory surgery centers (ASCs) wish to..., eligible beneficiaries may receive covered services in an ambulatory surgery center (ASC) that meet...

  9. Factors associated with program utilization of radiation therapy treatment for VHA and medicare dually enrolled patients.

    Science.gov (United States)

    French, Dustin D; Bradham, Douglas D; Campbell, Robert R; Haggstrom, David A; Myers, Laura J; Chumbler, Neale R; Hagan, Michael P

    2012-08-01

    We examine how distance to a Veterans Health Administration (VHA) facility, patient hometown classification (e.g., small rural town), and service-connected disability are associated with veterans' utilization of radiation therapy services across the VHA and Medicare. In 2008, 45,914 dually-enrolled veteran patients received radiation therapy. Over 3-quarters (35,513) of the patients received radiation therapy from the Medicare program. Younger age, male gender, shorter distance to a VHA facility, and VHA priority or disability status increased the odds of utilizing the VHA. However, veterans residing in urban areas were less likely to utilize the VHA. Urban dwelling patients' utilization of Medicare instead of the VHA suggests a complex decision that incorporates geographic access to VHA services, financial implications of veteran priority status, and the potential availability of multiple sources of radiation therapy in competitive urban markets.

  10. 77 FR 55479 - Medicare, Medicaid, and CHIP Programs: Research and Analysis on Impact of CMS Programs on the...

    Science.gov (United States)

    2012-09-10

    ... and Analysis on Impact of CMS Programs on the Indian Health Care System AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice of Single Source Award. SUMMARY: This notice supports expansion of research on the impact of CMS programs on the Indian health care system through a single...

  11. 78 FR 31558 - Medicare Program; Second Semi-Annual Meeting of the Advisory Panel on Hospital Outpatient Payment...

    Science.gov (United States)

    2013-05-24

    ... CMS Central Office, Auditorium, 7500 Security Boulevard, Woodlawn, Maryland 21244-1850. Alternately... [CMS-1458-N] Medicare Program; Second Semi-Annual Meeting of the Advisory Panel on Hospital Outpatient Payment (HOP Panel) August 26-27, 2013 AGENCY: Centers for Medicare & Medicaid Services (CMS),...

  12. 75 FR 78246 - Medicare Program; Re-Chartering of the Advisory Panel on Ambulatory Payment Classification (APC...

    Science.gov (United States)

    2010-12-15

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Re-Chartering of the Advisory... (CMS), HHS. ACTION: Notice. SUMMARY: This notice announces the re-chartering of the Advisory Panel on...

  13. Plenary III–04: Responses to Drug Costs: Year Three of the Medicare Part D Program

    OpenAIRE

    Fung, Vicki; Reed, Mary; Hsu, John

    2010-01-01

    Background/Aims: Many Medicare Part D beneficiaries face substantial prescription drug cost-sharing. In the first year of the program, many beneficiaries reported substantial drug use changes in response to the coverage gap. In response, an increasing number of plans offer generic drug coverage during the gap. We compared responses to Part D costs among beneficiaries with generic-only gap coverage and full gap coverage in 2008, the third year of the Part D program.

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

    Science.gov (United States)

    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.

  15. Medicare 1144 Outreach

    Data.gov (United States)

    Social Security Administration — The purpose of this exchange is to identify any Medicare beneficiary who may be eligible for Medicare cost sharing under the Medicaid program, notify these potential...

  16. TMA Uncovers Medicare Mistakes.

    Science.gov (United States)

    Sorrel, Amy Lynn

    2015-07-01

    The Texas Medical Association recently uncovered some major Medicare mistakes that show just why some physicians talk about leaving the federal program. Investigations and advocacy by TMA staff put Medicare on the path to a fix.

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

    Science.gov (United States)

    2016-09-16

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

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

    Science.gov (United States)

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

    2017-01-10

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

  19. Adding A Spending Metric To Medicare's Value-Based Purchasing Program Rewarded Low-Quality Hospitals.

    Science.gov (United States)

    Das, Anup; Norton, Edward C; Miller, David C; Ryan, Andrew M; Birkmeyer, John D; Chen, Lena M

    2016-05-01

    In fiscal year 2015 the Centers for Medicare and Medicaid Services expanded its Hospital Value-Based Purchasing program by rewarding or penalizing hospitals for their performance on both spending and quality. This represented a sharp departure from the program's original efforts to incentivize hospitals for quality alone. How this change redistributed hospital bonuses and penalties was unknown. Using data from 2,679 US hospitals that participated in the program in fiscal years 2014 and 2015, we found that the new emphasis on spending rewarded not only low-spending hospitals but some low-quality hospitals as well. Thirty-eight percent of low-spending hospitals received bonuses in fiscal year 2014, compared to 100 percent in fiscal year 2015. However, low-quality hospitals also began to receive bonuses (0 percent in fiscal year 2014 compared to 17 percent in 2015). All high-quality hospitals received bonuses in both years. The Centers for Medicare and Medicaid Services should consider incorporating a minimum quality threshold into the Hospital Value-Based Purchasing program to avoid rewarding low-quality, low-spending hospitals.

  20. Medicare Access and CHIP Reauthorization Act: What do Geriatrics Healthcare Professionals Need to Know About the Quality Payment Program?

    Science.gov (United States)

    Unroe, Kathleen T; Hollmann, Peter A; Goldstein, Alanna C; Malone, Michael L

    2017-04-01

    Commencing in 2017, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 will change how Medicare pays health professionals. By enacting MACRA, Congress brought an end to the (un)sustainable growth rate formula while also setting forth a vision for how to transform the U.S. healthcare system so that clinicians deliver higher-quality care with smarter spending by the Centers for Medicare and Medicaid Services (CMS). In October 2016, CMS released the first of what stakeholders anticipate will be a number of (annual) rules related to implementation of MACRA. CMS received extensive input from stakeholders including the American Geriatrics Society. Under the Quality Payment Program, CMS streamlined multiple Medicare value-based payment programs into a new Merit-based Incentive Payment System (MIPS). CMS also outlined how it will provide incentives for participation in Advanced Alternative Payment Models (called APMs). Although Medicare payments to geriatrics health professionals will not be based on the new MIPS formula until 2019, those payments will be based upon performance during a 90-day period in 2017. This article defines geriatrics health professionals as clinicians who care for a predominantly older adult population and who are eligible to bill under the Medicare Physician Fee Schedule. Given the current paucity of eligible APMs, this article will focus on MIPS while providing a brief overview of APMs. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

  1. Medicare's Hospital Readmissions Reduction Program in Surgery May Disproportionately Affect Minority-serving Hospitals.

    Science.gov (United States)

    Shih, Terry; Ryan, Andrew M; Gonzalez, Andrew A; Dimick, Justin B

    2015-06-01

    To project readmission penalties for hospitals performing cardiac surgery and examine how these penalties will affect minority-serving hospitals. The Hospital Readmissions Reduction Program will potentially expand penalties for higher-than-predicted readmission rates to cardiac procedures in the near future. The impact of these penalties on minority-serving hospitals is unknown. We examined national Medicare beneficiaries undergoing coronary artery bypass grafting in 2008 to 2010 (N = 255,250 patients, 1186 hospitals). Using hierarchical logistic regression, we calculated hospital observed-to-expected readmission ratios. Hospital penalties were projected according to the Hospital Readmissions Reduction Program formula using only coronary artery bypass grafting readmissions with a 3% maximum penalty of total Medicare revenue. Hospitals were classified into quintiles according to proportion of black patients treated. Minority-serving hospitals were defined as hospitals in the top quintile whereas non-minority-serving hospitals were those in the bottom quintile. Projected readmission penalties were compared across quintiles. Forty-seven percent of hospitals (559 of 1186) were projected to be assessed a penalty. Twenty-eight percent of hospitals (330 of 1186) would be penalized less than 1% of total Medicare revenue whereas 5% of hospitals (55 of 1186) would receive the maximum 3% penalty. Minority-serving hospitals were almost twice as likely to be penalized than non-minority-serving hospitals (61% vs 32%) and were projected almost triple the reductions in reimbursement ($112 million vs $41 million). Minority-serving hospitals would disproportionately bear the burden of readmission penalties if expanded to include cardiac surgery. Given these hospitals' narrow profit margins, readmission penalties may have a profound impact on these hospitals' ability to care for disadvantaged patients.

  2. 75 FR 67751 - Medicare Program: Community-Based Care Transitions Program (CCTP) Meeting

    Science.gov (United States)

    2010-11-03

    ... provide a forum for community-based organizations, hospitals, Quality Improvement Organizations... materials will be posted on the CMS Care Transitions Web site prior to the meeting. FOR FURTHER INFORMATION CONTACT: Juliana Tiongson, Social Science Research Analyst, Centers for Medicare & Medicaid Services,...

  3. 75 FR 43235 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

    Science.gov (United States)

    2010-07-23

    ... analyze the effectiveness of the 10-visit therapy threshold in ensuring that rehabilitation services were... Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Parts 409, 418, 424, et al... Centers for Medicare & Medicaid Services 42 CFR Parts 409, 418, 424, 484, and 489 RIN 0938-AP88 Medicare...

  4. Physician-owned Surgical Hospitals Outperform Other Hospitals in the Medicare Value-based Purchasing Program

    Science.gov (United States)

    Ramirez, Adriana G; Tracci, Margaret C; Stukenborg, George J; Turrentine, Florence E; Kozower, Benjamin D; Jones, R Scott

    2016-01-01

    Background The Hospital Value-Based Purchasing Program measures value of care provided by participating Medicare hospitals while creating financial incentives for quality improvement and fostering increased transparency. Limited information is available comparing hospital performance across healthcare business models. Study Design 2015 hospital Value-Based Purchasing Program results were used to examine hospital performance by business model. General linear modeling assessed differences in mean total performance score, hospital case mix index, and differences after adjustment for differences in hospital case mix index. Results Of 3089 hospitals with Total Performance Scores (TPS), categories of representative healthcare business models included 104 Physician-owned Surgical Hospitals (POSH), 111 University HealthSystem Consortium (UHC), 14 US News & World Report Honor Roll (USNWR) Hospitals, 33 Kaiser Permanente, and 124 Pioneer Accountable Care Organization affiliated hospitals. Estimated mean TPS for POSH (64.4, 95% CI 61.83, 66.38) and Kaiser (60.79, 95% CI 56.56, 65.03) were significantly higher compared to all remaining hospitals while UHC members (36.8, 95% CI 34.51, 39.17) performed below the mean (p UHC members (mean =1.99, p<0.0001) while Kaiser Permanente hospitals had lower case mix value (mean =1.54, p<0.0001). Re-estimation of TPS did not change the original results after adjustment for differences in hospital case mix index. Conclusions The Hospital Value-Based Purchasing Program revealed superior hospital performance associated with business model. Closer inspection of high-value hospitals may guide value improvement and policy-making decisions for all Medicare Value-Based Purchasing Program Hospitals. PMID:27502368

  5. Your Guide to Medicare Special Needs Plans (SNPs)

    Science.gov (United States)

    ... when your Medicare SNP notifies you that it’s leaving the Medicare Program. 16 Joining and Switching Medicare ... bills. For the phone number of the SHIP office near you, visit www. medicare. gov/ contacts, or ...

  6. Medicare program; physician fee schedule conversion factor for calendar year 1998 and sustainable growth rate for fiscal year 1998--HCFA. Final notice.

    Science.gov (United States)

    1997-10-31

    This final notice announces the calendar year 1998 Medicare physician fee schedule conversion factor and the fiscal year 1998 sustainable growth rate for expenditures for physicians' services under the Medicare Supplementary Medical Insurance (Part B) program as required by sections 1846(d) and (f), respectively, of the Social Security Act. The 1998 Medicare physician fee schedule conversion factor is $36,6873. The sustainable growth rate for fiscal year 1998 is 1.5 percent.

  7. Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations--Revised Benchmark Rebasing Methodology, Facilitating Transition to Performance-Based Risk, and Administrative Finality of Financial Calculations. Final rule.

    Science.gov (United States)

    2016-06-10

    Under the Medicare Shared Savings Program (Shared Savings Program), providers of services and suppliers that participate in an Accountable Care Organization (ACO) continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, but the ACO may be eligible to receive a shared savings payment if it meets specified quality and savings requirements. This final rule addresses changes to the Shared Savings Program, including: Modifications to the program's benchmarking methodology, when resetting (rebasing) the ACO's benchmark for a second or subsequent agreement period, to encourage ACOs' continued investment in care coordination and quality improvement; an alternative participation option to encourage ACOs to enter performance-based risk arrangements earlier in their participation under the program; and policies for reopening of payment determinations to make corrections after financial calculations have been performed and ACO shared savings and shared losses for a performance year have been determined.

  8. Medicare Program; FY 2017 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements. Final rule.

    Science.gov (United States)

    2016-08-05

    This final rule will update the hospice wage index, payment rates, and cap amount for fiscal year (FY) 2017. In addition, this rule changes the hospice quality reporting program, including adopting new quality measures. Finally, this final rule includes information regarding the Medicare Care Choices Model (MCCM).

  9. 78 FR 69926 - Privacy Act of 1974, as Amended; Computer Matching Program (SSA/Centers for Medicare & Medicaid...

    Science.gov (United States)

    2013-11-21

    ... ADMINISTRATION Privacy Act of 1974, as Amended; Computer Matching Program (SSA/ Centers for Medicare & Medicaid... accordance with the provisions of the Privacy Act, as amended, this notice announces a renewal of an existing... Act of 1988 (Pub. L 100-503), amended the Privacy Act (5 U.S.C. 552a) by describing the...

  10. MACRA, MIPS, and the New Medicare Quality Payment Program: An Update for Radiologists.

    Science.gov (United States)

    Rosenkrantz, Andrew B; Nicola, Gregory N; Allen, Bibb; Hughes, Danny R; Hirsch, Joshua A

    2017-03-01

    The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 advances the goal of tying Medicare payments to quality and value. In April 2016, CMS published an initial proposed rule for MACRA, renaming it the Quality Payment Program (QPP). Under QPP, clinicians receive payments through either advanced alternative payment models or the Merit-Based Incentive Payment System (MIPS), a consolidation of existing federal performance programs that applies positive or negative adjustments to fee-for-service payments. Most physicians will participate in MIPS. This review highlights implications of the QPP and MIPS for radiologists. Although MIPS incorporates radiology-specific quality measures, radiologists will also be required to participate in other practice improvement activities, including patient engagement. Recognizing physicians' unique practice patterns, MIPS will provide special considerations in performance evaluation for physicians with limited face-to-face patient interaction. Although such considerations will affect radiologists' likelihood of success under QPP, many practitioners will be ineligible for the considerations under currently proposed criteria. Reporting using qualified clinical data registries will benefit radiologists' performance by allowing expanded arrays of MIPS and non-MIPS specialty-specific measures. A group practice reporting option will substantially reduce administrative burden but introduce new challenges by requiring uniform determination of patient-facing status and performance measurement for all of the group's physicians (diagnostic radiologists, interventional radiologists, and nonradiologists) under the same taxpayer identification number. Given that the initial MIPS performance period begins in 2017, radiologists must begin preparing for QPP and taking actions to ensure their future success under this new quality-based payment system.

  11. Primary care focus and utilization in the Medicare shared savings program accountable care organizations.

    Science.gov (United States)

    Herrel, Lindsey A; Ayanian, John Z; Hawken, Scott R; Miller, David C

    2017-02-15

    Although Accountable Care Organizations (ACOs) are defined by the provision of primary care services, the relationship between the intensity of primary care and population-level utilization and costs of health care services has not been examined during early implementation of Medicare Shared Savings Program (MSSP) ACOs. Our objective was to evaluate the association between primary care focus and healthcare utilization and spending in the first performance period of the Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs). In this retrospective cohort study, we divided the 220 MSSP ACOs into quartiles of primary care focus based on the percentage of all ambulatory evaluation and management services delivered by a PCP (internist, family physician, or geriatrician). Using multivariable regression, we evaluated rates of utilization and spending during the initial performance period, adjusting for the percentage of non-white patients, region, number of months enrolled in the MSSP, number of beneficiary person years, percentage of dual eligible beneficiaries and percentage of beneficiaries over the age of 74. The proportion of ambulatory evaluation and management services delivered by a PCP ranged from 46% (highest quartile, ACOs with greatest PCP focus). ACOs in the highest quartile of PCP focus had higher adjusted rates of utilization of acute care hospital admissions (328 per 1000 person years vs 292 per 1000 person years, p = 0.01) and emergency department visits (756 vs 680 per 1000 person years, p = 0.02) compared with ACOs in the lowest quartile of PCP focus. ACOs in the highest quartile of PCP focus achieved no greater savings per beneficiary relative to their spending benchmarks ($142 above benchmark vs $87 below benchmark, p = 0.13). Primary care focus was not associated with increased savings or lower utilization of healthcare during the initial implementation of MSSP ACOs.

  12. Medicare and Medicaid programs; changes in provider and supplier enrollment, ordering and referring, and documentation requirements; and changes in provider agreements. Interim final rule with comment period.

    Science.gov (United States)

    2010-05-05

    This interim final rule with comment period implements several provisions set forth in the Patient Protection and Affordable Care Act (Affordable Care Act). It implements the provision which requires all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs. This interim final rule with comment period also requires physicians and eligible professionals to order and refer covered items and services for Medicare beneficiaries to be enrolled in Medicare. In addition, it adds requirements for providers, physicians, and other suppliers participating in the Medicare program to provide documentation on referrals to programs at high risk of waste and abuse, to include durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), home health services, and other items or services specified by the Secretary.

  13. 77 FR 70785 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Science.gov (United States)

    2012-11-27

    ... Family Foundation; Joseph Baker, President, Medicare Rights Center; Philip Bergquist, Manager, Health... & Dentistry of New Jersey; Megan Padden, Vice President, Sentara Health Plans; David W. Roberts,...

  14. 77 FR 37681 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Science.gov (United States)

    2012-06-22

    ...: Samantha Artiga, Principal Policy Analyst, Kaiser Family Foundation; Joseph Baker, President, Medicare... Professor of Medicine, University of Medicine & Dentistry of New Jersey; Megan Padden, Vice...

  15. 77 FR 2983 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Science.gov (United States)

    2012-01-20

    ... Family Foundation; Joseph Baker, President, Medicare Rights Center; Philip Bergquist, Manager, Health... & Dentistry of New Jersey; Megan Padden, Vice President, Sentara Health Plans; David W. Roberts,...

  16. 78 FR 12327 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Science.gov (United States)

    2013-02-22

    ... Family Foundation; Joseph Baker, President, Medicare Rights Center; Philip Bergquist, Manager, Health... & Dentistry of New Jersey; Megan Padden, Vice President, Sentara Health Plans; David W. Roberts,...

  17. 78 FR 32664 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Science.gov (United States)

    2013-05-31

    ...: Samantha Artiga, Principal Policy Analyst, Kaiser Family Foundation; Joseph Baker, President, Medicare... Professor of Medicine, University of Medicine & Dentistry of New Jersey; Megan Padden, Vice...

  18. Comparing mandated health care reforms: the Affordable Care Act, accountable care organizations, and the Medicare ESRD program.

    Science.gov (United States)

    Watnick, Suzanne; Weiner, Daniel E; Shaffer, Rachel; Inrig, Jula; Moe, Sharon; Mehrotra, Rajnish

    2012-09-01

    In addition to extending health insurance coverage, the Affordable Care Act of 2010 aims to improve quality of care and contain costs. To this end, the act allowed introduction of bundled payments for a range of services, proposed the creation of accountable care organizations (ACOs), and established the Centers for Medicare and Medicaid Innovation to test new care delivery and payment models. The ACO program began April 1, 2012, along with demonstration projects for bundled payments for episodes of care in Medicaid. Yet even before many components of the Affordable Care Act are fully in place, the Medicare ESRD Program has instituted legislatively mandated changes for dialysis services that resemble many of these care delivery reform proposals. The ESRD program now operates under a fully bundled, case-mix adjusted prospective payment system and has implemented Medicare's first-ever mandatory pay-for-performance program: the ESRD Quality Incentive Program. As ACOs are developed, they may benefit from the nephrology community's experience with these relatively novel models of health care payment and delivery reform. Nephrologists are in a position to assure that the ACO development will benefit from the ESRD experience. This article reviews the new ESRD payment system and the Quality Incentive Program, comparing and contrasting them with ACOs. Better understanding of similarities and differences between the ESRD program and the ACO program will allow the nephrology community to have a more influential voice in shaping the future of health care delivery in the United States.

  19. Recovery of renal function among ESRD patients in the US medicare program.

    Directory of Open Access Journals (Sweden)

    Sumit Mohan

    Full Text Available BACKGROUND: Patients started on long term hemodialysis have typically had low rates of reported renal recovery with recent estimates ranging from 0.9-2.4% while higher rates of recovery have been reported in cohorts with higher percentages of patients with acute renal failure requiring dialysis. STUDY DESIGN: Our analysis followed approximately 194,000 patients who were initiated on hemodialysis during a 2-year period (2008 & 2009 with CMS-2728 forms submitted to CMS by dialysis facilities, cross-referenced with patient record updates through the end of 2010, and tracked through December 2010 in the CMS SIMS registry. RESULTS: We report a sustained renal recovery (i.e no return to ESRD during the available follow up period rate among Medicare ESRD patients of > 5% - much higher than previously reported. Recovery occurred primarily in the first 2 months post incident dialysis, and was more likely in cases with renal failure secondary to etiologies associated with acute kidney injury. Patients experiencing sustained recovery were markedly less likely than true long-term ESRD patients to have permanent vascular accesses in place at incident hemodialysis, while non-White patients, and patients with any prior nephrology care appeared to have significantly lower rates of renal recovery. We also found widespread geographic variation in the rates of renal recovery across the United States. CONCLUSIONS: Renal recovery rates in the US Medicare ESRD program are higher than previously reported and appear to have significant geographic variation. Patients with diagnoses associated with acute kidney injury who are initiated on long-term hemodialysis have significantly higher rates of renal recovery than the general ESRD population and lower rates of permanent access placement.

  20. 78 FR 47859 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Science.gov (United States)

    2013-08-06

    ... Analysis D. Alternatives Considered E. Accounting Statement F. Conclusion Regulation Text I. Background A... require IRFs to submit patient assessments on Medicare Advantage (MA) (Medicare Part C) patients for use...- based entity which holds a performance measurement contract under section 1890(a) of the Act....

  1. 75 FR 21329 - Medicaid Program; State Allotments for Payment of Medicare Part B Premiums for Qualifying...

    Science.gov (United States)

    2010-04-23

    ...), specified low-income Medicare ] beneficiaries (SLMBs), and qualified disabled and working individuals (QDWIs... Medicaid whose family income is at least 120 percent but less than 135 percent of the poverty level. With..., among the States, Federal funds to provide Medicaid payment for Medicare Part B premiums for low-...

  2. 75 FR 14606 - Medicare Program; Request for Nominations to the Advisory Panel on Ambulatory Payment...

    Science.gov (United States)

    2010-03-26

    ...; Center for Medicare Management, Hospital & Ambulatory Policy Group, Division of Outpatient Care; 7500... components of the Medicare hospital Outpatient Prospective Payment System (OPPS). The Charter requires that... consist of a chair and up to 15 members who are full- time employees of hospitals, hospital systems,...

  3. Medicare and Medicaid programs; changes in provider and supplier enrollment, ordering and referring, and documentation requirements; and changes in provider agreements. Final rule.

    Science.gov (United States)

    2012-04-27

    This final rule finalizes several provisions of the Affordable Care Act implemented in the May 5, 2010 interim final rule with comment period. It requires all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs. In addition, it requires physicians and other professionals who are permitted to order and certify covered items and services for Medicare beneficiaries to be enrolled in Medicare. Finally, it mandates document retention and provision requirements on providers and supplier that order and certify items and services for Medicare beneficiaries.

  4. Medicare Advantage Plans Pay Hospitals Less Than Traditional Medicare Pays.

    Science.gov (United States)

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

    2016-08-01

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

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

    Science.gov (United States)

    2014-11-06

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

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

    Science.gov (United States)

    Veilleux, Jean Wright

    2012-01-01

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

  7. 75 FR 51464 - Medicare and Medicaid Programs; Approval of the American Association for Accreditation of...

    Science.gov (United States)

    2010-08-20

    ... American Association for Accreditation of Ambulatory Surgery Facilities for Continued Deeming Authority for Ambulatory Surgical Centers AGENCY: Centers for Medicare & Medicaid Services (CMS). ACTION: Final notice... for Accreditation of Ambulatory Surgery Facilities' (AAAASF) request for continued recognition as...

  8. 75 FR 24437 - Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering and...

    Science.gov (United States)

    2010-05-05

    ... described in section 1842(b)(18)(C) of Act; (3) a physical or occupational therapist or a qualified speech... chiropractic. Referring physicians are those who order covered items or services for Medicare...

  9. 76 FR 67567 - Medicare Program; Inpatient Hospital Deductible and Hospital and Extended Care Services...

    Science.gov (United States)

    2011-11-01

    ...)(3)(B)(xii)(II) of the Act), and an adjustment based on changes in the economy-wide productivity (the... that is located outside of a Metropolitan Statistical Area for Medicare payment regulations and has...

  10. Medicare program; inpatient rehabilitation facility prospective payment system for federal fiscal year 2015.

    Science.gov (United States)

    2014-08-01

    This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2015 as required by the statute. This final rule finalizes a policy to collect data on the amount and mode (that is, Individual, Concurrent, Group, and Co-Treatment) of therapy provided in the IRF setting according to therapy discipline, revises the list of diagnosis and impairment group codes that presumptively meet the "60 percent rule'' compliance criteria, provides a way for IRFs to indicate on the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) form whether the prior treatment and severity requirements have been met for arthritis cases to presumptively meet the "60 percent rule'' compliance criteria, and revises and updates quality measures and reporting requirements under the IRF quality reporting program (QRP). This rule also delays the effective date for the revisions to the list of diagnosis codes that are used to determine presumptive compliance under the "60 percent rule'' that were finalized in FY 2014 IRF PPS final rule and adopts the revisions to the list of diagnosis codes that are used to determine presumptive compliance under the "60 percent rule'' that are finalized in this rule. This final rule also addresses the implementation of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), for the IRF prospective payment system (PPS), which will be effective when ICD-10-CM becomes the required medical data code set for use on Medicare claims and IRF-PAI submissions.

  11. 76 FR 31547 - Medicare Program; Proposed Changes to the Electronic Prescribing (eRx) Incentive Program

    Science.gov (United States)

    2011-06-01

    ... Law 110-275, authorized the Secretary to establish a program to encourage the adoption and use of eRx... programs, and to encourage adoption of certified EHR technology. Accordingly, we are proposing changes to... hardship exemption requests using a Web-based tool or interface. However, our ability to receive...

  12. Numeracy and Medicare Part D: the importance of choice and literacy for numbers in optimizing decision making for Medicare's prescription drug program.

    Science.gov (United States)

    Wood, Stacey; Hanoch, Yaniv; Barnes, Andrew; Liu, Pi-Ju; Cummings, Janet; Bhattacharya, Chandrima; Rice, Thomas

    2011-06-01

    Studies on decision making have come to challenge the idea that having more choice is necessarily better. The Medicare prescription drug program (Part D) has been designed to maximize choice for the consumer but has simultaneously created a highly complex decision task with dozens of options. In this study, in a sample of 121 adults, we examined the impact that increasing choice options has on decision-making abilities in older versus younger adults. Consistent with our hypotheses, we found that participants performed better with less choice versus more choice, and that older adults performed worse than younger adults across conditions. We further examined the role that numeracy may play in making these decisions and the role of more traditional cognitive variables such as working memory, executive functioning, intelligence, and education. Finally, we examined how personality style may interact with cognitive variables and age in decision making. Regression analysis revealed that numeracy is related to performance across the lifespan. When controlling for additional measures of cognitive ability, we found that although age was no longer associated with performance, numeracy remained significant. In terms of decision style, personality characteristics were not related to performance. Our results add to the mounting evidence for the critical role of numeracy in decision making across decision domains and across the lifespan.

  13. Medicare program; limitation on recoupment of provider and supplier overpayments. Final rule.

    Science.gov (United States)

    2009-09-16

    This final rule implements a provision of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) which prohibits recouping Medicare overpayments from a provider or supplier that seeks a reconsideration from a Qualified Independent Contractor (QIC). This provision changes how interest is to be paid to a provider or supplier whose overpayment is reversed at subsequent administrative or judicial levels of appeal. This final rule defines the overpayments to which the limitation applies, how the limitation works in concert with the appeals process, and the change in our obligation to pay interest to a provider or supplier whose appeal is successful at levels above the QIC.

  14. Evaluation of an integrated adherence program aimed to increase Medicare Part D star rating measures.

    Science.gov (United States)

    Leslie, R Scott; Tirado, Breanne; Patel, Bimal V; Rein, Philip J

    2014-12-01

    The Centers for Medicare Medicaid Services (CMS) Plan Quality and Performance Program, or Star Ratings Program, allows Medicare beneficiaries to compare quality of care among available Medicare Advantage prescription drug (MA-PD) plans and stand-alone prescription drug plans (PDPs). Health plans have increased intervention efforts and applied existing care management infrastructure as an approach to improving member medication adherence and subsequent Part D star rating performance. Independent Care Health Plan (iCare), an MA-PD plan; MedImpact Healthcare Systems, Inc. (MedImpact), a pharmacy benefits manager; and US MED, a mail order pharmacy, partnered to engage and enroll iCare's dual-eligible special needs population in an intervention designed to improve patient medication adherence and health plan performance for 3 Part D patient safety outcome measures: Medication Adherence for Oral Diabetes Medications (ODM), Medication Adherence for Hypertension (HTN), and Medication Adherence for Cholesterol (CHOL). To (a) assess the effectiveness of a coordinated member-directed medication adherence intervention and (b) determine the overall impact of the intervention on adherence rates and CMS Part D star rating adherence measures.  Administrative pharmacy claims and health plan eligibility data from MedImpact's databases were used to identify members using 3 target medication classes. Adherence was estimated by the proportion of days covered (PDC) for all members. Those members considered at high risk for nonadherence were prioritized for care management services. Risk factors were based on members' use of more than 1 target medication class, newly started therapy, and suboptimal adherence (PDC  less than  80%) in the most recent 6-month period. Data files listing member adherence rates and contact information were formatted and loaded monthly into iCare's care management system, which triggered an alert for care coordinators to counsel members on the importance

  15. Patient Selection and Volume in the Era Surrounding Implementation of Medicare Conditions of Participation for Transplant Programs

    Science.gov (United States)

    White, Sarah L; Zinsser, Dawn M; Paul, Matthew; Levine, Gregory N; Shearon, Tempie; Ashby, Valarie B; Magee, John C; Li, Yi; Leichtman, Alan B

    2015-01-01

    Objective To evaluate evidence of practice changes affecting kidney transplant program volumes, and donor, recipient and candidate selection in the era surrounding the introduction of Centers for Medicare and Medicaid Services (CMS) conditions of participation (CoPs) for organ transplant programs. Data Scientific Registry of Transplant Recipients; CMS ESRD and Medicare claims databases. Design Retrospective analysis of national registry data. Methods A Cox proportional hazards model of 1-year graft survival was used to derive risks associated with deceased-donor kidney transplants performed from 2001 to 2010. Findings Among programs with ongoing noncompliance with the CoPs, kidney transplant volumes declined by 38 percent (n = 766) from 2006 to 2011, including a 55 percent drop in expanded criteria donor transplants. Volume increased by 6 percent (n = 638) among programs remaining in compliance. Aggregate risk of 1-year graft failure increased over time due to increasing recipient age and obesity, and longer ESRD duration. Conclusions Although trends in aggregate risk of 1-year kidney graft loss do not indicate that the introduction of the CoPs has systematically reduced opportunities for marginal candidates or that there has been a systematic shift away from utilization of higher risk deceased donor kidneys, total volume and expanded criteria donor utilization decreased overall among programs with ongoing noncompliance. PMID:24838079

  16. 77 FR 27869 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Science.gov (United States)

    2012-05-11

    ... record FAH Federation of Hospitals FDA Food and Drug Administration FFY Federal fiscal year FQHC... 2008, Public Law 110-275 MMA Medicare Prescription Drug, Improvement, and Modernization Act of 2003... (B) Antineoplastic Chemotherapy Induced Anemia (C) Cardiomyopathy and Congestive Heart Failure...

  17. 77 FR 53257 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Science.gov (United States)

    2012-08-31

    ... Electronic medical record FAH Federation of Hospitals FDA Food and Drug Administration FFY Federal fiscal... for Patients and Providers Act of 2008, Public Law 110-275 MMA Medicare Prescription Drug, Improvement... Diagnosis Codes for FY 2013 (A) Protein-Calorie Malnutrition (B) Antineoplastic Chemotherapy Induced Anemia...

  18. 78 FR 59701 - Medicare Program; Approval of Accrediting Organization for Suppliers of Advanced Diagnostic...

    Science.gov (United States)

    2013-09-27

    ... review process and the accreditation status decision-making process, including the process for addressing... decision. An agreement to conform accreditation requirements to any changes in Medicare statutory... burden and cost of accreditation to small and rural suppliers that include-- ++ The...

  19. 76 FR 48485 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Science.gov (United States)

    2011-08-08

    .... Statement of Need 3. Overall Impacts 4. Detailed Economic Analysis 5. Alternatives Considered 6. Accounting... Services) Global Insight, Inc. MDS Minimum Data Set MFP Multifactor Productivity MIPPA Medicare... and certain other types of practitioners), which remain separately billable under Part B when...

  20. 76 FR 26363 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Science.gov (United States)

    2011-05-06

    .... Accounting Statement 7. Conclusion B. Regulatory Flexibility Act Analysis C. Unfunded Mandates Reform Act... Insight, Inc. MDS Minimum Data Set MFP Multifactor Productivity MIPPA Medicare Improvements for Patients... consolidated billing provision (primarily those of physicians and certain other types of practitioners), which...

  1. 75 FR 46948 - Medicare Program; Listening Session Regarding Confidential Feedback Reports and the...

    Science.gov (United States)

    2010-08-04

    ..., September 24, 2010 AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice of meeting... related provisions under the Patient Protection and Affordable Care Act (known as the Affordable Care Act... CMS Web site at http://www.cms.hhs.gov/center/physician.asp approximately 1 week prior to the...

  2. 76 FR 70227 - Medicare Program; End-Stage Renal Disease Prospective Payment System and Quality Incentive...

    Science.gov (United States)

    2011-11-10

    ... Payment a. Reduction to the ESRD Wage Index Floor b. Policies for Areas with no Hospital Data c. Wage.... Anemia Management Measure ii. Dialysis Adequacy Measure iii. Vascular Access Type (VAT) Measure iv... Regulations CIP Core Indicators Project CMS Centers for Medicare & Medicaid Services CPM Clinical Performance...

  3. 78 FR 47935 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Science.gov (United States)

    2013-08-06

    ... Addendum to the annual SNF PPS rulemaking (that is, the SNF PPS proposed and final rules or, when... Hospital Inpatient PPS (IPPS) final rule (76 FR 51476). To be consistent with these other Medicare payment... approach for the SNF PPS as well. We also proposed to revise the applicable regulations text at Sec....

  4. 77 FR 23722 - Medicare Program; Extension of Certain Wage Index Reclassifications and Special Exceptions for...

    Science.gov (United States)

    2012-04-20

    ... (PPS) for Acute Care Hospitals and the Hospital Outpatient PPS AGENCY: Centers for Medicare & Medicaid... and the long-term care hospital prospective payment system (LTCH PPS) (hereinafter referred to as the FY 2012 IPPS/LTCH PPS final rule) appeared in the August 18, 2011 Federal Register (76 FR 51476)...

  5. 78 FR 46339 - Medicare, Medicaid, and Children's Health Insurance Programs: Announcement of Temporary Moratoria...

    Science.gov (United States)

    2013-07-31

    ... critical importance to CMS and our state partners, and CMS carefully evaluated access for the three target... of Medicare expenditures annually. Based on our analysis of each target market and review of MedPAC's... hotspots so that interagency teams can target emerging or migrating schemes along with chronic fraud...

  6. 78 FR 7434 - Medicare Program: Notice of Two Membership Appointments to the Advisory Panel on Hospital...

    Science.gov (United States)

    2013-02-01

    ... Appointments to the Advisory Panel on Hospital Outpatient Payment AGENCY: Centers for Medicare & Medicaid... announces two new membership appointments to the Advisory Panel on Hospital Outpatient Payment (HOP, the... prepare the annual updates for the hospital outpatient prospective payment system. FOR FURTHER INFORMATION...

  7. 77 FR 9255 - Medicare Program: Notice of Six Membership Appointments to the Advisory Panel on Hospital...

    Science.gov (United States)

    2012-02-16

    ... Appointments to the Advisory Panel on Hospital Outpatient Payment AGENCY: Centers for Medicare & Medicaid... announces six new membership appointments to the Advisory Panel on Hospital Outpatient Payment (HOP, the... prepare the annual updates for the hospital outpatient prospective payment system. FOR FURTHER INFORMATION...

  8. 75 FR 70371 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

    Science.gov (United States)

    2010-11-17

    ... Health and Human Services Center for Medicare & Medicaid Services 42 CFR Parts 409, 418, 424 et al... , No. 221 / Wednesday, November 17, 2010 / Rules and Regulations#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN... is the workforce impact--will health care workers take their talents to other care sectors because...

  9. 78 FR 8535 - Medicare Program: Comprehensive End-Stage Renal Disease Care Model Announcement

    Science.gov (United States)

    2013-02-06

    ... Disease Care Model Announcement AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION... the testing of the Comprehensive End- Stage Renal Disease (ESRD) Care Model, a new initiative from the... (CHIP) beneficiaries. We are interested in identifying models designed to improve care for...

  10. Medicare Program; termination of non-random prepayment complex medical review. Final rule.

    Science.gov (United States)

    2008-09-26

    This final rule implements requirements regarding the termination of non-random prepayment complex medical review as required under the Medicare Prescription Drug, Improvement and Modernization Act of 2003. This final rule sets forth the criteria CMS contractors will use for terminating a provider or supplier from non-random prepayment complex medical review.

  11. 75 FR 21207 - Medicare Program; Ambulatory Surgical Centers, Conditions for Coverage

    Science.gov (United States)

    2010-04-23

    ... requiring, that a written translation be provided in languages that non-English speaking clients can read, particularly for languages that are most commonly used by non-English-speaking clients of the ASC. We note that... referral must either refuse serving the patient for fear of violating Medicare requirements or accept...

  12. 77 FR 29033 - Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital Conditions of...

    Science.gov (United States)

    2012-05-16

    ... duties for which they are qualified through training and education and as allowed within their State... outpatient services......... Transplant Organ recovery--Remove duplicative blood typing 482.92 0.2 1.0... implications for Medicare reimbursement of graduate medical education, the ease of adding satellite...

  13. 75 FR 49029 - Medicare Program; End-Stage Renal Disease Prospective Payment System

    Science.gov (United States)

    2010-08-12

    ... Adjustments a. Patient Age b. Patient Sex c. Body Surface Area and Body Mass Index d. Onset of Dialysis (New... Facility-Level Adjustments a. Wage Index b. Low-Volume Adjustment i. Defining a Low-Volume facility ii... Laboratory Payments 7. Medicare as a Secondary Payer 8. Conforming Regulation Changes M. Anemia...

  14. 76 FR 31340 - Medicare Program; Notification of Closure of St. Vincent's Medical Center

    Science.gov (United States)

    2011-05-31

    ... a process to increase the full time equivalent (FTE) resident caps for other hospitals based upon... application process for hospitals to apply to the Centers for Medicare & Medicaid Services (CMS) to receive St. Vincent's Medical Center's full time equivalent (FTE) resident cap slots. DATES: We will...

  15. 76 FR 38342 - Medicare Program; Clinical Laboratory Fee Schedule: Signature on Requisition

    Science.gov (United States)

    2011-06-30

    ...; Clinical Laboratory Fee Schedule: Signature on Requisition AGENCY: Centers for Medicare & Medicaid Services... calendar year 2011 Physician Fee Schedule final rule with comment period that requires the signature of a... the prior policy that the signature of a physician or qualified non-physician practitioner is...

  16. 76 FR 25787 - Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for...

    Science.gov (United States)

    2011-05-05

    ... Hours With Major Operating Room (O.R.) Procedure c. Autologous Bone Marrow Transplant 2. MDC 1 (Diseases... Cost-to-charge ratio CDAC Clinical Data Abstraction Center CDAD Clostridium difficile-associated disease CIPI Capital input price index CMI Case-mix index CMS Centers for Medicare & Medicaid Services...

  17. Outcomes of a Digital Health Program With Human Coaching for Diabetes Risk Reduction in a Medicare Population.

    Science.gov (United States)

    Castro Sweet, Cynthia M; Chiguluri, Vinay; Gumpina, Rajiv; Abbott, Paul; Madero, Erica N; Payne, Mike; Happe, Laura; Matanich, Roger; Renda, Andrew; Prewitt, Todd

    2017-01-01

    To examine the outcomes of a Medicare population who participated in a program combining digital health with human coaching for diabetes risk reduction. People at risk for diabetes enrolled in a program combining digital health with human coaching. Participation and health outcomes were examined at 16 weeks and 6 and 12 months. A total of 501 participants enrolled; 92% completed at least nine of 16 core lessons. Participants averaged 19 of 31 possible opportunities for weekly program engagement. At 12 months, participants lost 7.5% ( SD = 7.8%) of initial body weight; among participants with clinical data, glucose control improved (glycosylated hemoglobin [HbA1c] change = -0.14%, p = .001) and total cholesterol decreased (-7.08 mg/dL, p = .008). Self-reported well-being, depression, and self-care improved ( p health, and well-being. The findings support digital programs with human coaching for reducing chronic disease risk among older adults.

  18. Medicare FFS Jurisdiction Error Rate Contribution Data

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Centers for Medicare and Medicaid Services CMS is dedicated to continually strengthening and improving the Medicare program, which provides vital services to...

  19. Statistical Uncertainty in the Medicare Shared Savings...

    Data.gov (United States)

    U.S. Department of Health & Human Services — According to analysis reported in Statistical Uncertainty in the Medicare Shared Savings Program published in Volume 2, Issue 4 of the Medicare and Medicaid Research...

  20. Medicare Non-Utilization Project (MNUP)

    Data.gov (United States)

    Social Security Administration — A program integrity initiative using a data exchange between SSA and the Centers for Medicare and Medicaid Services (CMS).CMS will identify Medicare Part B enrollees...

  1. Choice Inconsistencies Among the Elderly: Evidence from Plan Choice in the Medicare Part D Program

    Science.gov (United States)

    Abaluck, Jason; Gruber, Jonathan

    2010-01-01

    We evaluate the choices of elders across their insurance options under the Medicare Part D Prescription Drug plan, using a unique data set of prescription drug claims matched to information on the characteristics of choice sets. We document that elders place much more weight on plan premiums than on expected out of pocket costs; value plan financial characteristics beyond any impacts on their own financial expenses or risk; and place almost no value on variance reducing aspects of plans. Partial equilibrium welfare analysis implies that welfare would have been 27% higher if patients had all chosen rationally. PMID:21857716

  2. Predicting the Incremental Hospital Cost of Adverse Events Among Medicare Beneficiaries in the Comprehensive Joint Replacement Program During Fiscal Year 2014.

    Science.gov (United States)

    Culler, Steven D; Jevsevar, David S; McGuire, Kevin J; Shea, Kevin G; Little, Kenneth M; Schlosser, Michael J

    2017-06-01

    The Medicare program's Comprehensive Care for Joint Replacement (CJR) payment model places hospitals at financial risk for the treatment cost of Medicare beneficiaries (MBs) undergoing lower extremity joint replacement (LEJR). This study uses Medicare Provider Analysis and Review File and identified 674,777 MBs with LEJR procedure during fiscal year 2014. Adverse events (death, acute myocardial infarction, pneumonia, sepsis or shock, surgical site bleeding, pulmonary embolism, mechanical complications, and periprosthetic joint infection) were studied. Multivariable regressions were modeled to estimate the incremental hospital cost of treating each adverse event. The risk-adjusted estimated hospital cost of treating adverse events varied from a high of $29,061 (MBs experiencing hip fracture and joint infection) to a low of $6308 (MBs without hip fracture that experienced pulmonary embolism). Avoidance of adverse events in the LEJR hospitalization will play an important role in managing episode hospital costs in the Comprehensive Care for Joint Replacement program. Copyright © 2017 Elsevier Inc. All rights reserved.

  3. The Role of Geography in the Assessment of Quality: Evidence from the Medicare Advantage Program.

    Directory of Open Access Journals (Sweden)

    Rene Soria-Saucedo

    Full Text Available The Affordable Care Act set in motion a renewed emphasis on quality of care evaluation. However, the evaluation strategies of quality by the Centers for Medicare and Medicaid Services do not consider geography when comparisons are made among plans. Using an overall measure of a plan's quality in the public sector--the Medicare Advantage (MA star ratings--we explored the impact of geography in these ratings. We identified 2,872 U.S counties in 2010. The geographic factor predicted a larger fraction of the MA ratings' compared to socio-demographic factors which explained less. Also, after the risk adjustments, almost half of the U.S. states changed their ranked position in the star ratings. Further, lower MA star ratings were identified in the Southeastern region. These findings suggest that the geographic component effect on the ratings is not trivial and should be considered in future adjustments of the metric, which may enhance the transparency, accountability, and importantly level the playing field more effectively when comparing quality across health plans.

  4. The Role of Geography in the Assessment of Quality: Evidence from the Medicare Advantage Program.

    Science.gov (United States)

    Soria-Saucedo, Rene; Xu, Peng; Newsom, Jack; Cabral, Howard; Kazis, Lewis E

    2016-01-01

    The Affordable Care Act set in motion a renewed emphasis on quality of care evaluation. However, the evaluation strategies of quality by the Centers for Medicare and Medicaid Services do not consider geography when comparisons are made among plans. Using an overall measure of a plan's quality in the public sector--the Medicare Advantage (MA) star ratings--we explored the impact of geography in these ratings. We identified 2,872 U.S counties in 2010. The geographic factor predicted a larger fraction of the MA ratings' compared to socio-demographic factors which explained less. Also, after the risk adjustments, almost half of the U.S. states changed their ranked position in the star ratings. Further, lower MA star ratings were identified in the Southeastern region. These findings suggest that the geographic component effect on the ratings is not trivial and should be considered in future adjustments of the metric, which may enhance the transparency, accountability, and importantly level the playing field more effectively when comparing quality across health plans.

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

    Science.gov (United States)

    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."

  6. 77 FR 70447 - Medicare Program; Semi-Annual Meeting of the Advisory Panel on Hospital Outpatient Payment (HOP...

    Science.gov (United States)

    2012-11-26

    ... be held in the Auditorium, CMS Central Office, 7500 Security Boulevard, Woodlawn, Maryland 21244-1850... Medicare & Medicaid Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice announces the first semi... Medicare & Medicaid Services (CMS) (the Administrator) on the clinical integrity of the APC groups...

  7. 76 FR 78281 - Medicare Program; First Semi-Annual Meeting of the Advisory Panel on Hospital Outpatient Payment...

    Science.gov (United States)

    2011-12-16

    ... be held in the Auditorium, CMS Central Office, 7500 Security Boulevard, Woodlawn, Maryland 21244-1850... Medicare & Medicaid Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice announces the first semi... Administrator of the Centers for Medicare & Medicaid Services (CMS) (the Administrator) on the...

  8. 76 FR 5861 - Medicare, Medicaid, and Children's Health Insurance Programs; Additional Screening Requirements...

    Science.gov (United States)

    2011-02-02

    ..., and Children's Health Insurance Programs; Additional Screening Requirements, Application Fees..., Medicaid, and Children's Health Insurance Programs; Additional Screening Requirements, Application Fees... reauthorized Indian Health Care Improvement Act, `` ny requirement for participation as a provider of health...

  9. 78 FR 308 - Medicare Program; Request for Information on Hospital and Vendor Readiness for Electronic Health...

    Science.gov (United States)

    2013-01-03

    ... (77 FR 53968) outlines our commitment to aligning quality measurement and reporting programs... Incentive Program as set forth in the EHR Incentive Program--Stage 2 final rule (77 FR 53968) and any... payment update (APU). Sections 1886(b)(3)(B)(viii)(I) of the Act states that the applicable...

  10. 76 FR 41260 - Supplemental Funding for the Senior Medicare Patrol (SMP) Program

    Science.gov (United States)

    2011-07-13

    ... assistance and support from the National Consumer Protection Technical Resource Center (the Center). This need has been generated by CMS program expansion grants which have recently doubled the size of the SMP program. Funding Opportunity Title/Program Name: National Consumer Protection Technical Resource...

  11. Cumulative expenditures under the DI, SSI, Medicare, and Medicaid programs for a cohort of disabled working-age adults.

    Science.gov (United States)

    Riley, Gerald F; Rupp, Kalman

    2015-04-01

    To estimate cumulative DI, SSI, Medicare, and Medicaid expenditures from initial disability benefit award to death or age 65. Administrative records for a cohort of new CY2000 DI and SSI awardees aged 18-64. Actual expenditures were obtained for 2000-2006/7. Subsequent expenditures were simulated using a regression-adjusted Markov process to assign individuals to annual disability benefit coverage states. Program expenditures were simulated conditional on assigned benefit coverage status. Estimates reflect present value of expenditures at initial award in 2000 and are expressed in constant 2012 dollars. Expenditure estimates were also updated to reflect benefit levels and characteristics of new awardees in 2012. We matched records for a 10 percent nationally representative sample. Overall average cumulative expenditures are $292,401 through death or age 65, with 51.4 percent for cash benefits and 48.6 percent for health care. Expenditures are about twice the average for individuals first awarded benefits at age 18-30. Overall average expenditures increased by 10 percent when updated for a simulated 2012 cohort. Data on cumulative expenditures, especially combined across programs, are useful for evaluating the long-term payoff of investments designed to modify entry to and exit from the disability rolls. Published 2014. This article is a U.S. Government work and is in the public domain in the USA.

  12. Medicare program; physician fee schedule update for calendar year 1996 and physician volume performance standard rates of increase for federal fiscal year 1996--HCFA. Final notice.

    Science.gov (United States)

    1995-12-08

    This final notice announces the calendar year 1996 updates to the Medicare physician fee schedule and the Federal fiscal year 1996 volume performance standard rates of increase for expenditures for physicians' services under the Medicare Supplementary Medical Insurance (Part B) program as required by sections 1848 (d) and (f), respectively, of the Social Security Act. The fee schedule update for calendar year 1996 is 3.8 percent for surgical services, -2.3 percent for primary care services, and 0.4 percent for other nonsurgical services. While it does not affect payment for any particular service, there was a 0.8 percent increase in the update for all physicians' services for 1996. The physician volume performance standard rates of increase for Federal fiscal year 1996 are -0.5 percent for surgical services, 9.3 percent for primary care services, 0.6 percent for other nonsurgical services, and a weighted average of 1.8 percent for all physicians' services. In our July 26, 1995 proposed rule concerning revisions to payment policies under the Medicare physician fee schedule for calendar year 1996, we proposed using category-specific volume and intensity growth allowances in calculating the default Medicare Volume Performance Standard (MVPS). We received 20 comments on this proposal. Since this proposal is related to the MVPS and this notice deals with MVPS issues, we are responding to those comments in this notice instead of in the final rule for the fee schedule entitled "Medicare Program; Revisions to Payment Policies and Adjustments to the Relative Value Units Under the Physician Fee Schedule for Calendar Year 1996" published elsewhere in this Federal Register issue.

  13. 78 FR 61202 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Science.gov (United States)

    2013-10-03

    ... Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2014... for Skilled Nursing Facilities for FY 2014.'' DATES: These corrections are effective October 1,...

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

    Science.gov (United States)

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

    2015-01-01

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

  15. Medicare program; Home Health Prospective Payment System rate update for calendar year 2013, hospice quality reporting requirements, and survey and enforcement requirements for home health agencies. Final rule.

    Science.gov (United States)

    2012-11-08

    This final rule updates the Home Health Prospective Payment System (HH PPS) rates, including the national standardized 60-day episode rates, the national per-visit rates, the low-utilization payment amount (LUPA), the non-routine medical supplies (NRS) conversion factor, and outlier payments under the Medicare prospective payment system for home health agencies effective January 1, 2013. This rule also establishes requirements for the Home Health and Hospice quality reporting programs. This final rule will also establish requirements for unannounced, standard and extended surveys of home health agencies (HHAs) and sets forth alternative sanctions that could be imposed instead of, or in addition to, termination of the HHA's participation in the Medicare program, which could remain in effect up to a maximum of 6 months, until an HHA achieves compliance with the HHA Conditions of Participation (CoPs) or until the HHA's provider agreement is terminated.

  16. 78 FR 16795 - Medicare and Medicaid Programs; Requirements for Long-Term Care (LTC) Facilities; Notice of...

    Science.gov (United States)

    2013-03-19

    ... the current requirements for LTC facilities under the provisions of section 1128I(h) of the Social... addressing health care inequalities for racial and ethnic minorities that rely on Medicare and Medicaid...

  17. Medicare Program; FY 2016 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements. Final rule.

    Science.gov (United States)

    2015-08-06

    This final rule will update the hospice payment rates and the wage index for fiscal year (FY) 2016 (October 1, 2015 through September 30, 2016), including implementing the last year of the phase-out of the wage index budget neutrality adjustment factor (BNAF). Effective on January 1, 2016, this rule also finalizes our proposals to differentiate payments for routine home care (RHC) based on the beneficiary's length of stay and implement a service intensity add-on (SIA) payment for services provided in the last 7 days of a beneficiary's life, if certain criteria are met. In addition, this rule will implement changes to the aggregate cap calculation mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), align the cap accounting year for both the inpatient cap and the hospice aggregate cap with the federal fiscal year starting in FY 2017, make changes to the hospice quality reporting program, clarify a requirement for diagnosis reporting on the hospice claim, and discuss recent hospice payment reform research and analyses.

  18. 76 FR 59265 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Science.gov (United States)

    2011-09-26

    ... FURTHER INFORMATION CONTACT: John Kane, (410) 786-0557. SUPPLEMENTARY INFORMATION: I. Background In FR Doc... Medical Insurance Program) Dated: September 16, 2011. Barbara J. Holland, Deputy Executive Secretary to...

  19. Medicare Appeals Council Decisions

    Data.gov (United States)

    U.S. Department of Health & Human Services — Decisions of the Departmental Appeals Board's Medicare Appeals Council involving claims for entitlement to Medicare and individual claims for Medicare coverage and...

  20. Medicare Hospice Benefits

    Science.gov (United States)

    CENTERS for MEDICARE & MEDICAID SERVICES Medicare Hospice Benefits This official government booklet includes information about Medicare hospice benefits: Who’s eligible for hospice care What services are included in hospice ...

  1. What Is Medicare?

    Science.gov (United States)

    ... get about Medicare Lost/incorrect Medicare card Report fraud & abuse File a complaint Identity theft: protect yourself ... help cover specific services: Medicare Part A (Hospital Insurance) Part A covers inpatient hospital stays, care in ...

  2. Medicare Advantage Plans

    Science.gov (United States)

    ... get about Medicare Lost/incorrect Medicare card Report fraud & abuse File a complaint Identity theft: protect yourself ... Medicare Covers Drug Coverage (Part D) Supplements & Other Insurance Claims & Appeals Manage Your Health Forms, Help & Resources ...

  3. Medicare Appeals Council Decisions

    Data.gov (United States)

    U.S. Department of Health & Human Services — Decisions of the Departmental Appeals Board's Medicare Appeals Council involving claims for entitlement to Medicare and individual claims for Medicare coverage and...

  4. Design of a medication therapy management program for Medicare beneficiaries: qualitative findings from patients and physicians.

    Science.gov (United States)

    Lauffenburger, Julie C; Vu, Maihan B; Burkhart, Jena Ivey; Weinberger, Morris; Roth, Mary T

    2012-04-01

    The quality of pharmacologic care provided to older adults is less than optimal. Medication therapy management (MTM) programs delivered to older adults in the ambulatory care setting may improve the quality of medication use for these individuals. We conducted focus groups with older adults and primary care physicians to explore (1) older adults' experiences working with a clinical pharmacist in managing medications, (2) physician perspectives on the role of clinical pharmacists in facilitating medication management, and (3) key attributes of an effective MTM program and potential barriers from patient and provider perspectives. Five focus groups (4 with older adults, 1 with physicians) were conducted by a trained moderator using a semistructured interview guide. Each participant completed a demographic questionnaire. Sessions were recorded, transcribed verbatim, and analyzed using qualitative analysis software for theme identification. Twenty-eight older adults and 8 physicians participated. Older adults valued the professional, trusting nature of their interactions with the pharmacist. They found the clinical pharmacist to be a useful resource, thorough, personable, and a valuable team member. Physicians believe that the clinical pharmacist fills a unique role as a specialized practitioner, contributing meaningfully to patient care. Physicians emphasized the importance of effective communication, pharmacist access to the medical record, and a mutually trusting relationship as key attributes of a program. Potential barriers to an effective program include poor communication and lack of familiarity with the patient's history. The lack of a sustainable reimbursement model was cited as a barrier to widespread implementation of MTM. This study provides information to assist pharmacists in designing MTM programs in the ambulatory setting. Key attributes of an effective program include being comprehensive and addressing all medication-related needs over time. The

  5. 76 FR 25550 - Medicare and Medicaid Programs: Changes Affecting Hospital and Critical Access Hospital...

    Science.gov (United States)

    2011-05-05

    ... and Medicaid Programs: Changes Affecting Hospital and Critical Access Hospital Conditions of...) for both hospitals and critical access hospitals (CAHs). The final rule will implement a new.... Currently, a hospital or CAH receiving telemedicine services must go through a burdensome credentialing and...

  6. 78 FR 38043 - Medicare and Medicaid Programs; Application From the American Osteopathic Association/Health...

    Science.gov (United States)

    2013-06-25

    ..., Attention: CMS-3285-PN, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850. 4. By hand or... the American Osteopathic Association/Health Facilities Accreditation Program for Continued CMS.... ADDRESSES: In commenting, please refer to file code CMS-3285-PN. Because of staff and resource...

  7. 77 FR 17070 - Medicare and Medicaid Programs; Application From Det Norske Veritas Healthcare (DNVHC) for...

    Science.gov (United States)

    2012-03-23

    ... Det Norske Veritas Healthcare (DNVHC) for Continued Approval of Its Hospital Accreditation Program... notice with comment period acknowledges the receipt of an application from Det Norske Veritas Healthcare... for a hospital as compared with CMS' hospital conditions of participation. DNVHC's survey process...

  8. 78 FR 32663 - Medicare Program; Notification of Closure of Teaching Hospitals and Opportunity To Apply for...

    Science.gov (United States)

    2013-05-31

    ... for consideration of the direct graduate medical education (GME) and indirect medical education (IME... and Education Reconciliation Act of 2010 (Pub. L. 111-152) (collectively, the ``Affordable Care Act... residency slots after a hospital that trained residents in an approved medical residency program...

  9. The push to increase the use of EHR technology by hospitals and physicians in the United States through the HITECH Act and the Medicare incentive program.

    Science.gov (United States)

    Pipersburgh, Jessica

    2011-01-01

    This article reviews key health care spending and electronic health records (EHR) statistics in the United States (Section II); highlights positive and negative aspects of EHR technology (Sections III and IV); briefly reviews the passage of the Health Information Technology for Economic and Clinical Health Act (HITECH) (Section V); discusses the rule passed by the Office of the National Coordinator for Health Information Technology (ONCHIT) and to implement the goals of HITECH (Section VI); discusses the rule passed by the Centers for Medicare & Medicaid Services (CMS) to implement the goals of HITECH and focuses on significant requirements of the Medicare incentive program rule as it applies to hospitals and physicians (Section VII); and finally, concludes by highlighting certain issues that have been raised regarding the goals of HITECH (Section VIII).

  10. Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2017. Final rule.

    Science.gov (United States)

    2016-08-05

    This final rule will update the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2017 as required by the statute. As required by section 1886(j)(5) of the Act, this rule includes the classification and weighting factors for the IRF prospective payment system's (IRF PPS's) case-mix groups and a description of the methodologies and data used in computing the prospective payment rates for FY 2017. This final rule also revises and updates quality measures and reporting requirements under the IRF quality reporting program (QRP).

  11. Medicare Program; Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies. Final rule.

    Science.gov (United States)

    2015-12-30

    This final rule establishes a prior authorization program for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items that are frequently subject to unnecessary utilization. This rule defines unnecessary utilization and creates a new requirement that claims for certain DMEPOS items must have an associated provisional affirmed prior authorization decision as a condition of payment. This rule also adds the review contractor's decision regarding prior authorization of coverage of DMEPOS items to the list of actions that are not initial determinations and therefore not appealable.

  12. The Impact of Hospital-Acquired Conditions on Medicare..

    Data.gov (United States)

    U.S. Department of Health & Human Services — According to findings reported in The Impact of Hospital-Acquired Conditions on Medicare Program Payments, published in Volume 4, Issue 4 of the Medicare and...

  13. Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2016. Final rule.

    Science.gov (United States)

    2015-08-01

    This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2016 as required by the statute. As required by section 1886(j)(5) of the Act, this rule includes the classification and weighting factors for the IRF PPS's case-mix groups and a description of the methodologies and data used in computing the prospective payment rates for FY 2016. This final rule also finalizes policy changes, including the adoption of an IRF-specific market basket that reflects the cost structures of only IRF providers, a 1-year phase-in of the revised wage index changes, a 3-year phase-out of the rural adjustment for certain IRFs, and revisions and updates to the quality reporting program (QRP).

  14. Medicare program; inpatient rehabilitation facility prospective payment system for federal fiscal year 2014. Final rule.

    Science.gov (United States)

    2013-08-01

    This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2014 (for discharges occurring on or after October 1, 2013 and on or before September 30, 2014) as required by the statute. This final rule also revised the list of diagnosis codes that may be counted toward an IRF's "60 percent rule'' compliance calculation to determine "presumptive compliance,'' update the IRF facility-level adjustment factors using an enhanced estimation methodology, revise sections of the Inpatient Rehabilitation Facility-Patient Assessment Instrument, revise requirements for acute care hospitals that have IRF units, clarify the IRF regulation text regarding limitation of review, update references to previously changed sections in the regulations text, and revise and update quality measures and reporting requirements under the IRF quality reporting program.

  15. Medicare program; conditions for payment of power mobility devices, including power wheelchairs and power-operated vehicles. Final rule.

    Science.gov (United States)

    2006-04-05

    This final rule conforms our regulations to section 302(a)(2)(E)(iv) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. This rule defines the term power mobility devices (PMDs) as power wheelchairs and power operated vehicles (POVs or scooters). It sets forth revised conditions for Medicare payment of PMDs and defines who may prescribe PMDs. This rule also requires a face-to-face examination of the beneficiary by the physician or treating practitioner, a written prescription, and receipt of pertinent parts of the medical record by the supplier within 45 days after the face-to-face examination that the durable medical equipment suppliers maintain in their records and make available to CMS or its agents upon request. Finally, this rule discusses CMS' policy on documentation that may be requested by CMS or its agents to support a Medicare claim for payment, as well as the elimination of the Certificate of Medical Necessity (CMN) for PMDs.

  16. Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 1997 rates--HCFA. Final rule.

    Science.gov (United States)

    1996-08-30

    We are revising the Medicare hospital inpatient prospective payment systems for operating costs and capital-related costs to implement necessary changes arising from our continuing experience with the systems. In addition, in the addendum to this final rule, we are describing changes in the amounts and factors necessary to determine prospective payment rates for Medicare hospital inpatient services for operating costs and capital-related costs. These changes are applicable to discharges occurring on or after October 1, 1996. We are also setting forth rate-of-increase limits as well as policy changes for hospitals and hospital units excluded from the prospective payment systems.

  17. Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2018. Final rule.

    Science.gov (United States)

    2017-08-03

    This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2018 as required by the statute. As required by section 1886(j)(5) of the Social Security Act (the Act), this rule includes the classification and weighting factors for the IRF prospective payment system's (IRF PPS) case-mix groups and a description of the methodologies and data used in computing the prospective payment rates for FY 2018. This final rule also revises the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnosis codes that are used to determine presumptive compliance under the "60 percent rule," removes the 25 percent payment penalty for inpatient rehabilitation facility patient assessment instrument (IRF-PAI) late transmissions, removes the voluntary swallowing status item (Item 27) from the IRF-PAI, summarizes comments regarding the criteria used to classify facilities for payment under the IRF PPS, provides for a subregulatory process for certain annual updates to the presumptive methodology diagnosis code lists, adopts the use of height/weight items on the IRF-PAI to determine patient body mass index (BMI) greater than 50 for cases of single-joint replacement under the presumptive methodology, and revises and updates measures and reporting requirements under the IRF quality reporting program (QRP).

  18. Medicare Program; physician performance standard rates of increase for fiscal year 1994 and physician fee schedule update for calendar year 1994--HCFA. Correction of final notice with comment period.

    Science.gov (United States)

    1994-06-01

    This document corrects an error that occurred in the calculation of the fiscal year 1994 Medicare volume performance standard for surgical services and that appeared in the final notice with comment period published in the Federal Register on December 2, 1993 (58 FR 63856) entitled "Medicare Program; Physician Performance Standard Rates of Increase for Fiscal Year 1994 and Physician Fee Schedule Update for Calendar Year 1994." This notice also corrects a typographical error in a date.

  19. 75 FR 21175 - Medicare and Medicaid Programs; Waiver of Disapproval of Nurse Aide Training Program in Certain...

    Science.gov (United States)

    2010-04-23

    ... that facility-based nurse aide training could be offered either by the facility or in the facility by... training and have the State or a State-approved entity administer the nurse aide competency evaluation program, or it can offer the entire nurse aide training and competency evaluation program through...

  20. Medicare Care Choices Model Enables Concurrent Palliative and Curative Care.

    Science.gov (United States)

    2015-01-01

    On July 20, 2015, the federal Centers for Medicare & Medicaid Services (CMS) announced hospices that have been selected to participate in the Medicare Care Choices Model. Fewer than half of the Medicare beneficiaries use hospice care for which they are eligible. Current Medicare regulations preclude concurrent palliative and curative care. Under the Medicare Choices Model, dually eligible Medicare beneficiaries may elect to receive supportive care services typically provided by hospice while continuing to receive curative services. This report describes how CMS has expanded the model from an originally anticipated 30 Medicare-certified hospices to over 140 Medicare-certified hospices and extended the duration of the model from 3 to 5 years. Medicare-certified hospice programs that will participate in the model are listed.

  1. 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.

    Science.gov (United States)

    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

  2. 75 FR 58411 - Medicare Program; Town Hall Meeting on the Physician Compare Web Site, October 27, 2010

    Science.gov (United States)

    2010-09-24

    ... Physician Compare Web Site, October 27, 2010 AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice of meeting. SUMMARY: Section 10331 of the Patient Protection and Affordable Care Act of 2010, ``Public Reporting of Performance Information'' requires CMS to establish a Physician Compare...

  3. 76 FR 40497 - Medicare Program; Changes to the End-Stage Renal Disease Prospective Payment System for CY 2012...

    Science.gov (United States)

    2011-07-08

    ... Areas With No Hospital Data c. Proposed Wage Index Budget-Neutrality Adjustment d. ESRD PPS Wage Index... QIP i. Proposed Anemia Management Measure (Hemoglobin Greater Than 12g/dL) ii. Proposed Kt/V Dialysis... Infections CFR Code of Federal Regulations CIP Core Indicators Project CMS Centers for Medicare & Medicaid...

  4. 76 FR 17870 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-October Through December 2010

    Science.gov (United States)

    2011-03-31

    ... Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndrome (MDS) use CMS-Pub. 100... American College of Surgeons (ACS) as a Level 1 Bariatric Surgery Center (program standards and... surgery and have been certified by American College of Surgeons (ACS) or American Society for Metabolic...

  5. Use of Medicare's Diabetes Self-Management Training Benefit

    Science.gov (United States)

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

    2015-01-01

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

  6. Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 1999 rates--HCFA. Final rule.

    Science.gov (United States)

    1998-07-31

    We are revising the Medicare hospital inpatient prospective payment systems for operating costs and capital-related costs to implement applicable statutory requirements, including section 4407 of the Balanced Budget Act of 1997 (BBA), as well as changes arising from our continuing experience with the systems. In addition, in the addendum to this final rule, we describe changes in the amounts and factors necessary to determine rates for Medicare hospital inpatient services for operating costs and capital-related costs. These changes are applicable to discharges occurring on or after October 1, 1998. We also set forth rate-of-increase limits as well as changes for hospitals and hospital units excluded from the prospective payment systems. Finally, we are implementing the provisions of section 4625 of the BBA concerning payment for the direct costs of graduate medical education.

  7. Medicare Cost Reports

    Data.gov (United States)

    U.S. Department of Health & Human Services — Medicare certified institutional providers are required to submit an annual cost report to a Medicare Administrative Contractor. The cost report contains provider...

  8. Medicare Current Beneficiary Survey

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Characteristics and Perceptions of the Medicare Population Data from the 2010 Medicare Current Beneficiary Survey is a series of source books based on the...

  9. Medicare Prescription Drug Coverage - General Information

    Data.gov (United States)

    U.S. Department of Health & Human Services — The MMA legislation provides seniors and people with disabilities with the first comprehensive prescription drug benefit ever offered under the Medicare program, the...

  10. Monitoring outcomes for the Medicare Advantage program: methods and application of the VR-12 for evaluation of plans.

    Science.gov (United States)

    Kazis, Lewis E; Selim, Alfredo J; Rogers, William; Qian, Shirley X; Brazier, John

    2012-01-01

    The Veterans RAND 12-Item Health Survey (VR-12) is one of the major patient-reported outcomes for ranking the Medicare Advantage (MA) plans in the Health Outcomes Survey (HOS). Approaches for scoring physical and mental health are given using contemporary norms and regression estimators. A new metric approach for the VR-12 called the "VR-6D" is presented with case-mix adjustments for monitoring plans that combine utilities and mortality. Results show that the models for ranking health outcomes of the plans are robust and credible. Future directions include the use of utilities for evaluating and ranking of MA plans.

  11. Medicare program; physician fee schedule update for calendar year 1997 and physician volume performance standard rates of increase for Federal fiscal year 1997--HCFA. Final notice.

    Science.gov (United States)

    1996-11-22

    This final notice announces the calendar year 1997 updates to the Medicare physician fee schedule and the Federal fiscal year 1997 volume performance standard rates of increase for expenditures for physicians' services under the Medicare Supplementary Medical Insurance (Part B) program as required by sections 1848 (d) and, (f), respectively, of the Social Security Act. The fee schedule updates for calendar year 1997 are 1.9 percent for surgical services, 2.5 percent for primary care services, and -0.8 percent for other nonsurgical services. While it does not affect payment for any particular service, there was a 0.6 percent increase in the update for all physicians' services for 1997. The physician volume performance standard rates of increase for Federal fiscal year 1997 are -3.7 percent for surgical services, 4.5 percent for primary care services, -0.5 percent for other nonsurgical services, and a weighted average of -0.3 percent for all physicians' services.

  12. Medicare and Medicaid Programs; CY 2016 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements. Final rule.

    Science.gov (United States)

    2015-11-01

    This final rule will update Home Health Prospective Payment System (HH PPS) rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor under the Medicare prospective payment system for home health agencies (HHAs), effective for episodes ending on or after January 1, 2016. As required by the Affordable Care Act, this rule implements the 3rd year of the 4-year phase-in of the rebasing adjustments to the HH PPS payment rates. This rule updates the HH PPS case-mix weights using the most current, complete data available at the time of rulemaking and provides a clarification regarding the use of the "initial encounter'' seventh character applicable to certain ICD-10-CM code categories. This final rule will also finalize reductions to the national, standardized 60-day episode payment rate in CY 2016, CY 2017, and CY 2018 of 0.97 percent in each year to account for estimated case-mix growth unrelated to increases in patient acuity (nominal case-mix growth) between CY 2012 and CY 2014. In addition, this rule implements a HH value-based purchasing (HHVBP) model, beginning January 1, 2016, in which all Medicare-certified HHAs in selected states will be required to participate. Finally, this rule finalizes minor changes to the home health quality reporting program and minor technical regulations text changes.

  13. Medicare and Graduate Medical Education.

    Science.gov (United States)

    1995-09-01

    cost were adapted by the Congressional Budget Office (CBO) from Monica Noether , "The Growing Supply of Physicians: Has the Market Become More...spurred by the introduc- tion and expansion of the Medicaid and Medicare programs (and precursors of those programs), which 16. See Monica Noether ...competitive (see Monica Noether , "The Growing Supply of Physicians: Has the Market Be- come More Competitive?"./«?«/-««/ of Labor Economics vol. 4

  14. Medicare Payment Systems: A Look Back and a Look Forward.

    Science.gov (United States)

    Schaum, Kathleen Dianne

    2013-12-01

    Medicare is the major payer for patients with chronic wounds. Over the past 50 years, the Medicare payment systems have undergone numerous changes. At the beginning of the Medicare program, providers were paid based on fee-for-service. In 1997, many of the Medicare payment systems were converted to prospective payment systems (PPSs). Currently, Medicare is conducting many demonstration payment programs to provide the best quality outcomes, at the lowest total cost of care (not necessarily the lowest cost product or procedure), and with patient satisfaction. While the demonstration payment programs are being tested, providers may receive parallel Medicare payments: payment through current PPS and through the demonstration payment program. Wound care providers and manufacturers need to prepare now for the future payment systems.

  15. Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 1998 rates--HCFA. Final rule.

    Science.gov (United States)

    1998-05-12

    This final rule responds to public comments received on those portions of a final rule with comment period published in the Federal Register on August 29, 1997, that revised the Medicare hospital inpatient prospective payment systems for operating costs and capital-related costs to implement necessary changes resulting from the Balanced Budget Act (BBA) of 1997, Public Law 105-33. This rule also addresses public comments on other BBA changes relating to cost limits for hospitals and hospital units excluded from the prospective payment systems as well as direct graduate medical education payments that were included in the August 29, 1997 document. Generally, these BBA changes were applicable to hospital discharges occurring on or after October 1, 1997.

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

    Science.gov (United States)

    2017-07-28

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

  17. Rethinking Medicare reform.

    Science.gov (United States)

    Marmor, T; Oberlander, J

    1998-01-01

    Many health policy analysts argue that demographic pressures, the inflationary nature of fee-for-service payment, and the uncontrollable nature of defined-benefit insurance make Medicare unsustainable in its current form. They assert that Medicare can remain fiscally viable in the next century only by embracing a voucher system and exposing beneficiaries to the economic consequences of their medical care decisions. We argue here, however, that Medicare need not rely on vouchers or on placing financial incentives on individual beneficiaries to control costs. Instead, we contend that Medicare can control expenditures the way most other industrial democracies do: through budgetary caps and centralized regulation of provider payments.

  18. Medicare Modernization Act (MMA) IRS Medicare Part D

    Data.gov (United States)

    Social Security Administration — SSA uses the Internal Revenue Service (IRS) information in determing the eligibility of Medicare recipients to receive subsidy payments for Medicare premiums. SSA...

  19. Medicare Special Needs Plan (SNP)

    Science.gov (United States)

    ... get about Medicare Lost/incorrect Medicare card Report fraud & abuse File a complaint Identity theft: protect yourself ... Medicare Covers Drug Coverage (Part D) Supplements & Other Insurance Claims & Appeals Manage Your Health Forms, Help & Resources ...

  20. Medicare Preventive and Screening Services

    Science.gov (United States)

    ... get about Medicare Lost/incorrect Medicare card Report fraud & abuse File a complaint Identity theft: protect yourself ... often is it covered? Medicare Part B (Medical Insurance) covers: Abdominal aortic aneurysm screening Alcohol misuse screenings & ...

  1. A simple change to the Medicare Part D low-income subsidy program could save $5 billion.

    Science.gov (United States)

    Zhang, Yuting; Zhou, Chao; Baik, Seo Hyon

    2014-06-01

    Medicare Part D provides a subsidy to beneficiaries with incomes below 150 percent of the federal poverty level. Enrollees with the low-income subsidy accounted for 75 percent of the $60 billion in total federal Part D spending in 2013. The government randomly assigns any new beneficiary who automatically qualifies for the subsidy, or who successfully applies for it without indicating a preferred plan, to a stand-alone Part D plan whose premium is equal to or below the average premium for the basic Part D benefit in the region. We used an intelligent reassignment algorithm and 2008-09 Part D drug use and spending data to match enrollees to available plans according to their medication needs. We found that such a reassignment approach could have saved the federal government over $5 billion in 2009, for mean government savings of $710 (median: $368) per enrollee with a low-income subsidy. Implementing that simple change to reassign beneficiaries would have also lowered the proportion of prescriptions that required utilization review from 29 percent to 20 percent, and the proportion of prescriptions with quantity limits from 27 percent to 19 percent. Project HOPE—The People-to-People Health Foundation, Inc.

  2. Medicare program; replacement of reasonable charge methodology by fee schedules for parenteral and enteral nutrients, equipment, and supplies. Final rule.

    Science.gov (United States)

    2001-08-28

    This final rule implements fee schedules for payment of parenteral and enteral nutrition (PEN) items and services furnished under the prosthetic device benefit, defined in section 1861(s)(8) of the Social Security Act. The authority for establishing these fee schedules is provided by the Balanced Budget Act of 1997, which amended the Social Security Act at section 1842(s). Section 1842(s) of the Social Security Act specifies that statewide or other area wide fee schedules may be implemented for the following items and services still subject to the reasonable charge payment methodology: medical supplies; home dialysis supplies and equipment; therapeutic shoes; parenteral and enteral nutrients, equipment, and supplies; electromyogram devices; salivation devices; blood products; and transfusion medicine. This final rule describes changes made to the proposed fee schedule payment methodology for these items and services and provides that the fee schedules for PEN items and services are effective for all covered items and services furnished on or after January 1, 2002. Fee schedules will not be implemented for electromyogram devices and salivation devices at this time since these items are not covered by Medicare. In addition, fee schedules will not be implemented for medical supplies, home dialysis supplies and equipment, therapeutic shoes, blood products, and transfusion medicine at this time since the data required to establish these fee schedules are inadequate.

  3. Pre-Medicare Eligible Individuals’ Decision-Making In Medicare Part D: An Interview Study

    Directory of Open Access Journals (Sweden)

    Tao Jin, B.S. Pharm, Ph.D. Candidate

    2010-01-01

    Full Text Available ObjectivesThe objective of this study was to elicit salient beliefs among pre-Medicare eligible individuals regarding (1 the outcomes associated with enrolling in the Medicare Part D program; (2 those referents who might influence participants’ decisions about enrolling in the Part D program; and (3 the perceived barriers and facilitators facing those considering enrolling in the Part D program.MethodsFocused interviews were used for collecting data. A sample of 10 persons between 62 and 64 years of age not otherwise enrolled in the Medicare program was recruited. Interviews were audio taped and field notes were taken concurrently. Audio recordings were reviewed to amend field notes until obtaining a thorough reflection of interviews. Field notes were analyzed to elicit a group of beliefs, which were coded into perceived outcomes, the relevant others who might influence Medicare Part D enrollment decisions and perceived facilitators and impediments. By extracting those most frequently mentioned beliefs, modal salient sets of behavioral beliefs, relevant referents, and control beliefs were identified.ResultsAnalyses showed that (1 most pre-Medicare eligible believed that Medicare Part D could “provide drug coverage”, “save money on medications”, and “provide financial and health security in later life”. However, “monthly premiums”, “the formulary with limited drug coverage” and “the complexity of Medicare Part D” were perceived as major disadvantages; (2 immediate family members are most likely to influence pre-Medicare eligible’s decisions about Medicare Part D enrollment; and (3 internet and mailing educational brochures are considered to be most useful resources for Medicare Part D enrollment. Major barriers to enrollment included the complexity and inadequacy of insurance plan information.ConclusionThere are multiple factors related to decision-making surrounding the Medicare Part D enrollment. These factors

  4. 42 CFR 422.108 - Medicare secondary payer (MSP) procedures.

    Science.gov (United States)

    2010-10-01

    ... SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Benefits and Beneficiary Protections § 422... enrollees with the benefits of the primary payers, including reporting, on an ongoing basis, information... instructions. (c) Collecting from other entities. The MA organization may bill, or authorize a provider to...

  5. What Medicare Covers

    Science.gov (United States)

    ... What Part A covers Medicare Part A hospital insurance covers inpatient hospital care, skilled nursing facility, hospice, lab tests, surgery, ... Medicare Covers Drug Coverage (Part D) Supplements & Other Insurance Claims & ... doctors, providers, hospitals & plans Where can I get covered medical items? ...

  6. Medicare and Rural Health

    Science.gov (United States)

    ... 1.9 million rural beneficiaries participated in Medicare Advantage (MA) and other prepaid plans, accounting for 13.4% of MA enrollees. While rural participation is not proportionate to urban participation, strong rural enrollment in ... Medicare Advantage – The ACA reduces the payments to companies providing ...

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

    Science.gov (United States)

    2016-08-22

    We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2017. Some of these changes will implement certain statutory provisions contained in the Pathway for Sustainable Growth Reform Act of 2013, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Notice of Observation Treatment and Implications for Care Eligibility Act of 2015, and other legislation. We also are providing the estimated market basket update to apply to the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2017. We are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2017. In addition, we are making changes relating to direct graduate medical education (GME) and indirect medical education payments; establishing new requirements or revising existing requirements for quality reporting by specific Medicare providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities), including related provisions for eligible hospitals and critical access hospitals (CAHs) participating in the Electronic Health Record Incentive Program; updating policies relating to the Hospital Value-Based Purchasing Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition Reduction Program; implementing statutory provisions that require hospitals and CAHs to furnish notification to Medicare beneficiaries, including Medicare Advantage enrollees, when the beneficiaries receive outpatient observation services for more than 24 hours; announcing the implementation of the Frontier Community Health Integration Project Demonstration; and

  8. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2018 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Program Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Provider-Based Status of Indian Health Service and Tribal Facilities and Organizations; Costs Reporting and Provider Requirements; Agreement Termination Notices. Final rule.

    Science.gov (United States)

    2017-08-14

    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 2018. Some of these changes implement certain statutory provisions contained in the Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Medicare Access and CHIP Reauthorization Act of 2015, the 21st Century Cures Act, and other legislation. We also are making changes relating to the provider-based status of Indian Health Service (IHS) and Tribal facilities and organizations and to the low-volume hospital payment adjustment for hospitals operated by the IHS or a Tribe. In addition, we are providing the market basket update that will apply to the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2018. We are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2018. In addition, we are establishing new requirements or revising existing requirements for quality reporting by specific Medicare providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities). We also are establishing new requirements or revising existing requirements for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. We 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. We also are making changes relating to transparency of accrediting organization survey

  9. Effect of medicare payment on rural health care systems.

    Science.gov (United States)

    McBride, Timothy D; Mueller, Keith J

    2002-01-01

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

  10. 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.

    Science.gov (United States)

    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.

  11. Medicare: FY2009 Budget Issues

    Science.gov (United States)

    2008-02-06

    Proposals include savings achieved through reductions in many of the Medicare payment updates. The Medicare Prescription Drug, Improvement and...9 Short-Term Power Wheelchair Rentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Current Law...five- year budget window. Proposals include savings achieved through reductions in many of the Medicare payment updates. The Medicare Prescription

  12. Physician Engagement Strategies in Care Coordination: Findings from the Centers for Medicare & Medicaid Services' Health Care Innovation Awards Program.

    Science.gov (United States)

    Skillman, Megan; Cross-Barnet, Caitlin; Singer, Rachel Friedman; Ruiz, Sarah; Rotondo, Christina; Ahn, Roy; Snyder, Lynne Page; Colligan, Erin M; Giuriceo, Katherine; Moiduddin, Adil

    2017-02-01

    To identify roles physicians assumed as part of new health care delivery models and related strategies that facilitated physician engagement across 21 Health Care Innovation Award (HCIA) programs. Site-level in-depth interviews, conducted from 2014 to 2015 (N = 672) with program staff, leadership, and partners (including 95 physicians) and direct observations. NORC conducted a mixed-method evaluation, including two rounds of qualitative data collected via site visits and telephone interviews. We used qualitative thematic coding for data from 21 programs actively engaging physicians as part of HCIA interventions. Establishing physician champions and ensuring an innovation-values fit between physicians and programs, including the strategies programs employed, facilitated engagement. Among engagement practices identified in this study, tailoring team working styles to meet physician preferences and conducting physician outreach and education were the most common successful approaches. We describe engagement strategies derived from a diverse range of programs. Successful programs considered physicians' values and engagement as components of process and policy, rather than viewing them as exogenous factors affecting innovation adoption. These types of approaches enabled programs to accelerate acceptance of innovations within organizations. © Health Research and Educational Trust.

  13. Analysis Of Medicare Advantage HMOs compared with traditional Medicare shows lower use of many services during 2003-09.

    Science.gov (United States)

    Landon, Bruce E; Zaslavsky, Alan M; Saunders, Robert C; Pawlson, L Gregory; Newhouse, Joseph P; Ayanian, John Z

    2012-12-01

    Enrollment in Medicare Advantage, the managed care program for Medicare beneficiaries, has grown rapidly, from 4.6 million enrollees in 2003 to 12.8 million by 2012, or 27 percent of all current Medicare beneficiaries. We analyzed utilization patterns of enrollees in Medicare Advantage health maintenance organization (HMO) plans compared to matched samples of people in traditional Medicare during 2003-09, to ascertain whether the HMO enrollees demonstrated different levels of use of services, which can be a hallmark of more integrated care. We found that utilization rates in some major categories, including emergency departments and ambulatory surgery or procedures, generally were 20-30 percent lower in Medicare Advantage HMOs in all years. Medicare Advantage HMO enrollees initially had lower rates of ambulatory visits and hospitalizations, although these rates converged by 2008; they also received about 10 percent fewer hip or knee replacements. In contrast, HMO enrollees underwent more coronary bypass surgery than patients in traditional Medicare. These findings suggest that overall, Medicare Advantage HMO enrollees might use fewer services and be experiencing more appropriate use of services than enrollees in traditional Medicare.

  14. Medicare Data to Calculate Your Primary Service Areas

    Data.gov (United States)

    U.S. Department of Health & Human Services — The following data is being made available to applicants to the Medicare Shared Savings Program (Shared Savings Program), in order to allow them to calculate their...

  15. Medicare Program; FY 2018 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements. Final rule.

    Science.gov (United States)

    2017-08-04

    This final rule will update the hospice wage index, payment rates, and cap amount for fiscal year (FY) 2018. Additionally, this rule includes new quality measures and provides an update on the hospice quality reporting program.

  16. Medicare Hospice Data

    Data.gov (United States)

    U.S. Department of Health & Human Services — More Medicare beneficiaries are taking advantage of the quality and compassionate care provided through the hospice benefit. As greater numbers of beneficiaries have...

  17. Mapping Medicare Disparities Tool

    Data.gov (United States)

    U.S. Department of Health & Human Services — The CMS Office of Minority Health has designed an interactive map, the Mapping Medicare Disparities Tool, to identify areas of disparities between subgroups of...

  18. Medicare Enrollment Dashboard

    Data.gov (United States)

    U.S. Department of Health & Human Services — The CMS Office of Enterprise Data and Analytics has developed a new interactive Medicare Enrollment Dashboard, which provides current information on the number of...

  19. Medicare Coverage Database

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Medicare Coverage Database (MCD) contains all National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), local articles, and proposed NCD...

  20. 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.

    Science.gov (United States)

    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.

  1. Medicare program; revisions to the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) supplier safeguards. Final rule.

    Science.gov (United States)

    2012-03-14

    This final rule removes the definition of "direct solicitation'' and allows DMEPOS suppliers, including DMEPOS competitive bidding program contract suppliers, to contract with licensed agents to provide DMEPOS supplies, unless prohibited by State law. It also removes the requirement for compliance with local zoning laws and modifies certain State licensure requirement exceptions.

  2. 78 FR 21314 - Medicare and State Health Care Programs: Fraud and Abuse; Electronic Health Records Safe Harbor...

    Science.gov (United States)

    2013-04-10

    ... Programs: Fraud and Abuse; Electronic Health Records Safe Harbor Under the Anti-Kickback Statute AGENCY... update to the provision under which electronic health records software is deemed interoperable; removal... protect certain arrangements involving the provision of interoperable electronic health records software...

  3. 78 FR 57857 - Medicare and Medicaid Programs; Application from the Compliance Team for Initial CMS-Approval of...

    Science.gov (United States)

    2013-09-20

    ... the Compliance Team for Initial CMS-Approval of its Rural Health Clinic Accreditation Program AGENCY... below, no later than 5 p.m. on October 21, 2013. ADDRESSES: In commenting, please refer to file code CMS... Services, Attention: CMS-3287-PN, P.O. Box 8016, Baltimore, MD 21244-8010. Please allow sufficient time...

  4. 42 CFR 403.206 - General standards for Medicare supplemental policies.

    Science.gov (United States)

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false General standards for Medicare supplemental policies. 403.206 Section 403.206 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS SPECIAL PROGRAMS AND PROJECTS Medicare Supplemental...

  5. 42 CFR 420.405 - Rewards for information relating to Medicare fraud and abuse.

    Science.gov (United States)

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Rewards for information relating to Medicare fraud... Information Relating to Medicare Fraud and Abuse, and Establishment of a Program to Collect Suggestions for... information relating to Medicare fraud and abuse. (a) General rule. CMS pays a monetary reward for information...

  6. Clinical and Economic Impact of a Digital, Remotely-Delivered Intensive Behavioral Counseling Program on Medicare Beneficiaries at Risk for Diabetes and Cardiovascular Disease

    Science.gov (United States)

    Chen, Fang; Su, Wenqing; Becker, Shawn H.; Payne, Mike; Peters, Anne L.; Dall, Timothy M.

    2016-01-01

    Background Type 2 diabetes and cardiovascular disease impose substantial clinical and economic burdens for seniors (age 65 and above) and the Medicare program. Intensive Behavioral Counseling (IBC) interventions like the National Diabetes Prevention Program (NDPP), have demonstrated effectiveness in reducing excess body weight and lowering or delaying morbidity onset. This paper estimated the potential health implications and medical savings of a digital version of IBC modeled after the NDPP. Methods and Findings Participants in this digital IBC intervention, the Omada program, include 1,121 overweight or obese seniors with additional risk factors for diabetes or heart disease. Weight changes were objectively measured via participant use of a networked weight scale. Participants averaged 6.8% reduction in body weight within 26 weeks, and 89% of participants completed 9 or more of the 16 core phase lessons. We used a Markov-based microsimulation model to simulate the impact of weight loss on future health states and medical expenditures over 10 years. Cumulative per capita medical expenditure savings over 3, 5 and 10 years ranged from $1,720 to 1,770 (3 years), $3,840 to $4,240 (5 years) and $11,550 to $14,200 (10 years). The range reflects assumptions of weight re-gain similar to that seen in the DPP clinical trial (lower bound) or minimal weight re-gain aligned with age-adjusted national averages (upper bound). The estimated net economic benefit after IBC costs is $10,250 to $12,840 cumulative over 10 years. Simulation outcomes suggest reduced incidence of diabetes by 27–41% for participants with prediabetes, and stroke by approximately 15% over 5 years. Conclusions A digital, remotely-delivered IBC program can help seniors at risk for diabetes and cardiovascular disease achieve significant weight loss, reduces risk for diabetes and cardiovascular disease, and achieve meaningful medical cost savings. These findings affirm recommendations for IBC coverage by the

  7. Medicare and Medicaid programs; physicians' referrals to health care entities with which they have financial relationships. Health Care Financing Administration (HCFA), HHS. Final rule with comment period.

    Science.gov (United States)

    2001-01-04

    This final rule with 90-day comment period (Phase I of this rulemaking) incorporates into regulations the provisions in paragraphs (a), (b), and (h) of section 1877 of the Social Security Act (the Act). Under section 1877, if a physician or a member of a physician's immediate family has a financial relationship with a health care entity, the physician may not make referrals to that entity for the furnishing of designated health services (DHS) under the Medicare program, unless an exception applies. The following services are DHS: clinical laboratory services; physical therapy services; occupational therapy services; radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services; radiation therapy services and supplies; durable medical equipment and supplies; parenteral and enteral nutrients, equipment, and supplies; prosthetics, orthotics, and prosthetic devices and supplies; home health services; outpatient prescription drugs; and inpatient and outpatient hospital services. In addition, section 1877 of the Act provides that an entity may not present or cause to be presented a Medicare claim or bill to any individual, third party payer, or other entity for DHS furnished under a prohibited referral, nor may we make payment for a designated health service furnished under a prohibited referral. Paragraph (a) of section 1877 of the Act includes the general prohibition. Paragraph (b) of the Act includes exceptions that pertain to both ownership and compensation relationships, including an in-office ancillary services exception. Paragraph (h) includes definitions that are used throughout section 1877 of the Act, including the group practice definition and the definitions for each of the DHS. We intend to publish a second final rule with comment period (Phase II of this rulemaking) shortly addressing, to the extent necessary, the remaining sections of the Act. Phase II of this rulemaking will address comments

  8. Medicare Hospital Spending Per Patient - National

    Data.gov (United States)

    U.S. Department of Health & Human Services — The "Medicare hospital spending per patient (Medicare Spending per Beneficiary)" measure shows whether Medicare spends more, less or about the same per Medicare...

  9. Medicare Hospital Spending Per Patient - State

    Data.gov (United States)

    U.S. Department of Health & Human Services — The "Medicare hospital spending per patient (Medicare Spending per Beneficiary)" measure shows whether Medicare spends more, less or about the same per Medicare...

  10. Medicare Hospital Spending Per Patient - Hospital

    Data.gov (United States)

    U.S. Department of Health & Human Services — The "Medicare hospital spending per patient (Medicare Spending per Beneficiary)" measure shows whether Medicare spends more, less or about the same per Medicare...

  11. Medicare program; conditions for payment of power mobility devices, including power wheelchairs and power-operated vehicles. Interim final rule with comment period.

    Science.gov (United States)

    2005-08-26

    This interim final rule conforms our regulations to section 302(a)(2)(E)(iv) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Pub. L. 108-173). This rule defines the term power mobility devices (PMDs) as power wheelchairs and power operated vehicles (POVs or scooters). It sets forth revised conditions for Medicare payment of PMDs and defines who may prescribe PMDs. This rule also requires a face-to-face examination of the beneficiary by the physician or treating practitioner and a PMD prescription and pertinent parts of the medical record that the durable medical equipment supplier maintains in records and makes available to CMS or its agents upon request. Finally, this rule discusses CMS' policy on documentation that may be requested by CMS or its agents to support a Medicare claim for payment, as well as the elimination for the Certificate of Medical Necessity for PMDs.

  12. Medicare program: data, standards, and methodology used to establish fiscal year 1994 budgets for fiscal intermediaries and carriers--HCFA. Final notice.

    Science.gov (United States)

    1994-07-14

    This notice is published in accordance with sections 1816(c)(1) and 1842(c)(1) of the Social Security Act which require us to publish the final data, standards, and methodology used to establish budgets for Medicare intermediaries and carriers. In this notice, we respond to the comments received in response to our notice of October 5, 1993 and we announce the adoption of the proposed data, standards, and methodology that we used to establish the Medicare fiscal intermediary and carrier budgets for fiscal year (FY) 1994, beginning October 1, 1993, as final and without revision.

  13. Medicare Benefits and Your Eyes

    Science.gov (United States)

    ... Subscribe to eNews Close Donate Medicare Benefits & Your Eyes Eye Health is Important! As you age, your risk ... that you need. Ask about eye exams! Routine Eye Exams Medicare does not generally cover the costs ...

  14. Medicare Administrative Contractor Performance Evaluation

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Centers for Medicare and Medicaid Services (CMS) has compiled a summary of overall Medicare Administrative Contractor (MAC) performance information as measured...

  15. Medicare and Medicaid Linked Files

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Medicare-Medicaid Linked Enrollee Analytic Data Source (MMLEADS) has been developed to allow for the examination of all Medicare and Medicaid enrollment and...

  16. Medicare Utilization for Part B

    Data.gov (United States)

    U.S. Department of Health & Human Services — This link takes you to the Medicare utilization statistics for Part B (Supplementary Medical Insurance SMI) which includes the Medicare Part B Physician and Supplier...

  17. Medicare Utilization for Part A

    Data.gov (United States)

    U.S. Department of Health & Human Services — This link takes you to the Medicare utilization statistics for Part A (Hospital Insurance HI) which include the Medicare Ranking for all Short-Stay Hospitals by...

  18. Medicare and Medicaid Research Review

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Centers for Medicare and Medicaid Services (CMS), Office of Information Products and Data Analysis (OIPDA), is pleased to present our journal, Medicare and...

  19. Staying Healthy: Medicare's Preventive Services

    Science.gov (United States)

    ... Screening and Counseling Medicare covers one alcohol misuse screening per year for adults with Medicare (including pregnant women) to identify those ... for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are ... for sexually active adults at increased risk for STIs. Medicare will only ...

  20. Medicare Program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system changes and FY2011 rates; provider agreements and supplier approvals; and hospital conditions of participation for rehabilitation and respiratory care services; Medicaid program: accreditation for providers of inpatient psychiatric services. Final rules and interim final rule with comment period.

    Science.gov (United States)

    2010-08-16

    : 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 and to implement certain provisions of the Affordable Care Act and other legislation. In addition, we describe the changes to the amounts and factors used to determine the rates for Medicare acute care hospital inpatient services for operating costs and capital-related costs. We also are setting forth the update to the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits. We are updating the payment policy and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) and setting forth the changes to the payment rates, factors, and other payment rate policies under the LTCH PPS. In addition, we are finalizing the provisions of the August 27, 2009 interim final rule that implemented statutory provisions relating to payments to LTCHs and LTCH satellite facilities and increases in beds in existing LTCHs and LTCH satellite facilities under the LTCH PPS. We are making changes affecting the: Medicare conditions of participation for hospitals relating to the types of practitioners who may provide rehabilitation services and respiratory care services; and determination of the effective date of provider agreements and supplier approvals under Medicare. We are also setting forth provisions that offer psychiatric hospitals and hospitals with inpatient psychiatric programs increased flexibility in obtaining accreditation to participate in the Medicaid program. Psychiatric hospitals and hospitals with inpatient psychiatric programs will have the choice of undergoing a State survey or of obtaining accreditation from a national accrediting organization whose hospital accreditation

  1. Urban-Rural Differences in the Effect of a Medicare Health Promotion and Disease Self-Management Program on Physical Function and Health Care Expenditures

    Science.gov (United States)

    Meng, Hongdao; Wamsley, Brenda; Liebel, Diane; Dixon, Denise; Eggert, Gerald; Van Nostrand, Joan

    2009-01-01

    Purpose: To evaluate the impact of a multicomponent health promotion and disease self-management intervention on physical function and health care expenditures among Medicare beneficiaries. To determine if these outcomes vary by urban or rural residence. Design and Methods: We analyzed data from a 22-month randomized controlled trial of a health…

  2. Urban-Rural Differences in the Effect of a Medicare Health Promotion and Disease Self-Management Program on Physical Function and Health Care Expenditures

    Science.gov (United States)

    Meng, Hongdao; Wamsley, Brenda; Liebel, Diane; Dixon, Denise; Eggert, Gerald; Van Nostrand, Joan

    2009-01-01

    Purpose: To evaluate the impact of a multicomponent health promotion and disease self-management intervention on physical function and health care expenditures among Medicare beneficiaries. To determine if these outcomes vary by urban or rural residence. Design and Methods: We analyzed data from a 22-month randomized controlled trial of a health…

  3. Applying the 2003 Beers Update to Elderly Medicare Enr...

    Data.gov (United States)

    U.S. Department of Health & Human Services — Applying the 2003 Beers Update to Elderly Medicare Enrollees in the Part D Program Inappropriate prescribing of certain medications known as Beers drugs may be...

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

    Science.gov (United States)

    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.

  5. Medicare as insurance innovator: the case of hospice.

    Science.gov (United States)

    Taylor, Donald H

    2013-09-01

    The stylized fact is that while private insurance has tended to innovate on the benefit design side of the insurance contract, Medicare has lead innovation on the payment side. Traditional or Fee-For-Service Medicare has produced many innovations in the payment for health care services, such as Prospective Payment for hospitals, Diagnostic-Related Groups to categorize care, and the Resource-Based Relative Value System used by the program to pay physicians, while private insurance has produced a series of benefit design innovations. This story misses one important example of Medicare benefit innovation: the creation of the Medicare hospice benefit. A key question is whether Medicare can again lead a system-wide benefit design effort to improve upon current hospice and palliative care policy.

  6. How Medicare Prescription Drug Coverage Works with a Medicare Advantage Plan or Medicare Cost Plan

    Science.gov (United States)

    ... plans . Medicare drug plans are run by insurance companies and other private companies approved by Medicare. Each plan can vary in ... Plan (PDP). • Medicare HMO Plans —You must use network providers for ... or call Social Security at 1-800-772-1213. TTY users ...

  7. Health and Health Care of Medicare Beneficiaries in 2030.

    Science.gov (United States)

    Gaudette, Étienne; Tysinger, Bryan; Cassil, Alwyn; Goldman, Dana P

    2015-12-01

    On Medicare's 50th anniversary, we use the Future Elderly Model (FEM) - a microsimulation model of health and economic outcomes for older Americans - to generate a snapshot of changing Medicare demographics and spending between 2010 and 2030. During this period, the baby boomers, who began turning 65 and aging into Medicare in 2011, will drive Medicare demographic changes, swelling the estimated US population aged 65 or older from 39.7 million to 67.0 million. Among the risks for Medicare sustainability, the size of the elderly population in the future likely will have the highest impact on spending but is easiest to forecast. Population health and the proportion of the future elderly with disabilities are more uncertain, though tools such as the FEM can provide reasonable forecasts to guide policymakers. Finally, medical technology breakthroughs and their effect on longevity are most uncertain and perhaps riskiest. Policymakers will need to keep these risks in mind if Medicare is to be sustained for another 50 years. Policymakers may also want to monitor the equity of Medicare financing amid signs that the program's progressivity is declining, resulting in higher-income people benefiting relatively more from Medicare than lower-income people.

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

    Science.gov (United States)

    2016-08-03

    This document announces the extension of temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance suppliers and Medicare home health agencies (HHAs), subunits, and branch locations in specific locations within designated metropolitan areas in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey to prevent and combat fraud, waste, and abuse. It also announces the implementation of temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance suppliers and Medicare HHAs, subunits, and branch locations in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey on a statewide basis. In addition, it announces the lifting of the moratoria on all Part B emergency ground ambulance suppliers. These moratoria, and the changes described in this document, also apply to the enrollment of HHAs and non-emergency ground ambulance suppliers in Medicaid and the Children's Health Insurance Program.

  9. Predictors of regional Medicare expenditures for otolaryngology physician services.

    Science.gov (United States)

    Smith, Alden; Handorf, Elizabeth; Arjmand, Ellis; Lango, Miriam N

    2017-06-01

    To describe geographic variation in spending and evaluate regional Medicare expenditures for otolaryngologist services with population- and beneficiary-related factors, physician supply, and hospital system factors. Cross-sectional study. The average regional expenditures for otolaryngology physician services were defined as the total work relative value units (wRVUs) collected by otolaryngologists in a hospital referral region (HRR) per thousand Medicare beneficiaries in the HRR. A multivariable linear regression model tested associations with regional sociodemographics (age, sex, race, income, education), the physician and hospital bed supply, and the presence of an otolaryngology residency program. In 2012, the mean Medicare expenditure for otolaryngology provider services across HRRs was 224 wRVUs per thousand Medicare beneficiaries (standard deviation [SD] 104), ranging from 31 to 604 wRVUs per thousand Medicare beneficiaries. In 2013, the average Medicare expenditures for each HRR was highly correlated with expenditures collected in 2012 (Pearson correlation coefficient .997, P = .0001). Regional Medicare expenditures were independently and positively associated with otolaryngology, medical specialist, and hospital bed supply in the region, and were negatively associated with the supply of primary care physicians and presence of an otolaryngology residency program after adjusting for other factors. The magnitude of associations with physician supply and hospital factors was stronger than any population or Medicare beneficiary factor. Wide variations in regional Medicare expenditures for otolaryngology physician services, highly stable over 2 years, were strongly associated with regional health system factors. Changes in health policy for otolaryngology care may require coordination with other physician specialties and integrated hospital systems. NA. Laryngoscope, 127:1312-1317, 2017. © 2016 The American Laryngological, Rhinological and Otological Society

  10. Diversity in delivery: the Medicare home health benefit.

    Science.gov (United States)

    St Pierre, M

    1996-12-01

    Most home care providers know that Medicare covers home care nursing; home care aide and medical social services; physical, speech, and occupational therapy; as well as medical supplies and durable medical equipment. However, few agencies realize that they can also use dietitians and respiratory therapists to help meet their patients' needs. Also, few agencies use available resources or establish programs to deliver care to special-needs populations. Yet all of these home care services are reimbursable under the Medicare home health benefit.

  11. Examining Measures of Income and Poverty in Medicare Administrative Data.

    Science.gov (United States)

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

    2016-07-29

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

  12. Medicare Part D in 2008: rising prices and growing confusion.

    Science.gov (United States)

    Flaer, Paul J; Younis, Mustafa Z; Hussain, Ali Al Sayed; Malow, Robert M

    2008-01-01

    Medicare Part D, implemented in January 2006, has failed in the promise of inexpensive medications for all recipients, including those US citizens aged 65 years or older and the disabled. Conceived as a privatization program for a prescription drug benefit tied to Medicare, the program has brought increased costs to middle- and upper-class seniors. Seniors who are continuing users of expensive brand name or specialty drugs face significantly higher prices. Medicare D recipients must deal with capitation payments, deductibles, subsidies, drug substitutions, and extensive coverage gaps or "donut holes" in which they must pay 100 percent of their medication costs. For low-income and indigent patients, especially those with chronic diseases like HIV or cancer, the Medicare Part D program seemed beneficial. However, for such patients, there is likely to be a growing realization that the old system of receiving medications at public hospitals was less expensive than prescription coverage under Medicare Part D. At Miami's public hospital, Jackson Memorial Medical Center, low-income and indigent patients pay $5 per medication whether it is a generic, brand name, or specialty drug. Return to the public hospital pharmacy system from the neighborhood pharmacy and Medicare Part D plan can mean significant savings to low-income or indigent patients.

  13. Medicare Managed Care plan Performance, A Comparison...

    Data.gov (United States)

    U.S. Department of Health & Human Services — The study evaluates the performance of Medicare managed care, Medicare Advantage, Plans in comparison to Medicare fee-for-service Plans in three states with...

  14. Medicare program; end-stage renal disease prospective payment system, quality incentive program, and durable medical equipment, prosthetics, orthotics, and supplies.

    Science.gov (United States)

    2013-12-02

    This rule updates and makes revisions to the End-Stage Renal Disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2014. This rule also sets forth requirements for the ESRD quality incentive program (QIP), including for payment year (PY) 2016 and beyond. In addition, this rule clarifies the grandfathering provision related to the 3-year minimum lifetime requirement (MLR) for Durable Medical Equipment (DME), and provides clarification of the definition of routinely purchased DME. This rule also implements budget-neutral fee schedules for splints and casts, and intraocular lenses (IOLs) inserted in a physician's office. Finally, this rule makes a few technical amendments and corrections to existing regulations related to payment for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items and services.

  15. Medicare and Medicaid programs; CY 2015 Home Health Prospective Payment System rate update; Home Health Quality Reporting Requirements; and survey and enforcement requirements for home health agencies. Final rule.

    Science.gov (United States)

    2014-11-06

    This final rule updates Home Health Prospective Payment System (HH PPS) rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor under the Medicare prospective payment system for home health agencies (HHAs), effective for episodes ending on or after January 1, 2015. As required by the Affordable Care Act, this rule implements the second year of the four-year phase-in of the rebasing adjustments to the HH PPS payment rates. This rule provides information on our efforts to monitor the potential impacts of the rebasing adjustments and the Affordable Care Act mandated face-to-face encounter requirement. This rule also implements: Changes to simplify the face-to-face encounter regulatory requirements; changes to the HH PPS case-mix weights; changes to the home health quality reporting program requirements; changes to simplify the therapy reassessment timeframes; a revision to the Speech-Language Pathology (SLP) personnel qualifications; minor technical regulations text changes; and limitations on the reviewability of the civil monetary penalty provisions. Finally, this rule also discusses Medicare coverage of insulin injections under the HH PPS, the delay in the implementation of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), and a HH value-based purchasing (HH VBP) model.

  16. 42 CFR 136.30 - Payment to Medicare-participating hospitals for authorized Contract Health Services.

    Science.gov (United States)

    2010-10-01

    ... prospective payment system (PPS) will be based on that PPS. For example, payment for inpatient hospital services shall be made per discharge based on the applicable PPS used by the Medicare program to pay for... based on a PPS used in the Medicare program to pay for similar hospital services under 42 CFR part...

  17. Medicare Update: Annual Wellness Visit

    Science.gov (United States)

    ... and nutrition. • Review of the responses to the Health Risk Assessment Prepared by Leslie Fried, Alzheimer’s Association Medicare Advocacy Project. Rev. Feb 1, 2012 The Medicare Advocacy Project is supported by a generous grant by the Eisenberg Family Trust.

  18. Improving the design of competitive bidding in Medicare Advantage.

    Science.gov (United States)

    Cawley, John H; Whitford, Andrew B

    2007-04-01

    In 2003, Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act, which required that in 2006 the Centers for Medicare and Medicaid Services (CMS) implement a system of competitive bids to set payments for the Medicare Advantage program. Managed care plans now bid for the right to enroll Medicare beneficiaries. Data from the first year of bidding suggest that imperfect competition is limiting the success of the bidding system. This article offers suggestions to improve this system based on findings from auction theory and previous government-run auctions. In particular, CMS can benefit by adjusting its system of competitive bids in four ways: credibly committing to regulations governing bidding; limiting the scope for collusion, entry deterrence, and predatory behavior among bidders; adjusting how benchmark reimbursement rates are set; and accounting for asymmetric information among bidders.

  19. Medicare depreciation; useful life guidelines--HCFA. Proposed rule.

    Science.gov (United States)

    1982-09-30

    We are proposing to amend Medicare regulations to clarify which useful life guidelines providers of health care services may use to determine the useful life of a depreciable asset for Medicare reimbursement purposes. Current regulations state that providers must utilize HHS useful life guidelines or, if none have been published by HHS, the American Hospital Association (AHA) useful life guidelines of 1973 or IRS guidelines. We are proposing to eliminate the reference to IRS guidelines because those previously acceptable for Medicare purposes are outdated and have been made obsolete by the IRS or by statutory change. We would also delete the specific reference to the 1973 AHA guidelines. In addition, we intend this amendment to clarify that certain tax legislation on accelerated depreciation, recently passed by Congress, does not apply to the Medicare program.

  20. Center for Medicare & Medicaid Services (CMS) , Medicare Claims data

    Data.gov (United States)

    U.S. Department of Health & Human Services — 2003 forward. CMS compiles claims data for Medicare and Medicaid patients across a variety of categories and years. This includes Inpatient and Outpatient claims,...

  1. Competitive pricing and the challenge of cost control in medicare.

    Science.gov (United States)

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

    2011-08-01

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

  2. Medicare and Medicaid Statistical Supplement

    Data.gov (United States)

    U.S. Department of Health & Human Services — The CMS Office of Enterprise Data and Analytics (OEDA) produced an annual Medicare and Medicaid Statistical Supplement report providing detailed statistical...

  3. Chronic Conditions among Medicare Beneficiaries

    Data.gov (United States)

    U.S. Department of Health & Human Services — The data used in the chronic condition reports are based upon CMS administrative enrollment and claims data for Medicare beneficiaries enrolled in the...

  4. Medicare Provider Data - Hospice Providers

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Hospice Utilization and Payment Public Use File provides information on services provided to Medicare beneficiaries by hospice providers. The Hospice PUF...

  5. Dental Services Among Medicare Beneficiaries

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Medicare Current Beneficiary Survey (MCBS) has a data highlight based on the 2012 Cost and Use Research Files. This work highlights dental information collected...

  6. Medicare Hospital Spending by Claim

    Data.gov (United States)

    U.S. Department of Health & Human Services — Also known as Medicare Spending per Beneficiary (MSPB) Spending Breakdowns by Claim Type file. The data displayed here show average spending levels during...

  7. Medicare Referring Provider DMEPOS PUF

    Data.gov (United States)

    U.S. Department of Health & Human Services — This dataset, which is part of CMSs Medicare Provider Utilization and Payment Data, details information on Durable Medical Equipment, Prosthetics, Orthotics and...

  8. 42 CFR 403.804 - General rules for solicitation, application and Medicare endorsement period.

    Science.gov (United States)

    2010-10-01

    ... Medicare endorsement period. 403.804 Section 403.804 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES... Prescription Drug Discount Card and Transitional Assistance Program § 403.804 General rules for solicitation...) Eligibility to receive endorsement. Except as specified in §§ 403.814, 403.816 and 403.817, an applicant...

  9. Medicare fraud in the United States: can it ever be stopped?

    Science.gov (United States)

    Hill, Chelsea; Hunter, Alex; Johnson, Leslie; Coustasse, Alberto

    2014-01-01

    The majority of the United States health care fraud has been focused on the major public program, Medicare. The yearly financial loss from Medicare fraud has been estimated at about $54 billion. The purpose of this research study was to explore the current state of Medicare fraud in the United States, identify current policies and laws that foster Medicare fraud, and determine the financial impact of Medicare fraud. The methodology for this study was a literature review. Research was conducted using a scholarly online database search and government Web sites. The number of individuals charged with criminal fraud increased from 797 cases in fiscal year 2008 to 1430 cases in fiscal year 2011-an increase of more than 75%. According to 2010 data, of the 7848 subjects investigated for criminal fraud, 25% were medical facilities, and 16% were medical equipment suppliers. In 2009 and 2010, the Health Care Fraud and Abuse Control Program recovered approximately $25.2 million of taxpayers' money. Educating providers about the policies and laws designed to prevent fraud would help them to become partners. Many new programs and partnerships with government agencies have also been developed to combat Medicare fraud. Medicare fraud has been a persistent crime, and laws and policies alone have not been enough to control the problem. With investments in governmental partnerships and new systems, the United States can reduce Medicare fraud but probably will not stop it altogether.

  10. Ostomy Home Skills Program

    Medline Plus

    Full Text Available ... Medicare Inpatient & Outpatient Rules Physician Quality Reporting System Value-Based Payment Modifier DEA, FDA, and Medicare Part ... Records (EHR) Incentive Program Physician Quality Reporting System Value-Based Payment Modifier Quality and Resource Use Reports ...

  11. Ostomy Home Skills Program

    Medline Plus

    Full Text Available ... FAQs Features of the SSR CMS Merit-Based Incentive Payment System MOC Part 4 and Recertification SSR ... Regulatory Issues How to Avoid Medicare Penalties EHR Incentive Program Global Codes and Data Collection Medicare Inpatient & ...

  12. Ostomy Home Skills Program

    Medline Plus

    Full Text Available ... How to Avoid Medicare Penalties EHR Incentive Program Global Codes and Data Collection Medicare Inpatient & Outpatient Rules ... Legislative Action Center Leadership & Advocacy Summit Webinars Practice Management Practice Management Practice Management CPT Coding Bulletin Articles ...

  13. Ostomy Home Skills Program

    Medline Plus

    Full Text Available ... How to Avoid Medicare Penalties EHR Incentive Program Global Codes and Data Collection New Medicare Card Project ... Legislative Action Center Leadership & Advocacy Summit Webinars Practice Management Practice Management Practice Management CPT Coding Bulletin Articles ...

  14. Ostomy Home Skills Program

    Medline Plus

    Full Text Available ... How to Avoid Medicare Penalties EHR Incentive Program Global Codes and Data Collection Medicare Inpatient & Outpatient Rules ... Liability Surgeons as Advocates Surgeons and Bundled Payment Models Surgeons as Institutional Employees Our Changing Health Care ...

  15. Ostomy Home Skills Program

    Medline Plus

    Full Text Available ... How to Avoid Medicare Penalties EHR Incentive Program Global Codes and Data Collection Medicare Inpatient & Outpatient Rules ... ACS Catalog About the ACS Catalog Find a Product Contribute Education Journal of the American College of ...

  16. Analytic dimensions of a prescription-medication benefit in medicare.

    Science.gov (United States)

    Vogel, R J; Cox, E R

    2000-04-01

    Many analysts believe that the lack of coverage for outpatient prescription medications represents a conspicuous deficiency in the Medicare benefits package. This paper uses insurance theory to design and estimate the costs of a Medicare catastrophic-medication outpatient benefit. For efficiency and equity purposes, and to accommodate the tradeoff between the cost to the federal government and the insurance value of such a benefit to Medicare enrollees, we favor a benefit that would be means-tested by employing deductibles, coinsurance rates, and catastrophic limits, all of which would be progressively graduated for 7 household income classes. For equity reasons, we propose that the government's share of the medication benefit be financed from the general tax fund, using the progressive income tax. Another source of potential savings within the Medicare program that could pay for a medication benefit would be elimination of fraud, waste, and abuse. Because our proposal addresses both the efficiency and equity dimensions of a Medicare outpatient medication benefit, we believe it is worthy of serious consideration by both policymakers and Congress.

  17. Beneficiary Activation in the Medicare Population

    Data.gov (United States)

    U.S. Department of Health & Human Services — According to findings reported in Beneficiary Activation in the Medicare Population, published in Volume 4, Issue 4 of the Medicare and Medicaid Research Review,...

  18. Measuring Coding Intensity in Medicare Advantage - SUPP.

    Data.gov (United States)

    U.S. Department of Health & Human Services — In 2004, Medicare implemented a risk-adjustment system that pays Medicare Advantage (MA) plans based on diagnoses reported for their enrollees, giving the plans an...

  19. Measuring Coding Intensity in Medicare Advantage - SUPP.

    Data.gov (United States)

    U.S. Department of Health & Human Services — In 2004, Medicare implemented a risk-adjustment system that pays Medicare Advantage (MA) plans based on diagnoses reported for their enrollees, giving the plans an...

  20. Assessing Measurement Error in Medicare Coverage

    Data.gov (United States)

    U.S. Department of Health & Human Services — Assessing Measurement Error in Medicare Coverage From the National Health Interview Survey Using linked administrative data, to validate Medicare coverage estimates...

  1. Medicares Hospice Benefit - Analysis of Utilization and..

    Data.gov (United States)

    U.S. Department of Health & Human Services — Descriptive analyses reported in Medicares Hospice Benefit - Analysis of Utilization and Resource Use, published in Volume 4, Issue 3 of the Medicare and Medicaid...

  2. Medicares Physician Quality Reporting System (PQRS)...

    Data.gov (United States)

    U.S. Department of Health & Human Services — Medicares Physician Quality Reporting System (PQRS) allows providers to report measures of process quality and health outcomes. The authors of Medicares Physician...

  3. Identifiable Data Files - Medicare Provider Analysis and ...

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Medicare Provider Analysis and Review (MEDPAR) File contains data from claims for services provided to beneficiaries admitted to Medicare certified inpatient...

  4. Assessing Measurement Error in Medicare Coverage

    Data.gov (United States)

    U.S. Department of Health & Human Services — Assessing Measurement Error in Medicare Coverage From the National Health Interview Survey Using linked administrative data, to validate Medicare coverage estimates...

  5. Beneficiary Activation in the Medicare Population

    Data.gov (United States)

    U.S. Department of Health & Human Services — According to findings reported in Beneficiary Activation in the Medicare Population, published in Volume 4, Issue 4 of the Medicare and Medicaid Research Review,...

  6. Medicare Current Beneficiary Survey - Limited Data Set

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Medicare Current Beneficiary Survey (MCBS) is a continuous, multipurpose survey of a representative national sample of the Medicare population. There are two...

  7. Medicare Physician and Other Supplier Interactive Dataset

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Centers for Medicare and Medicaid Services (CMS) has prepared a public data set, the Medicare Provider Utilization and Payment Data - Physician and Other...

  8. The impact of weight loss among seniors on Medicare spending.

    Science.gov (United States)

    Thorpe, Kenneth E; Yang, Zhou; Long, Kathleen M; Garvey, W Timothy

    2013-03-20

    To examine the impact of temporary and permanent weight loss of 10% and 15% on 10-year and lifetime Medicare spending among adults with overweight and obesity aged 65 years and older. Weight loss of this magnitude is consistent with next generation anti-obesity medications recently approved by the Food and Drug Administration. We follow the approach of a longitudinal dynamic aging process model developed by our research team. This model considers the dynamic relationships between weight, chronic disease, acute medical events, functional status, mortality, health care utilization and spending among Medicare beneficiaries from age 65 until death. Using this model, we estimate baseline Medicare spending over the next decade and then over the lifetime of seniors with a body mass index (BMI) ≥ 27 with at least one weight-related comorbidity (overweight), and seniors with obesity having a BMI ≥ 30 and ≥ 35. We then estimate Medicare spending for this population between ages 65 and 70 over the course of a year, assuming 10% and 15% weight loss under alternative scenarios: with and without weight regain. (Weight regain is assumed to be 90% over a 10-year period.) The difference in spending between baseline (no weight-loss intervention) and the alternative scenarios represent potential gross savings to the Medicare program. Permanent weight loss of 10 to 15% will yield $9,445 to $15,987 in gross per capita savings throughout their lifetime, and $8,070 to $13,474 over ten years. Similarly, initial weight loss of 10 to 15% followed by 90% weight regain will result in gross per capita savings of $7,556 to $11,109 over their lifetime, and $6,456 to $8,911 over ten years. Targeting weight loss medications to adults with obesity (BMI ≥ 30) produces greater savings to the Medicare program. Medicare can realize significant cost savings through anti-obesity medications that produce substantial weight loss, and as a result, reduce the progression to type 2 diabetes, and

  9. Medicare's risk-adjusted capitation method.

    Science.gov (United States)

    Grimaldi, Paul L

    2002-01-01

    Since 1997, the method to establish capitation rates for Medicare beneficiaries who are members of risk-bearing managed care plans has undergone several important developments. This includes the factoring of beneficiary health status into the rate-setting calculations. These changes were expected to increase the number of participating health plans, accelerate Medicare enrollment growth, and slice Medicare spending.

  10. The Star Rating System and Medicare Advantage Plans.

    Science.gov (United States)

    Sprague, Lisa

    2015-05-05

    With nearly 30 percent of Medicare beneficiaries opting to enroll in Medicare Advantage (MA) plans instead of fee-for-service Medicare, it's safe to say the MA program is quite popular. The Centers for Medicare & Medicaid Services (CMS) administers a Star Ratings program for MA plans, which offers measures of quality and service among the plans that are used not only to help beneficiaries choose plans but also to award additional payments to plans that meet high standards. These additional payments, in turn, are used by plans to provide additional benefits to beneficiaries or to reduce cost sharing--added features that are likely to factor into beneficiaries' choice of MA plans. The Star Ratings program is also meant to drive improvements in the quality of plans, and this secondary effort seems to have been successful. Despite this success, issues with the Star Ratings system remain, including: how performance metrics are developed, chosen, and maintained; how differences among beneficiary populations (particularly with regard to the dually eligible and those receiving low-income subsidies) should be recognized; and the extent to which health plans can control the variables on which they are being measured. Because the Star Ratings approach has been extended to providers of health care as well--hospitals, nursing homes, and dialysis facilities--these issues are worth exploring as CMS fine-tunes its methods of measurement.

  11. Trends in readmission rates for safety net hospitals and non-safety net hospitals in the era of the US Hospital Readmission Reduction Program: a retrospective time series analysis using Medicare administrative claims data from 2008 to 2015

    Science.gov (United States)

    Salerno, Amy M; Horwitz, Leora I; Kwon, Ji Young; Herrin, Jeph; Grady, Jacqueline N; Lin, Zhenqiu; Ross, Joseph S; Bernheim, Susannah M

    2017-01-01

    Objective To compare trends in readmission rates among safety net and non-safety net hospitals under the US Hospital Readmission Reduction Program (HRRP). Design A retrospective time series analysis using Medicare administrative claims data from January 2008 to June 2015. Setting We examined 3254 US hospitals eligible for penalties under the HRRP, categorised as safety net or non-safety net hospitals based on the hospital’s proportion of patients with low socioeconomic status. Participants Admissions for Medicare fee-for-service patients, age ≥65 years, discharged alive, who had a valid five-digit zip code and did not have a principal discharge diagnosis of cancer or psychiatric illness were included, for a total of 52 516 213 index admissions. Primary and secondary outcome measures Mean hospital-level, all-condition, 30-day risk-adjusted standardised unplanned readmission rate, measured quarterly, along with quarterly rate of change, and an interrupted time series examining: April–June 2010, after HRRP was passed, and October–December 2012, after HRRP penalties were implemented. Results 58.0% (SD 15.3) of safety net hospitals and 17.1% (SD 10.4) of non-safety net hospitals’ patients were in the lowest quartile of socioeconomic status. The mean safety net hospital standardised readmission rate declined from 17.0% (SD 3.7) to 13.6% (SD 3.6), whereas the mean non-safety net hospital declined from 15.4% (SD 3.0) to 12.7% (SD 2.5). The absolute difference in rates between safety net and non-safety net hospitals declined from 1.6% (95% CI 1.3 to 1.9) to 0.9% (0.7 to 1.2). The quarterly decline in standardised readmission rates was 0.03 percentage points (95% CI 0.03 to 0.02, phospitals over the entire study period, and no differential change among safety net and non-safety net hospitals was found after either HRRP was passed or penalties enacted. Conclusions Since HRRP was passed and penalties implemented, readmission rates for safety net hospitals have

  12. The Relationship between Physician Compensation Strategies and the Intensity of Care Delivered to Medicare Beneficiaries

    National Research Council Canada - National Science Library

    Landon, Bruce E; Reschovsky, James D; O'Malley, A. James; Pham, Hoangmai H; Hadley, Jack

    2011-01-01

    .... Data Sources/Study Setting. We combined data from the 2004 to 2005 Community Tracking Study Physician Survey on PCP compensation methods with administrative data from the Medicare program for beneficiaries to whom...

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

    Science.gov (United States)

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

    2013-12-01

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

  14. Use of pharmacists or pharmacies as Medicare Part D information sources.

    Science.gov (United States)

    Kennelty, Korey A; Thorpe, Joshua M; Chewning, Betty; Mott, David A

    2012-01-01

    To characterize beneficiaries who used a pharmacy or pharmacist as a Medicare Part D information source. This cross-sectional descriptive study involved 4,724 Medicare Part D beneficiaries who graduated from Wisconsin high schools in 1957. The main outcome measure was beneficiary self-reported use of a pharmacy or pharmacist as a Medicare Part D information source. Only 13% of the total sample and 15% of those with three or more medications used a pharmacy or pharmacist for Medicare Part D information. Adjusted logistic regression revealed that beneficiaries living in rural communities, compared with metropolitan areas, and with higher out-of-pocket prescription costs were more likely to use a pharmacy or pharmacist for Medicare Part D information. Beneficiaries with lower educational attainment were less likely to use a pharmacy or pharmacist for Medicare Part D information. Pharmacists have the knowledge and are in the position in the community to effectively educate beneficiaries about the Medicare Part D program. However, this study suggests that few beneficiaries are using pharmacists or pharmacies for Medicare Part D information.

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

    Science.gov (United States)

    Kelly, Andrew S

    2016-06-01

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

  16. Prevalence of multiple chronic conditions in the United States' Medicare population

    Directory of Open Access Journals (Sweden)

    Dean Debbie

    2009-09-01

    Full Text Available Abstract In 2006, the Centers for Medicare & Medicaid Services, which administers the Medicare program in the United States, launched the Chronic Condition Data Warehouse (CCW. The CCW contains all Medicare fee-for-service (FFS institutional and non-institutional claims, nursing home and home health assessment data, and enrollment/eligibility information from January 1, 1999 forward for a random 5% sample of Medicare beneficiaries (and 100% of the Medicare population from 2000 forward. Twenty-one predefined chronic condition indicator variables are coded within the CCW, to facilitate research on chronic conditions. The current article describes this new data source, and the authors demonstrate the utility of the CCW in describing the extent of chronic disease among Medicare beneficiaries. Medicare claims were analyzed to determine the prevalence, utilization, and Medicare program costs for some common and high cost chronic conditions in the Medicare FFS population in 2005. Chronic conditions explored include diabetes, chronic obstructive pulmonary disease (COPD, heart failure, cancer, chronic kidney disease (CKD, and depression. Fifty percent of Medicare FFS beneficiaries were receiving care for one or more of these chronic conditions. The highest prevalence is observed for diabetes, with nearly one-fourth of the Medicare FFS study cohort receiving treatment for this condition (24.3 percent. The annual number of inpatient days during 2005 is highest for CKD (9.51 days and COPD (8.18 days. As the number of chronic conditions increases, the average per beneficiary Medicare payment amount increases dramatically. The annual Medicare payment amounts for a beneficiary with only one of the chronic conditions is $7,172. For those with two conditions, payment jumps to $14,931, and for those with three or more conditions, the annual Medicare payments per beneficiary is $32,498. The CCW data files have tremendous value for health services research. The

  17. Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2017, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and SNF Payment Models Research. Final rule.

    Science.gov (United States)

    2016-08-01

    This final rule updates the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2017. In addition, it specifies a potentially preventable readmission measure for the Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP), and implements requirements for that program, including performance standards, a scoring methodology, and a review and correction process for performance information to be made public, aimed at implementing value-based purchasing for SNFs. Additionally, this final rule includes additional polices and measures in the Skilled Nursing Facility Quality Reporting Program (SNF QRP). This final rule also responds to comments on the SNF Payment Models Research (PMR) project.

  18. Variation in Screening Mammography Rates Among Medicare Advantage Plans.

    Science.gov (United States)

    Rosenkrantz, Andrew B; Fleming, Margaret; Duszak, Richard

    2017-08-01

    Prior studies have shown higher screening mammography rates for beneficiaries in capitated managed care Medicare Advantage (MA) plans compared with traditional fee-for-service Medicare. The aim of this study was to explore variation in screening mammography rates at the level of MA managed care plans. Using the 2016 MA Healthcare Effectiveness Data and Information Set Public Use File, screening mammography rates were identified for all 385 reporting MA plans. Associations were explored with a range of plan characteristics from this file, as well as from the CMS Part C and Part D Medicare Star Ratings Data File, Medicare Advantage Plan Directory, and Medicare Monthly Enrollment by Plan File. Overall MA plan screening rates were high (mean, 72.6 ± 9.4%) but varied substantially among plans (range, 14.3%-91.8%). Screening rates were higher in nonprofit versus for-profit plans (77.3% versus 71.8%, P plans versus private fee-for-service or regional preferred provider organization plans (71.9%-73.2% versus 65.5%-66.8%, P = .001). Among parent organizations with five or more plans, screening rates were highest for Kaiser Foundation (median, 88.4%) and lowest for Molina Healthcare (median, 65.3%). Screening rates showed small but significant associations with plans' contract lengths, enrolled populations, and counties served. Screening rates showed strong associations (r = 0.796-0.798) with colorectal cancer screening and annual flu vaccine rates and showed moderate associations (r = 0.283-0.365) with ambulatory and preventive care visits, osteoporosis screenings, body mass index assessments, and nonrecommended prostate-specific antigen screenings after age 70. Screening mammography rates vary considerably among MA plans. With increased federal interest in promoting the MA program, enhanced transparency will be necessary to ensure appropriate Medicare beneficiary participation decision making. Copyright © 2017 American College of Radiology. Published by Elsevier Inc

  19. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2013 rates; hospitals' resident caps for graduate medical education payment purposes; quality reporting requirements for specific providers and for ambulatory surgical centers. final rule.

    Science.gov (United States)

    2012-08-31

    (ASCs) that are participating in Medicare. We are establishing requirements for the Hospital Value-Based Purchasing (VBP) Program and the Hospital Readmissions Reduction Program.

  20. 75 FR 32858 - Medicare Program; Policy and Technical Changes to the Medicare Advantage and the Medicare...

    Science.gov (United States)

    2010-06-10

    ... Drug Administration's most recent publication of ``Approved Drug Products with Therapeutic Equivalence... with the Department of Health and Human Services Guidelines for the Use of Antiretroviral Agents in HIV...

  1. 76 FR 63017 - Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug...

    Science.gov (United States)

    2011-10-11

    ..., Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201. (Because access to the.... 422.100 and Sec. 422.111) a. Access to Preferred DME Items and Supplies b. Medical Necessity.... 423.458) 11. Access to Covered Part D Drugs Through Use of Standardized Technology and...

  2. 77 FR 22071 - Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit...

    Science.gov (United States)

    2012-04-12

    .... Sec. 423.100 and 423.104) 9. Medication Therapy Management Comprehensive Medication Reviews and.../13 Management applicable 01/01/13 Comprehensive Medication Reviews and Beneficiaries in LTC Settings... the Independent Review Entity (Sec. 423.600 and Sec. 423.602) 5. Independence of LTC Consultant...

  3. Innovation in Medicare and Medicaid will be central to health reform's success.

    Science.gov (United States)

    Guterman, Stuart; Davis, Karen; Stremikis, Kristof; Drake, Heather

    2010-06-01

    The health reform legislation signed into law by President Barack Obama contains numerous payment reform provisions designed to fundamentally transform the nation's health care system. Perhaps the most noteworthy of these is the establishment of a Center for Medicare and Medicaid Innovation within the Centers for Medicare and Medicaid Services. This paper presents recommendations that would maximize the new center's effectiveness in promoting reforms that can improve the quality and value of care in Medicare, Medicaid, and the Children's Health Insurance Program, while helping achieve health reform's goals of more efficient, coordinated, and effective care.

  4. Medicare program; FY 2014 hospice wage index and payment rate update; hospice quality reporting requirements; and updates on payment reform. final rule.

    Science.gov (United States)

    2013-08-07

    This final rule updates the hospice payment rates and the wage index for fiscal year (FY) 2014, and continues the phase out of the wage index budget neutrality adjustment factor (BNAF). Including the FY 2014 15 percent BNAF reduction, the total 5 year cumulative BNAF reduction in FY 2014 will be 70 percent. The BNAF phase-out will continue with successive 15 percent reductions in FY 2015 and FY 2016. This final rule also clarifies how hospices are to report diagnoses on hospice claims, and provides updates to the public on hospice payment reform. Additionally, this final rule changes the requirements for the hospice quality reporting program by discontinuing currently reported measures and implementing a Hospice Item Set with seven National Quality Forum (NFQ) endorsed measures beginning July 1, 2014, as proposed. Finally, this final rule will implement the hospice Experience of Care Survey on January 1, 2015, as proposed.

  5. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2015 rates; quality reporting requirements for specific providers; reasonable compensation equivalents for physician services in excluded hospitals and certain teaching hospitals; provider administrative appeals and judicial review; enforcement provisions for organ transplant centers; and electronic health record (EHR) incentive program. Final rule.

    Science.gov (United States)

    2014-08-22

    are participating in Medicare. We 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. In addition, we are making technical corrections to the regulations governing provider administrative appeals and judicial review; updating the reasonable compensation equivalent (RCE) limits, and revising the methodology for determining such limits, for services furnished by physicians to certain teaching hospitals and hospitals excluded from the IPPS; making regulatory revisions to broaden the specified uses of Medicare Advantage (MA) risk adjustment data and to specify the conditions for release of such risk adjustment data to entities outside of CMS; and making changes to the enforcement procedures for organ transplant centers. We are aligning the reporting and submission timelines for clinical quality measures for the Medicare HER Incentive Program for eligible hospitals and critical access hospitals (CAHs) with the reporting and submission timelines for the Hospital IQR Program. In addition, we provide guidance and clarification of certain policies for eligible hospitals and CAHs such as our policy for reporting zero denominators on clinical quality measures and our policy for case threshold exemptions. In this document, we are finalizing two interim final rules with comment period relating to criteria for disproportionate share hospital uncompensated care payments and extensions of temporary changes to the payment adjustment for low-volume hospitals and of the Medicare-Dependent, Small Rural Hospital (MDH) Program.

  6. Medicare Telehealth Services and Nephrology: Policies for Eligibility and Payment.

    Science.gov (United States)

    Frilling, Stephanie

    2017-01-01

    The criteria for Medicare payment of telehealth nephrology services, and all other Medicare telehealth services, are set forth in section 1834(m) of the Social Security Act. There are just over 80 professional physician or practitioner services that may be furnished via telehealth and paid under Medicare Part B, when an interactive audio and video telecommunication system that permits real-time communication between a beneficiary at the originating site and the physician or practitioner at the distant site substitutes for an in-person encounter. These services include 16 nephrology billing codes for furnishing ESRD services for monthly monitoring and assessment and two billing codes for chronic kidney disease education. In recent years, many mobile health devices and other web-based tools have been developed in support of monitoring, observation, and collaboration for people living with chronic disease. This article reviews the statutory and program guidance that governs Medicare telehealth services, defines payment policy terms (e.g., originating site and distant site), and explains payment policies when telehealth services are furnished.

  7. The Medicare Access and CHIP Reauthorization Act: Implications for Nephrology.

    Science.gov (United States)

    Lin, Eugene; MaCurdy, Thomas; Bhattacharya, Jay

    2017-09-01

    In response to rising Medicare costs, Congress passed the Medicare Access and Children's Health Insurance Program Reauthorization Act in 2015. The law fundamentally changes the way that health care providers are reimbursed by implementing a pay for performance system that rewards providers for high-value health care. As of the beginning of 2017, providers will be evaluated on quality and in later years, cost as well. High-quality, cost-efficient providers will receive bonuses in reimbursement, and low-quality, expensive providers will be penalized financially. The Centers for Medicare and Medicaid Services will evaluate provider costs through episodes of care, which are currently in development, and alternative payment models. Although dialysis-specific alternative payment models have already been implemented, current models do not address the transition of patients from CKD to ESRD, a particularly vulnerable time for patients. Nephrology providers have an opportunity to develop cost-efficient ways to care for patients during these transitions. Efforts like these, if successful, will help ensure that Medicare remains solvent in coming years. Copyright © 2017 by the American Society of Nephrology.

  8. Medicare and Medicaid Programs; CY 2017 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements. Final rule.

    Science.gov (United States)

    2016-11-03

    This final rule updates the Home Health Prospective Payment System (HH PPS) payment rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor; effective for home health episodes of care ending on or after January 1, 2017. This rule also: Implements the last year of the 4-year phase-in of the rebasing adjustments to the HH PPS payment rates; updates the HH PPS case-mix weights using the most current, complete data available at the time of rulemaking; implements the 2nd-year of a 3-year phase-in of a reduction to the national, standardized 60-day episode payment to account for estimated case-mix growth unrelated to increases in patient acuity (that is, nominal case-mix growth) between CY 2012 and CY 2014; finalizes changes to the methodology used to calculate payments made under the HH PPS for high-cost "outlier" episodes of care; implements changes in payment for furnishing Negative Pressure Wound Therapy (NPWT) using a disposable device for patients under a home health plan of care; discusses our efforts to monitor the potential impacts of the rebasing adjustments; includes an update on subsequent research and analysis as a result of the findings from the home health study; and finalizes changes to the Home Health Value-Based Purchasing (HHVBP) Model, which was implemented on January 1, 2016; and updates to the Home Health Quality Reporting Program (HH QRP).

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

    Science.gov (United States)

    Glied, Sherry; Zaylor, Abigail

    2015-07-01

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

  10. Offshore energy boom providing opportunities outside medicare`s umbrella

    Energy Technology Data Exchange (ETDEWEB)

    Robb, N.

    1998-09-08

    Establishment of Atlantic Offshore Medical Associates (AOMA) by a group of physicians to provide occupational health services, emergency and routine medical coverage outside the national health care system for personnel on offshore rigs, off Canada`s east coast, is described. The service is described as mostly third-party medicine paid for by the companies. Medicare or private insurance plans only come into play when onshore treatment of illness and injury is involved. According to the physicians involved in this partnership, practicing medicine outside of medicare is not for everyone. Nevertheless, it is beginning to look attractive to more and more physicians as rising overhead costs and fee restrictions chip away at their incomes. It also provides opportunities to add unique dimensions to the work between physicians and industry, to set some new standards and to make a contribution. In this form of medicine physicians are land-based, principally providing on-going advice to nurse-medics who staff infirmaries in offshore installations. In providing occupational medicine services, the physician`s primary function is preventive in focus, aiming to minimize the need to access the acute care system. Telemedicine is being considered for future application because it may help avoid some evacuations, which could reduce both the cost and the risk posed by such travel. As far as operating outside the medicare system is concerned, liability-insurance issues provide the most significant challenges. Organizing the practice to address the needs of the oil companies, and the ability to withstand economic fluctuations, are some of the others.

  11. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and Fiscal Year 2014 rates; quality reporting requirements for specific providers; hospital conditions of participation; payment policies related to patient status. Final rules.

    Science.gov (United States)

    2013-08-19

    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. Some of the 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) and other legislation. These changes will be applicable to discharges occurring on or after October 1, 2013, unless otherwise specified in this final rule. We also are updating the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits. The updated rate-of-increase limits will be effective for cost reporting periods beginning on or after October 1, 2013. 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) and implementing certain statutory changes that were applied to the LTCH PPS by the Affordable Care Act. Generally, these updates and statutory changes will be applicable to discharges occurring on or after October 1, 2013, unless otherwise specified in this final rule. In addition, we are making a number of changes relating to direct graduate medical education (GME) and indirect medical education (IME) payments. We are establishing new requirements or have revised requirements for quality reporting by specific providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities (IPFs)) that are participating in Medicare. We are updating policies relating to the Hospital Value-Based Purchasing (VBP) Program and the Hospital Readmissions Reduction Program. In addition, we are revising the conditions of participation (CoPs) for hospitals relating to the

  12. Medicare: a strategy for quality assurance.

    Science.gov (United States)

    Lohr, K N

    1991-01-01

    This paper has outlined a strategy proposed by an IOM study committee for a quality review and assurance program for Medicare. The committee intended that such a program respond to several major issues, including: the burdens of harm of poor quality of care (poor performance of clinicians in both technical and interpersonal ways, unnecessary and inappropriate services, and lack of needed and appropriate services); difficulties and incentives presented by the organization and financing of healthcare; the state of scientific knowledge; the problems of adversarial, punitive, and burdensome external QA activities and the need to foster successful internal, organization-based QA programs; the adequacy of quality review and assurance methods and tools; and the human and financial resources for quality assurance. In comparison with the existing federal peer review organization program, the IOM's proposed program is intended to focus far more directly on quality assurance, cover all major settings of care, emphasize both a wide range of patient outcomes and the process of care, and have a greatly expanded program evaluation component and greater public oversight and accountability. In laying out the details of such a program, the IOM committee advanced 10 recommendations to support its proposed program. Two of these call for the Secretary of DHHS to support and expand research and educational activities designed to improve the nation's knowledge base and capacity for quality assurance. Finally, the committee emphasized both the extraordinary challenges of quality assurance and the diversity of support for addressing those challenges, noting that patients, providers, and societal agents all have a responsibility in this regard. Building the nation's capacity through additional research and expanded educational efforts is a major cornerstone of the entire enterprise.

  13. March 2013: Medicare Advantage update.

    Science.gov (United States)

    Sayavong, Sarah; Kemper, Leah; Barker, Abigail; McBride, Timothy

    2013-09-01

    Key Data Findings. (1) From March 2012 to March 2013, rural enrollment in Medicare Advantage (MA) and other prepaid plans increased by over 200,000 enrollees, to more than 1.9 million. (2) Preferred provider organization (PPO) plan enrollment increased to nearly one million enrollees, accounting for more than 51% of the rural MA market (up from 48% in March 2012). (3) Health maintenance organization (HMO) enrollment continued to grow in 2013, with over 31% of the rural MA market, while private fee-for-service (PFFS) plan enrollment decreased to less than 10% of market share. (4) Despite recent changes to MA payment, rural MA enrollment continues to increase.

  14. Ostomy Home Skills Program

    Medline Plus

    Full Text Available ... Education Trauma Education Trauma Education Achieving Zero Preventable Deaths Trauma Systems Conference ... Incentive Program Medicare Inpatient & Outpatient Rules Physician ...

  15. Qualified Entity Certification Program for Medicare Data

    Data.gov (United States)

    U.S. Department of Health & Human Services — QECP welcomes any entities that would like to participate in, learn more about, or assess their capability to function as a qualified entity (QE) under section 10332...

  16. Medicare Resources That You Should Use.

    Science.gov (United States)

    Schaum, Kathleen Dianne

    2013-12-01

    Wound care scientists, manufacturers, and wound care professionals should take time to visit the Centers for Medicare & Medicaid Services' website. It is easy to navigate and contains information for all wound care stakeholders. This article reviews some of the most popular Medicare website pages that should prove useful to wound care stakeholders. The links to those pages are also provided.

  17. Conclusions from a NAIVE Bayes Operator Predicting the Medicare 2011 Transaction Data Set

    CERN Document Server

    Williams, Nick

    2014-01-01

    Introduction: The United States Federal Government operates one of the worlds largest medical insurance programs, Medicare, to ensure payment for clinical services for the elderly, illegal aliens and those without the ability to pay for their care directly. This paper evaluates the Medicare 2011 Transaction Data Set which details the transfer of funds from Medicare to private and public clinical care facilities for specific clinical services for the operational year 2011. Methods: Data mining was conducted to establish the relationships between reported and computed transaction values in the data set to better understand the drivers of Medicare transactions at a programmatic level. Results: The models averaged 88 for average model accuracy and 38 for average Kappa during training. Some reported classes are highly independent from the available data as their predictability remains stable regardless of redaction of supporting and contradictory evidence. DRG or procedure type appears to be unpredictable from the...

  18. Changes in drug utilization during a gap in insurance coverage: an examination of the medicare Part D coverage gap.

    OpenAIRE

    Polinski, Jennifer M.; Shrank, William H.; Huskamp, Haiden A.; Glynn, Robert J.; Liberman, Joshua N.; Sebastian Schneeweiss

    2011-01-01

    Editors' Summary Background Every year, more effective drugs for more diseases become available. But the availability of so many drugs poses a problem. How can governments provide their citizens with access to essential medications but control drug costs? Many different approaches have been tried, among them the “coverage gap” or “donut hole” approach that the US government has incorporated into its Medicare program. Medicare is the US government's health insurance program for people aged 65 ...

  19. At least half of new Medicare advantage enrollees had switched from traditional Medicare during 2006-11.

    Science.gov (United States)

    Jacobson, Gretchen A; Neuman, Patricia; Damico, Anthony

    2015-01-01

    With ongoing interest in rising Medicare Advantage enrollment, we examined whether the growth in enrollment between 2006 and 2011 was mainly due to new beneficiaries choosing Medicare Advantage when they first become eligible for Medicare. We also examined the extent to which beneficiaries in traditional Medicare switched to Medicare Advantage, and vice versa. We found that 22 percent of new Medicare beneficiaries elected Medicare Advantage over traditional Medicare in 2011; they accounted for 48 percent of new Medicare Advantage enrollees that year. People ages 65-69 switched from traditional Medicare to Medicare Advantage at higher-than-average rates. Dual eligibles (people eligible for both Medicare and Medicaid) and beneficiaries younger than age sixty-five with disabilities disenrolled from Medicare Advantage at higher-than-average rates. On average, in each year of the study period we found that fewer than 5 percent of traditional Medicare beneficiaries switched to Medicare Advantage, and a similar percentage of Medicare Advantage enrollees switched to traditional Medicare. These results suggest that initial coverage decisions have long-lasting effects. Project HOPE—The People-to-People Health Foundation, Inc.

  20. Facts you should know about ordering/referring providers for Medicare Part B items and services.

    Science.gov (United States)

    Schaum, Kathleen D

    2010-08-01

    To avoid Medicare Part B claim rejection, wound care providers and suppliers, who are qualified to bill Medicare Part B, should ensure that they are correctly and currently enrolled in the Internet-based PECOS. In addition, wound care providers, who are billing for Medicare Part B-covered items and services that were ordered or referred, need to ensure that the physicians and nonphysician practitioners from whom they accept orders and referrals have current Medicare enrollment records (ie, they have enrollment records that contain their NPIs in PECOS) and are of a type/specialty that is eligible to order or refer in the Medicare program.Wound care providers can verify this by checking the Internet-based Ordering Referring Report. If ordering/referring providers are not yet enrolled in PECOS, remind them that time is running out before the full implementation of the Medicare Part B claims edits on January 3, 2011! For a complete review of the ordering/referring edit process, visit http://www.cms.gov/MLNMattersArticles/downloads/SE1011.pdf.

  1. 42 CFR 407.11 - Forms used to apply for enrollment under Medicare Part B.

    Science.gov (United States)

    2010-10-01

    ... Medicare Part B. The following forms, available free of charge by mail from CMS, or at any Social Security... program. CMS-4040—Application for Enrollment in the Supplementary Medical Insurance Program. (This form is....) CMS-40-B—Application for Medical Insurance. (For general use by the SSA District Office in...

  2. Medicare Demonstration Projects and Evaluation Reports

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Centers for Medicare and Medicaid Services (CMS) conducts and sponsors a number of innovative demonstration projects to test and measure the effect of potential...

  3. Medicare Provider Analysis and Review (MEDPAR)

    Data.gov (United States)

    U.S. Department of Health & Human Services — MEDPAR files contain information on Medicare beneficiaries using hospital inpatient services. The data is provided by the state and the Diagnosis Related Groups...

  4. Enhancing Medicares Hospital Acquired Conditions Policy

    Data.gov (United States)

    U.S. Department of Health & Human Services — The current Medicare policy of non-payment to hospitals for Hospital Acquired Conditions (HAC) seeks to avoid payment for preventable complications identified within...

  5. Linking Medicare, Medicaid, and Cancer Registry Data...

    Data.gov (United States)

    U.S. Department of Health & Human Services — Linking Medicare, Medicaid, and Cancer Registry Data to Study the Burden of Cancers in West Virginia In the United States, the elderly carry an unequal burden of...

  6. Medicare Provider Utilization and Payment Data - Inpatient

    Data.gov (United States)

    U.S. Department of Health & Human Services — The data provided here include hospital-specific charges for the more than 3,000 U.S. hospitals that receive Medicare Inpatient Prospective Payment System (IPPS)...

  7. Medicare Referring Provider DMEPOS PUF CY2013

    Data.gov (United States)

    U.S. Department of Health & Human Services — This dataset, which is part of CMSs Medicare Provider Utilization and Payment Data, details information on Durable Medical Equipment, Prosthetics, Orthotics and...

  8. Medicare Geographic Variation - Public Use File

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Medicare Geographic Variation Public Use File provides the ability to view demographic, utilization and quality indicators at the state level (including...

  9. Medicare Provider Payment Data - Home Health Agencies

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Home Health Agency PUF contains information on utilization, payment (Medicare payment and standard payment), and submitted charges organized by CMS Certification...

  10. Medicare Advantage HEDIS Public Use Files

    Data.gov (United States)

    U.S. Department of Health & Human Services — In 2012, CMS collected data from 473 Medicare managed care contracts for health care delivered in 2011. CMS considers the reporting unit for a health plan as the...

  11. Medicare Preventive Services Quick Reference Tool

    Data.gov (United States)

    U.S. Department of Health & Human Services — This educational tool provides the following information on Medicare preventive services Healthcare Common Procedure Coding System (HCPCS)-Current Procedural...

  12. Costs and Clinical Quality Among Medicare Beneficiaries..

    Data.gov (United States)

    U.S. Department of Health & Human Services — Authors of Costs and Clinical Quality Among Medicare Beneficiaries - Associations with Health Center Penetration of Low-Income Residents, published in Volume 4,...

  13. Medicare Referring Provider (DMEPOS) Data CY2013

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Centers for Medicare and Medicaid Services (CMS) released a new dataset, the Referring Provider Durable Medical Equipment, Prosthetics, Orthotics and Supplies...

  14. Linking Medicare, Medicaid, and Cancer Registry Data...

    Data.gov (United States)

    U.S. Department of Health & Human Services — Linking Medicare, Medicaid, and Cancer Registry Data to Study the Burden of Cancers in West Virginia In the United States, the elderly carry an unequal burden of...

  15. Costs and Clinical Quality Among Medicare Beneficiaries..

    Data.gov (United States)

    U.S. Department of Health & Human Services — Authors of Costs and Clinical Quality Among Medicare Beneficiaries - Associations with Health Center Penetration of Low-Income Residents, published in Volume 4,...

  16. Basic Stand Alone Medicare Hospice Beneficiary PUF

    Data.gov (United States)

    U.S. Department of Health & Human Services — This release contains the Basic Stand Alone (BSA) Hospice Beneficiary Public Use Files (PUF) with information from Medicare hospice claims. The CMS BSA Hospice...

  17. Medicare Demonstration Projects and Evaluation Reports

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Centers for Medicare and Medicaid Services (CMS) conducts and sponsors a number of innovative demonstration projects to test and measure the effect of potential...

  18. Telehealth and Medicare - Payment Policy, Current Use...

    Data.gov (United States)

    U.S. Department of Health & Human Services — Despite legislative changes from 2001 to 2008 that increased Medicare payment rates for telehealth and decreased regulatory burdens, the study Telehealth and...

  19. Medicare Contracting - Redacted Benchmark Metric Reports

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Centers for Medicare and Medicaid Services has compiled aggregate national benchmark cost and workload metrics using data submitted to CMS by the AB MACs and the...

  20. Medicare-Medicaid Eligible Beneficiaries and Potentiall...

    Data.gov (United States)

    U.S. Department of Health & Human Services — More than one in four hospitalizations for those with both Medicare and full Medicaid coverage was potentially avoidable, according to findings reported in...

  1. Standardizing Medicare Payment Information to Support...

    Data.gov (United States)

    U.S. Department of Health & Human Services — Examination of efficiency in health care requires that cost information be normalized. Medicare payments include both geographic and policy-based facility type...

  2. Medicare Part D Opioid Drug Mapping Tool

    Data.gov (United States)

    U.S. Department of Health & Human Services — The opioid prescribing rate interactive mapping tool shows geographic comparisons, at the state, county, and ZIP code levels, of de-identified Medicare Part D opioid...

  3. Enhancing Medicares Hospital Acquired Conditions Policy

    Data.gov (United States)

    U.S. Department of Health & Human Services — The current Medicare policy of non-payment to hospitals for Hospital Acquired Conditions (HAC) seeks to avoid payment for preventable complications identified within...

  4. Telehealth and Medicare - Payment Policy, Current Use...

    Data.gov (United States)

    U.S. Department of Health & Human Services — Despite legislative changes from 2001 to 2008 that increased Medicare payment rates for telehealth and decreased regulatory burdens, the study Telehealth and...

  5. Medicare Part D Prescriber Interactive Dataset

    Data.gov (United States)

    U.S. Department of Health & Human Services — As part of the Obama Administrations efforts to make our healthcare system more transparent, affordable, and accountable, the Centers for Medicare and Medicaid...

  6. Medicare Provider Payment Data - Skilled Nursing Facilities

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Skilled Nursing Facility Utilization and Payment Public Use File (Skilled Nursing Facility PUF) provides information on services provided to Medicare...

  7. Medicare, swing beds, and critical access hospitals.

    Science.gov (United States)

    Reiter, Kristin L; Holmes, George M; Broyles, Ila H

    2013-04-01

    Critical Access Hospitals (CAHs) receive cost-based reimbursement from Medicare for inpatient care, including post-acute skilled care provided in swing beds (skilled swing days). Because the reimbursement formula treats swing bed and acute days equally, there is concern that CAH skilled swing days are "overreimbursed" as compared with skilled days provided in other settings. The reimbursement formula is complex; thus, empirical estimates are needed to identify the marginal cost per day to the hospital and the implied Medicare expenditure per day, accounting for fixed cost transfers between services. Using Medicare cost report data, we find that Medicare paid, on average, $581 for the routine portion of a CAH skilled swing day in 2009--more than the estimated marginal cost of $262, but less than the 2009 average per diem of $1,302. Estimates varied widely across the 1,300 CAHs; therefore, payment policy changes would likely have a broad range of effects.

  8. Medicare-Medicaid Eligible Beneficiaries and Potentiall...

    Data.gov (United States)

    U.S. Department of Health & Human Services — More than one in four hospitalizations for those with both Medicare and full Medicaid coverage was potentially avoidable, according to findings reported in...

  9. Appeals - Redetermination by a Medicare Contractor

    Data.gov (United States)

    U.S. Department of Health & Human Services — A redetermination is an examination of a claim by the fiscal intermediary (FI), carrier, or Medicare Administrative Contractor (MAC) personnel who are different from...

  10. Basic Stand Alone Medicare Inpatient Claims PUF

    Data.gov (United States)

    U.S. Department of Health & Human Services — This release contains the Basic Stand Alone (BSA) Inpatient Public Use Files (PUF) named CMS 2008 BSA Inpatient Claims PUF with information from 2008 Medicare...

  11. Basic Stand Alone Medicare Outpatient Procedures PUF

    Data.gov (United States)

    U.S. Department of Health & Human Services — This release contains the Basic Stand Alone (BSA) Outpatient Procedures Public Use Files (PUF) with information from Medicare outpatient claims. The CMS BSA...

  12. Medicare Provider Data - Physician and Other Supplier

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Physician and Other Supplier Public Use File (Physician and Other Supplier PUF) provides information on services and procedures provided to Medicare...

  13. Pilot assessment of patient satisfaction and clinical impact of Medicare Part D in diabetic geriatric patients

    Directory of Open Access Journals (Sweden)

    Kim SL

    2008-09-01

    Full Text Available Objectives: To assess patients’ 1 satisfaction with their decision to enroll or not enroll in the Medicare Part D program, and 2 clinical status of diabetes before and after decision to enroll in Medicare Part D.Methods: Patients 65 years or older were enrolled in the study from November 2006 through February 2007. Patients were screened by a clinical pharmacist at their clinician visit and administered a Medicare Part D satisfaction survey. Upon completion of the survey, a retrospective chart review was completed in diabetic patients who were enrolled in Medicare Part D to assess goal attainment of glycosylated hemoglobin (HbA1c, low-density lipoprotein (LDL and blood pressure. Pre-enrollment values were obtained in the 6 months prior to the start of Medicare Part D enrollment (July 1- December 31, 2005. Post-enrollment values were obtained after enrollment was complete for the 2006 year (May 1- October 31, 2006.Results: Results show that 74% (60/81 of patients surveyed were enrolled into the Medicare Part D program, including patients who have dual eligibility. Of the 60 patients who were enrolled in Medicare Part D, 48 patients (80.0% responded that they were satisfied with their decision to enroll. Clinical outcomes were unchanged from the pre-enrollment to the post-enrollment periods. Mean HbA1c was 7.47% in the pre-enrollment period and 7.25% post-enrollment (differencepre-post = 0.23; 95%CI = -0.28 to 0.73. There was no change in LDL in the two time periods (pre = 79.4 mg/dL; post = 79.7; differencepre-post = -0.25; 95%CI = -13.6 to 13.1. Similarly, there were no significant differences observed for blood pressure. Mean systolic blood pressure was 129.5 in the pre-enrollment period and 131.6 in the post-enrollment period (differencepre-post = -2.1; 95%CI = -7.0 to 2.7. Mean diastolic blood pressure was 70.3 for the pre-enrollment period and 70.7 for the post-enrollment period (differencepre-post = -0.4; 95%CI = -4.2 to 3.4.Conclusion

  14. Medicare program; limit on the valuation of a depreciable asset recognized as an allowance for depreciation and interest on capital indebtedness after a change of ownership--HCFA. Final rule with comment period.

    Science.gov (United States)

    1998-01-09

    This final rule with comment period revises the Medicare provider reimbursement regulations relative to allowable costs and sets a limit on the valuation of a depreciable asset that may be recognized in establishing an appropriate allowance for depreciation and for interest on capital indebtedness after a change of ownership that occurs on or after December 1, 1997. These provisions apply to providers that are reimbursed on the basis of reasonable costs. This change implements the mandate in section 4404 of the Balanced Budget Act of 1997 (Pub. L. 105-33).

  15. Using research for successful Medicare and Medicaid risk marketing.

    Science.gov (United States)

    Jacobs, S; Nelson, A M; Wood, S D

    1996-01-01

    Medicare/Medicaid risk marketing is a vital business challenge, one that countless managed care organizations are facing right now. Early entry into new markets and aggressive participation in existing markets are essential to meet competitive pressures. Health plans intent on success in government risk programs should conduct research to learn the medical needs, wants, and desires of older persons in the geographic area they serve. Original, market-specific research yields critical marketing and clinical data that can be used to improve care and member satisfaction along with customer loyalty and retention.

  16. Measuring outcomes and efficiency in medicare value-based purchasing.

    Science.gov (United States)

    Tompkins, Christopher P; Higgins, Aparna R; Ritter, Grant A

    2009-01-01

    The Medicare program may soon adopt value-based purchasing (VBP), in which hospitals could receive incentives that are conditional on meeting specified performance objectives. The authors advocate for a market-oriented framework and direct measures of system-level value that are focused on better outcomes and lower total cost of care. They present a multidimensional framework for measuring outcomes of care and a method to adjust incentive payments based on efficiency. Incremental reforms based on VBP could provoke transformational changes in total patient care by linking payments to value related to the whole patient experience, recognizing shared accountability among providers.

  17. Seeking value in Medicare: performance measurement for clinical professionals.

    Science.gov (United States)

    Sprague, Lisa

    2013-10-30

    The Medicare program, despite its reputation of being a bill payer with little regard to the worth of the services it buys, has begun to put in place a range of programs aimed at assessing quality and value, with more to come. Attention to resource use and cost is nascent. The issues are complex, and it is no surprise that there is a level of contention between providers and regulators, even though both profess commitment to improved quality. This paper summarizes the quality and value programs that apply to physicians and other clinical professionals, as well as programs designed to encourage the adoption of technology to support quality improvement. Participation in all is voluntary. However, a decision not to participate increasingly carries a financial penalty, as Congress (and, by extension, the U.S. Department of Health and Human Services, or HHS) tries to encourage behavior it cannot force.

  18. Use of the Medicare database in epidemiologic and health services research: a valuable source of real-world evidence on the older and disabled populations in the US

    Directory of Open Access Journals (Sweden)

    Mues KE

    2017-05-01

    Full Text Available Katherine E Mues,1 Alexander Liede,1 Jiannong Liu,2 James B Wetmore,2 Rebecca Zaha,1 Brian D Bradbury,1 Allan J Collins,2 David T Gilbertson2 1Center for Observational Research, Amgen Inc., Thousand Oaks and San Francisco, CA, 2Chronic Disease Research Group, Minneapolis, MN, USA Abstract: Medicare is the federal health insurance program for individuals in the US who are aged ≥65 years, select individuals with disabilities aged <65 years, and individuals with end-stage renal disease. The Centers for Medicare and Medicaid Services grants researchers access to Medicare administrative claims databases for epidemiologic and health outcomes research. The data cover beneficiaries’ encounters with the health care system and receipt of therapeutic interventions, including medications, procedures, and services. Medicare data have been used to describe patterns of morbidity and mortality, describe burden of disease, compare effectiveness of pharmacologic therapies, examine cost of care, evaluate the effects of provider practices on the delivery of care and patient outcomes, and explore the health impacts of important Medicare policy changes. Considering that the vast majority of US citizens ≥65 years of age have Medicare insurance, analyses of Medicare data are now essential for understanding the provision of health care among older individuals in the US and are critical for providing real-world evidence to guide decision makers. This review is designed to provide researchers with a summary of Medicare data, including the types of data that are captured, and how they may be used in epidemiologic and health outcomes research. We highlight strengths, limitations, and key considerations when designing a study using Medicare data. Additionally, we illustrate the potential impact that Centers for Medicare and Medicaid Services policy changes may have on data collection, coding, and ultimately on findings derived from the data. Keywords: Medicare

  19. 77 FR 1877 - Medicare Program; Medicare Advantage and Prescription Drug Benefit Programs: Negotiated Pricing...

    Science.gov (United States)

    2012-01-12

    ... Subsidy (RDS) sponsors report the pass-through negotiated prices and included a proposed definition of ``negotiated price'' to be included at Sec. 423.882 that paralleled the definition at Sec. 423.100. The May... prices'' and implemented, on an interim final basis, definitions of the other terms that...

  20. 76 FR 67801 - Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations

    Science.gov (United States)

    2011-11-02

    ... Shield of Massachusetts BIPA Benefits Improvement and Protection Act CAD Coronary Artery Disease CAHPS... Hospital Value Based Purchasing IME Indirect Medical Education IOM Institute of Medicine IPPS Inpatient... All Inclusive Care for the Elderly PACFs Post-Acute Care Facilities PCMH Patient Centered Medical...

  1. 76 FR 54599 - Medicare Program; Medicare Advantage and Prescription Drug Benefit Programs

    Science.gov (United States)

    2011-09-01

    ... comprehensive initial assessment and annual reassessments of an individual's physical, psychosocial, and... benefit packages (for example, an extra benefit of independent living skills was approved one year...

  2. Recent determinants of new entry of HMOs into a Medicare risk contract: a diversification strategy.

    Science.gov (United States)

    Pai, C W; Clement, D G

    1999-01-01

    This study provides knowledge of more recent entry of health maintenance organizations (HMOs) into the Medicare risk program than earlier analyses. Based on a diversification framework, this study examines new market entry from three dimensions: attractiveness of the market, market area attributes, and organizational attributes. The analysis uses a 1994-1995 cross-sectional, lagged time sample with 440 HMOs that did not have a Medicare risk contract as of January 1994; it defines an HMO's market as its service area. HMO enrollment growth in the market, individual HMO enrollment size, and adjusted average per capita cost (AAPCC) rates are found to be significant in predicting new market entry.

  3. Footing the bill: the introduction of Medicare Benefits Schedule rebates for podiatry services in Australia

    Directory of Open Access Journals (Sweden)

    Short Anthony J

    2009-12-01

    Full Text Available Abstract The introduction of Medicare Benefits Schedule items for allied health professionals in 2004 was a pivotal event in the public funding of non-medical primary care services. This commentary seeks to provide supplementary discussion of the article by Menz (Utilisation of podiatry services in Australia under the Medicare Enhanced Primary Care program, 2004-2008 Journal of Foot and Ankle Research 2009, 2:30, by placing these findings within the context of the podiatry profession, clinical decision making and the broader health workforce and government policy.

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

    Directory of Open Access Journals (Sweden)

    Shin Jaeun

    2006-04-01

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

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

    Science.gov (United States)

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

    2015-10-01

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

  6. Estimating the cost of direct reimbursement of marriage and family therapy under Medicare.

    Science.gov (United States)

    Christenson, Jacob D; Crane, D Russell

    2004-10-01

    In this article, we investigated the estimated cost to the Medicare program for covering psychotherapy services provided by marriage and family therapists (MFTs). Historical trends were identified by using psychotherapy cost and utilization data for the years 1999-2001. Using these trends, projections for the years 2002-2006 were made with MFTs included as providers. Employing this methodology, the 5-year estimated net increase and gross increase in cost due to the provision of psychotherapy services by MFTs was found to be approximately dollar 10.5 million (or dollar 2.1 million per year) and dollar 13.9 million (or dollar 2.8 million per year), respectively. This represents an increase of less than 1/2 of 1% of the Medicare mental health budget, and less than .0015% of Medicare expenditures overall.

  7. Ever Enrolled Medicare Population Estimates from the MCBS..

    Data.gov (United States)

    U.S. Department of Health & Human Services — Findings reported in Ever Enrolled Medicare Population Estimates from the MCBS Access to Care (ATC) Files, published in Volume 4, Issue 2 of the Medicare and...

  8. Medicare-Medicaid Enrollee Profiles (State and National)

    Data.gov (United States)

    U.S. Department of Health & Human Services — Today there are over 10 million Medicare-Medicaid enrollees in the United States.To provide a greater understanding of the Medicare-Medicaid enrollee population, the...

  9. Medicare Post-Acute Care Episodes and Payment Bundling

    Data.gov (United States)

    U.S. Department of Health & Human Services — Published in Volume 4, Issue 1, of Medicare and Medicaid Research Review, this paper provides an overview of results examining alternative Medicare post-acute care...

  10. Medicare-Medicaid Dual Enrollment from 2006 through 2011

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Medicare-Medicaid Coordination Office (MMCO) is releasing an analysis of trends in Medicare-Medicaid enrollee population and demographic characteristics from...

  11. Medicare Part D Roulette, Potential Implications of Random..

    Data.gov (United States)

    U.S. Department of Health & Human Services — Medicare Part D Roulette, Potential Implications of Random Assignment and Plan Restrictions Dual-eligible (Medicare and Medicaid) beneficiaries are randomly assigned...

  12. Medicare Advantage Rates and Statistics - FFS Data (1998-...

    Data.gov (United States)

    U.S. Department of Health & Human Services — Medicare fee-for-service data for each county broken out by aged, disabled, and ESRD beneficiaries including data on total Medicare fee-for-service reimbursement and...

  13. Medicare-Medicaid Enrollee Profiles (State and National)

    Data.gov (United States)

    U.S. Department of Health & Human Services — Today there are over 10 million Medicare-Medicaid enrollees in the United States.To provide a greater understanding of the Medicare-Medicaid enrollee population,...

  14. Medicare Part D Roulette, Potential Implications of Random..

    Data.gov (United States)

    U.S. Department of Health & Human Services — Medicare Part D Roulette, Potential Implications of Random Assignment and Plan Restrictions Dual-eligible (Medicare and Medicaid) beneficiaries are randomly...

  15. Medicare Advantage Rates and Statistics - FFS Data 2008-2014

    Data.gov (United States)

    U.S. Department of Health & Human Services — Medicare fee-for-service data for each county broken out by aged, disabled, and ESRD beneficiaries including data on total Medicare fee-for-service reimbursement and...

  16. Medicare and Medicaid Trends in Health Care Sectors

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Centers for Medicare and Medicaid Services (CMS) provides monthly and fiscal-year-to-date income and expenditure trends for Medicare Hospital Insurance (HI) and...

  17. 42 CFR 403.205 - Medicare supplemental policy.

    Science.gov (United States)

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Medicare supplemental policy. 403.205 Section 403.205 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES... private entity offers to a Medicare beneficiary; and (2) Is primarily designed, or is advertised,...

  18. Ostomy Home Skills Program

    Medline Plus

    Full Text Available ... Collection Medicare Inpatient & Outpatient Rules Physician Quality Reporting System Value-Based Payment Modifier DEA, FDA, and Medicare Part B ... Health Records (EHR) Incentive Program Physician Quality Reporting System Value-Based Payment Modifier Quality and Resource Use Reports Physician ...

  19. Medicare Prescription Drug Benefit Manual

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Part D Prescription Drug Benefit Manual (PDBM) is user guide to Part D Prescription Drug Program. It includes information on general provisions, benefits,...

  20. The Affordable Care Act versus Medicare for All.

    Science.gov (United States)

    Seidman, Laurence

    2015-08-01

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

  1. 76 FR 79193 - Medicare Program; Independence at Home Demonstration Program

    Science.gov (United States)

    2011-12-21

    ... primary care teams aimed at improving health outcomes and reducing expenditures, beginning December 21... model that utilizes physician and nurse practitioner directed primary care teams to provide services to...

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

    Science.gov (United States)

    Ryan, Andrew M; Damberg, Cheryl L

    2013-06-01

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

  3. Pay for performance in Medicare: evidentiary irony and the politics of value.

    Science.gov (United States)

    Tanenbaum, Sandra J

    2009-10-01

    Pay for performance (P4P) is of growing importance in the Medicare program. Pay-for-performance policy has the support of political actors in both parties and in the legislative and executive branches; of experts, business, and consumer interests; and in a qualified way, of health care providers. The evidence that P4P improves quality or reduces cost, however, is scant, although P4P proponents claim that the program is evidence based. This article reviews the history of Medicare P4P, documents its widespread support, and evaluates both the evidence of its effectiveness and the expert discourse about that evidence. The article analyzes the political reasons for Medicare P4P's popularity despite its evidentiary deficiencies and emphasizes its role in the politics of value. Pay for performance allows Medicare policy makers to (1) reformulate intractable cost and quality problems as more malleable value problems; (2) offer an acceptable quid pro quo for payment negotiations with providers; and (3) reach a rare, if shallow, consensus based on the ideological ambiguity of P4P.

  4. Special interests or citizens' rights? "Senior power," Social Security, and Medicare.

    Science.gov (United States)

    Street, D

    1997-01-01

    Conventional political analysts and mainstream media accounts attribute substantial political power to the elderly in the United States. This attribution of "senior power" is usually made in the context of the politics of Social Security and Medicare. This article contrasts the conventional construction of elderly political actors as a special interest with a more critical perspective that views Social Security and Medicare as citizens' rights. Critical examination of the welfare state's role in creating age as a potential political cleavage and the politics of Social Security and Medicare reveals that there is no undifferentiated politics of aging in the United States. Rather, age interacts with a variety of other statuses such as race/ethnicity, gender, and class to condition citizens' political mobilization. Welfare state policies--social insurance programs like Social Security and Medicare, means--tested programs like Medicaid and Supplemental Security Income, and targeted tax expenditures for private pensions and health insurance--differentially empower particular subgroups of elderly citizens and routinely disadvantage the most vulnerable elderly, including minority elders, women, and the oldest old.

  5. Medicare program: changes to the hospital inpatient prospective payment systems and fiscal year 2009 rates; payments for graduate medical education in certain emergency situations; changes to disclosure of physician ownership in hospitals and physician self-referral rules; updates to the long-term care prospective payment system; updates to certain IPPS-excluded hospitals; and collection of information regarding financial relationships between hospitals. Final rules.

    Science.gov (United States)

    2008-08-19

    We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital related costs to implement changes arising from our continuing experience with these systems, and to implement certain provisions made by the Deficit Reduction Act of 2005, the Medicare Improvements and Extension Act, Division B, Title I of the Tax Relief and Health Care Act of 2006, the TMA, Abstinence Education, and QI Programs Extension Act of 2007, and the Medicare Improvements for Patients and Providers Act of 2008. In addition, in the Addendum to this final rule, we describe the changes to the amounts and factors used to determine the rates for Medicare hospital inpatient services for operating costs and capital-related costs. These changes are generally applicable to discharges occurring on or after October 1, 2008. We also are setting forth the update to the rate-of-increase limits for certain hospitals and hospital units excluded from the IPPS that are paid on a reasonable cost basis subject to these limits. The updated rate-of-increase limits are effective for cost reporting periods beginning on or after October 1, 2008. In addition to the changes for hospitals paid under the IPPS, this document contains revisions to the patient classifications and relative weights used under the long-term care hospital prospective payment system (LTCH PPS). This document also contains policy changes relating to the requirements for furnishing hospital emergency services under the Emergency Medical Treatment and Labor Act of 1986 (EMTALA). In this document, we are responding to public comments and finalizing the policies contained in two interim final rules relating to payments for Medicare graduate medical education to affiliated teaching hospitals in certain emergency situations. We are revising the regulatory requirements relating to disclosure to patients of physician ownership or investment interests in hospitals and responding to public comments on a

  6. Varied Differences in the Health Status Between Medicare Advantage and Fee-for-Service Enrollees

    Directory of Open Access Journals (Sweden)

    Yunjie Song PhD

    2014-12-01

    Full Text Available This article examines the differences in mortality measured health status between the Medicare Advantage (MA program and Fee-for-Service (FFS program from 1999 to 2007. At the national level, differences in mortality rates were associated with MA market share. In some counties, enrollees in the MA program were 40% less likely to die than their peers in the FFS program, but in other counties, they were 20% more likely to die. Cost shifting between the two programs could bias county classifications of average FFS spending, and enlarged disparities in health status could make it difficult to evaluate risk adjusters.

  7. Using the Medicare Current Beneficiary Survey to conduct research on Medicare-eligible veterans

    Directory of Open Access Journals (Sweden)

    Yvonne Jonk, PhD

    2010-10-01

    Full Text Available The Medicare Current Beneficiary Survey (MCBS is a longitudinal, multipurpose panel survey of a nationally representative sample of Medicare beneficiaries sponsored by the Centers for Medicare and Medicaid Services (CMS. The MCBS serves as a comprehensive data source on self-reported health and socioeconomic status, health insurance, healthcare utilization and costs, and patient satisfaction. CMS uses Medicare claims data to validate self-reported Medicare Fee-For-Service (FFS utilization. Because the Veterans Health Administration (VHA does not bill for services, CMS imputes VHA costs. This article addresses the quality of the MCBS dataset for conducting research on Medicare-eligible veterans by addressing the sample's representativeness, quality of self-reported data, and accuracy of imputed VHA cost estimates. We compared demographic data from the 1992 and 2001 National Survey of Veterans (NSV with the MCBS 1992 and 2001 Cost and Use files. We compared self-reported VHA utilization and CMS's imputed costs with VHA administrative datasets. The VHA's Pharmacy Benefits Management (PBM database is available from fiscal year (FY 1999 onward, and the VHA Health Economics Resource Center's (HERC Average Cost datasets are available from FY1998 onward. While the samples were comparable in terms of age, sex, and race, the MCBS respondents were in better health, less likely to be married, and more likely to be widowed than NSV respondents. MCBS underreporting rates were higher for VHA than Medicare outpatient events. Underreporting and differences between CMS's and HERC's costing methodologies contributed to lower MCBS versus VHA administrative person- and event- level costs. Alternatively, average annual VHA prescription costs per capita were higher in the MCBS than in the PBM data. Differences in socioeconomic characteristics of the NSV and MCBS samples may be attributable to differences in sampling methodologies. Higher underreporting rates for VHA

  8. Examining Race and Ethnicity Information in Medicare Administrative Data.

    Science.gov (United States)

    Filice, Clara E; Joynt, Karen E

    2016-07-29

    Racial and ethnic disparities are observed in the health status and health outcomes of Medicare beneficiaries. Reducing these disparities is a national priority, and having high-quality data on individuals' race and ethnicity is critical for researchers working to do so. However, using Medicare data to identify race and ethnicity is not straightforward. Currently, Medicare largely relies on Social Security Administration data for information about Medicare beneficiary race and ethnicity. Directly self-reported race and ethnicity information is collected for subsets of Medicare beneficiaries but is not explicitly collected for the purpose of populating race/ethnicity information in the Medicare administrative record. As a consequence of historical data collection practices, the quality of Medicare's administrative data on race and ethnicity varies substantially by racial/ethnic group; the data are generally much more accurate for whites and blacks than for other racial/ethnic groups. Identification of Hispanic and Asian/Pacific Islander beneficiaries has improved through use of an imputation algorithm recently applied to the Medicare administrative database. To improve the accuracy of race/ethnicity data for Medicare beneficiaries, researchers have developed techniques such as geocoding and surname analysis that indirectly assign Medicare beneficiary race and ethnicity. However, these techniques are relatively new and data may not be widely available. Understanding the strengths and limitations of different approaches to identifying race and ethnicity will help researchers choose the best method for their particular purpose, and help policymakers interpret studies using these measures.

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

    Science.gov (United States)

    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.

  10. Expanding Medicare and employer plans to achieve universal health insurance.

    Science.gov (United States)

    Davis, K

    1991-05-15

    This article presents a proposal for expanding Medicare and employer-based health insurance plans to achieve universal health insurance. Under this proposed health care financing system, employees would provide basic health insurance coverage to workers and dependents, or pay a payroll tax contribution toward the cost of their coverage under Medicare. States would have the option of buying all Medicaid beneficiaries and other poor individuals into Medicare by paying the Medicare premiums and cost sharing. Other uninsured individuals would be automatically covered by Medicare. Employer plans would incorporate Medicare's provider payment methods. This proposal would result in incremental federal governmental outlays on the order of $25 billion annually. These new federal budgetary costs would be met through a combination of premiums, employer payroll tax, income tax, and general tax revenues. The principal advantage of this plan is that it draws on the strengths of the current system while simplifying the benefit and provider payment structure and instituting innovations to promote efficiency.

  11. CMS Program Statistics

    Data.gov (United States)

    U.S. Department of Health & Human Services — The CMS Office of Enterprise Data and Analytics has developed CMS Program Statistics, which includes detailed summary statistics on national health care, Medicare...

  12. Recovery Audit Program

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Recovery Audit Programs mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on...

  13. Volume of Requests for Internet Medicare Replacement Cards

    Data.gov (United States)

    Social Security Administration — This dataset provides monthly volumes at the national level from federal fiscal year 2008 onwards for Internet Medicare Replacement Card. The dataset includes only...

  14. Use of Surveillance, Epidemiology, and End Results-Medicare Data to Conduct Case-Control Studies of Cancer Among the US Elderly

    Science.gov (United States)

    Engels, Eric A.; Pfeiffer, Ruth M.; Ricker, Winnie; Wheeler, William; Parsons, Ruth; Warren, Joan L.

    2011-01-01

    Cancer is an important cause of morbidity in the elderly, and many medical conditions and treatments influence cancer risk. The Surveillance, Epidemiology, and End Results (SEER)-Medicare database can be used to conduct population-based case-control studies that elucidate the etiology of cancer among the US elderly. SEER-Medicare links data on malignancies ascertained through SEER cancer registries to claims from Medicare, the US government insurance program for people over age 65 years. Under one approach described herein, elderly cancer cases are ascertained from SEER data (1987–2005). Matched controls are selected from a 5% random sample of Medicare beneficiaries. Risk factors of interest, including medical conditions and procedures, are identified by using linked Medicare claims. Strengths of this design include the ready availability of data, representative sampling from the US elderly population, and large sample size (e.g., under one scenario: 1,176,950 cases, including 221,389 prostate cancers, 185,853 lung cancers, 138,041 breast cancers, and 124,442 colorectal cancers; and 100,000 control subjects). Limitations reflect challenges in exposure assessment related to Medicare claims: restricted range of evaluable risk factors, short time before diagnosis/selection for ascertainment, and inaccuracies in claims. With awareness of limitations, investigators have in SEER-Medicare data a valuable resource for epidemiologic research on cancer etiology. PMID:21821540

  15. Medicare payment data for spine reimbursement; important but flawed data for evaluating utilization of resources.

    Science.gov (United States)

    Menger, Richard P; Wolf, Michael E; Kukreja, Sunil; Sin, Anthony; Nanda, Anil

    2015-01-01

    Medicare data showing physician-specific reimbursement for 2012 were recently made public in the mainstream media. Given the ongoing interest in containing healthcare costs, we analyze these data in the context of the delivery of spinal surgery. Demographics of 206 leading surgeons were extracted including state, geographic area, residency training program, fellowship training, and academic affiliation. Using current procedural terminology (CPT) codes, information was evaluated regarding the number of lumbar laminectomies, lumbar fusions, add-on laminectomy levels, and anterior cervical fusions reimbursed by Medicare in 2012. In 2012 Medicare reimbursed the average neurosurgeon slightly more than an orthopedic surgeon for all procedures ($142,075 vs. $110,920), but this was not found to be statistically significant (P = 0.218). Orthopedic surgeons had a statistical trend illustrating increased reimbursement for lumbar fusions specifically, $1187 versus $1073 (P = 0.07). Fellowship trained spinal surgeons also, on average, received more from Medicare ($125,407 vs. $76,551), but again this was not statistically significant (P = 0.112). A surgeon in private practice, on average, was reimbursed $137,495 while their academic counterparts were reimbursed $103,144 (P = 0.127). Surgeons performing cervical fusions in the Centers for Disease Control West Region did receive statistically significantly less reimbursement for that procedure then those surgeons in other parts of the country (P = 0.015). Surgeons in the West were reimbursed on average $849 for CPT code 22,551 while those in the Midwest received $1475 per procedure. Medicare reimbursement data are fundamentally flawed in determining healthcare expenditure as it shows a bias toward delivery of care in specific patient demographics. However, neurosurgeons, not just policy makers, must take ownership to analyze, investigate, and interpret these data as it will affect healthcare reimbursement and delivery moving

  16. Limited life expectancy among a subgroup of medicare beneficiaries receiving screening colonoscopies.

    Science.gov (United States)

    Mittal, Sahil; Lin, Yu-Li; Tan, Alai; Kuo, Yong-Fang; El-Serag, Hashem B; Goodwin, James S

    2014-03-01

    Life expectancy is an important consideration when assessing appropriateness of preventive programs for older individuals. Most studies on this subject have used age cutoffs as a proxy for life expectancy. We analyzed patterns of utilization of screening colonoscopy in Medicare enrollees by using estimated life expectancy. We used a 5% random national sample of Medicare claims data to identify average-risk patients who underwent screening colonoscopies from 2008 to 2010. Colonoscopies were considered to be screening colonoscopies in the absence of diagnoses for nonscreening indications, which were based on either colonoscopies or any claims in the preceding 3 months. We estimated life expectancies by using a model that combined age, sex, and comorbidity. Among patients who underwent screening colonoscopies, we calculated the percentage of those with life expectancies <10 years. Among the 57,597 Medicare beneficiaries 66 years old or older who received at least 1 screening colonoscopy, 24.8% had an estimated life expectancy of <10 years. There was a significant positive association between total Medicare per capita costs in hospital referral regions and the proportion of patients with limited life expectancies (<10 years) at the time of screening colonoscopy (R = 0.25; P < .001, Pearson correlation test). In a multivariable analysis, men were substantially more likely than women to have limited life expectancy at the time of screening colonoscopy (odds ratio, 2.25; 95% confidence interval, 2.16-2.34). Nearly 25% of Medicare beneficiaries, especially men, had life expectancies <10 years at the time of screening colonoscopies. Life expectancy should therefore be incorporated in decision-making for preventive services. Copyright © 2014 AGA Institute. Published by Elsevier Inc. All rights reserved.

  17. Are You a Hospital Inpatient or Outpatient? If You have Medicare -- Ask!

    Science.gov (United States)

    ... information on how Medicare covers hospital services, including premiums, deductibles, and copayments, visit Medicare.gov/publications to ... an inpatient day. What are my rights? No matter what type of Medicare coverage you have, you ...

  18. 42 CFR 408.21 - Reduction in Medicare Part B premium as an additional benefit under Medicare+Choice plans.

    Science.gov (United States)

    2010-10-01

    .... After determining the Medicare Part B premium reduction amount for each eligible beneficiary, CMS will— (1) Transmit this information to the Social Security Administration, Railroad Retirement Board,...

  19. The Relationship Between Magnet Designation, Electronic Health Record Adoption, and Medicare Meaningful Use Payments.

    Science.gov (United States)

    Lippincott, Christine; Foronda, Cynthia; Zdanowicz, Martin; McCabe, Brian E; Ambrosia, Todd

    2017-03-02

    The objective of this study was to examine the relationship between nursing excellence and electronic health record adoption. Of 6582 US hospitals, 4939 were eligible for the Medicare Electronic Health Record Incentive Program, and 6419 were eligible for evaluation on the HIMSS Analytics Electronic Medical Record Adoption Model. Of 399 Magnet hospitals, 330 were eligible for the Medicare Electronic Health Record Incentive Program, and 393 were eligible for evaluation in the HIMSS Analytics Electronic Medical Record Adoption Model. Meaningful use attestation was defined as receipt of a Medicare Electronic Health Record Incentive Program payment. The adoption electronic health record was defined as Level 6 and/or 7 on the HIMSS Analytics Electronic Medical Record Adoption Model. Logistic regression showed that Magnet-designated hospitals were more likely attest to Meaningful Use than non-Magnet hospitals (odds ratio = 3.58, P < .001) and were more likely to adopt electronic health records than non-Magnet hospitals (Level 6 only: odds ratio = 3.68, P < .001; Level 6 or 7: odds ratio = 4.02, P < .001). This study suggested a positive relationship between Magnet status and electronic health record use, which involves earning financial incentives for successful adoption. Continued investigation is needed to examine the relationships between the quality of nursing care, electronic health record usage, financial implications, and patient outcomes.

  20. Medical Education Funding by Medicare. Hearing before the Subcommittee on Health of the Committee on Finance. United States Senate, Second Session.

    Science.gov (United States)

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

    Hearings on the status of medical education funded under the Medicare program are presented, with attention to how the program reimburses hospitals for medical education costs. The Social Security Act Amendments of 1983 provided for a radical reform in hospital payment. By the end of a 3-year phase-in period, the program was designed to set…

  1. Medication adherence behaviors of Medicare beneficiaries

    Directory of Open Access Journals (Sweden)

    Carr-Lopez SM

    2014-09-01

    Full Text Available Sian M Carr-Lopez,1 Allen Shek,1 Janine Lastimosa,2 Rajul A Patel,1 Joseph A Woelfel,1 Suzanne M Galal,1 Berit Gundersen1 1Pharmacy Practice Department, 2Thomas J Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA, USA Background: Medication adherence is crucial for positive outcomes in the management of chronic conditions. Comprehensive medication consultation can improve medication adherence by addressing intentional and unintentional nonadherence. The Medicare Part D prescription drug benefit has eliminated some cost barriers. We sought to examine variables that impact self-reported medication adherence behaviors in an ambulatory Medicare-beneficiary population and to identify the factors that influence what information is provided during a pharmacist consultation.Methods: Medicare beneficiaries who attended health fairs in northern California were offered medication therapy management (MTM services during which demographic, social, and health information, and responses to survey questions regarding adherence were collected. Beneficiaries were also asked which critical elements of a consultation were typically provided by their community pharmacist. Survey responses were examined as a function of demographic, socioeconomic, and health-related factors. Results: Of the 586 beneficiaries who were provided MTM services, 575 (98% completed the adherence questions. Of responders, 406 (70% reported taking medications “all of the time”. Of the remaining 169 (30%, the following reasons for nonadherence were provided: 123 (73% forgetfulness; 18 (11% side effects; and 17 (10% the medication was not needed. Lower adherence rates were associated with difficulty paying for medication, presence of a medication-related problem, and certain symptomatic chronic conditions. Of the 532 who completed survey questions regarding the content of a typical pharmacist consultation, the topics included: 378 (71% medication name and

  2. Medicare means-testing: a skeptical view.

    Science.gov (United States)

    Moon, Marilyn

    2004-01-01

    In response to claims that Medicare is unsustainable over time, Mark Pauly has suggested a means-testing approach as a solution to its financing problems. To obtain enough resources in this way, however, it is necessary to ask middle-class beneficiaries to pay much more for their health care, by subjecting them to vouchers. The spending limits Pauly suggests are arbitrary and would likely place an untenable burden on beneficiaries with modest incomes. A better approach to financing would be to examine the ability of both taxpayers and beneficiaries to pay in the future-likely resulting in a different outcome.

  3. All-cause mortality rates of hip fractures treated in the VHA: do they differ from Medicare facilities?

    Science.gov (United States)

    Lapcevic, William A; French, Dustin D; Campbell, Robert R

    2010-02-01

    To estimate the 1-year all-cause mortality rates for hip fracture (HFx) patients hospitalized at Veterans Health Administration (VHA) facilities and compare with previous published mortality rates for veterans treated in Medicare facilities. In total, 7 years of VHA discharge data on HFxs for 12,539 patients age 65 and older were combined with national death registry data. We performed a 1-year survival analysis using the Cox proportional hazard method. The adjusted rates for veterans treated in the VHA (30 days=9.3%, 90 days=17.5%, 180 days=23.3%, 365 days=29.8%) were similar to veterans treated in Medicare facilities (30 days=8.9%, 90 days=15.6%, 180 days=21.8%, 365 days=29.9%). For veterans treated for a HFx in Medicare facilities, the average length of stay was 7 days and 49% were discharged to a nursing home. Veterans treated in the VHA had an average length of stay of 14 days and only 35% were discharged to a nursing home. Our study suggests no difference in HFx-adjusted mortality rates between the VHA and Medicare facilities. Given the institutional factor differences between Medicare and the VHA, future study and comparison of health outcomes for nursing home HFx patients and related costs between these two health care programs may contribute to the on-going health care reform debate. Published by Elsevier Inc.

  4. 42 CFR 423.1974 - Medicare Appeals Council (MAC) review.

    Science.gov (United States)

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Medicare Appeals Council (MAC) review. 423.1974..., MAC review, and Judicial Review § 423.1974 Medicare Appeals Council (MAC) review. An enrollee who is dissatisfied with an ALJ hearing decision may request that the MAC review the ALJ's decision or dismissal as...

  5. 42 CFR 422.608 - Medicare Appeals Council (MAC) review.

    Science.gov (United States)

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Medicare Appeals Council (MAC) review. 422.608... and Appeals § 422.608 Medicare Appeals Council (MAC) review. Any party to the hearing, including the MA organization, who is dissatisfied with the ALJ hearing decision, may request that the MAC review...

  6. Institutional responses to Medicare's prospective payment system.

    Science.gov (United States)

    Maarse, H; Rooijakkers, D; Duzijn, R

    1993-10-01

    The introduction of Medicare's prospective payment system (PPS) meant an important change in the environment of US hospitals. The new payment system was expected to improve clinical and non-clinical efficiency in hospitals. A case study in a non-profit Pennsylvania hospital was performed to analyse the impact of PPS on hospital services. The hospital responded to PPS by a twofold strategy. First, attempts were made to achieve effective cost containment by improving the efficiency of intermediate and final outputs. Here special attention is paid to the activities of the DRG coordinator and the Utilization Review Committee and to the activities of nurses in their role as case manager. The second strategy was directed at revenue enhancement, initially mainly by shifting more costs to non-Medicare patients and later by trying to strengthen the position of the hospital in the local health care market. This second strategy was considered more important than the strategy of cost containment. With respect to organizational structure and policy-making, the following changes can be observed: a growing importance of strategic management; more integrated hospital-physician relationships; and the development of an adequate medical information system and a medical records department.

  7. Rural Medicare Advantage Plan Payment in 2015.

    Science.gov (United States)

    Kemper, Leah; Barker, Abigail R; McBride, Timothy D; Mueller, Keith

    2015-12-01

    Payment to Medicare Advantage (MA) plans was fundamentally altered in the Patient Protection and Affordable Care Act of 2010 (ACA). MA plans now operate under a new formula for county-level payment area benchmarks, and in 2012 began receiving quality-based bonus payments. The Medicare Advantage Quality Bonus Payment Demonstration expanded the bonus payments to most MA plans through 2014; however, with the end of the demonstration bonus payments has been reduced for intermediate quality MA plans. This brief examines the impact that these changes in MA baseline payment are having on MA plans and beneficiaries in rural and urban areas. Key Data Findings. (1) Payments to plans in rural areas were 3.9 percent smaller under ACA payment policies in 2015 than they would have been in the absence of the ACA. For plans in urban areas, the payments were 8.8 percent smaller than they would have been. These figures were determined using hypothetical pre-ACA and actual ACA-mandated benchmarks for 2015. (2) MA plans in rural areas received an average annual bonus payment of $326.77 per enrollee in 2014, but only $63.76 per enrollee in 2015, with the conclusion of the demonstration. (3) In 2014, 92 percent of rural MA beneficiaries were in a plan that received quality-based bonus payments under the demonstration, while in March 2015, 56 percent of rural MA beneficiaries were in a plan that was eligible for quality-based bonus payments.

  8. 75 FR 52629 - Medicare Program; Establishing Additional Medicare Durable Medical Equipment, Prosthetics...

    Science.gov (United States)

    2010-08-27

    ..., hospital beds, nebulizers, oxygen delivery systems, and wheelchairs. Prosthetic devices are included in the... using wheelchairs. In Sec. 424.57(c)(8), we proposed to clarify this provision by revising (c)(8) to... for inventory, storage, including patient records, a desk and chairs, and in most cases a restroom for...

  9. 78 FR 79081 - Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid...

    Science.gov (United States)

    2013-12-27

    ... Health Preparedness and Response OPO Organ Procurement Organization OPT Outpatient Physical Therapy OPTN..., and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology... Outpatient Physical Therapy and Speech-Language Pathology (``Organizations'')--Testing (Sec. 485.727(d)(2)(i...

  10. 78 FR 59702 - Medicare Program; Medicare Appeals: Adjustment to the Amount in Controversy Threshold Amounts for...

    Science.gov (United States)

    2013-09-27

    ... & Medicaid Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice announces the annual adjustment in the... notice is effective on January 1, 2014. FOR FURTHER INFORMATION CONTACT: Liz Hosna ( Katherine.Hosna@cms... Improvement and Protection Act of 2000 (BIPA), established the amount in controversy (AIC) threshold...

  11. 76 FR 44011 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Science.gov (United States)

    2011-07-22

    ... regarding antivascular endothelial growth factor (anti-VEGF) treatment of diabetic macular edema (DME). This... endothelial growth factor (anti-VEGF) treatment of diabetic macular edema (DME). Background information about... organizations with expertise in the treatment of diabetic retinopathy (DR) and DME. II. Meeting Format This...

  12. 76 FR 53477 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Science.gov (United States)

    2011-08-26

    ... growth factor (anti-VEGF) treatment of diabetic macular edema (DME). This meeting is open to the public... regarding antivascular endothelial growth factor (anti-VEGF) treatment of diabetic macular edema (DME... participation of appropriate organizations with expertise in the treatment of diabetic retinopathy (DR) and DME...

  13. 75 FR 78705 - Medicare Program; Request for Nominations for Members for the Medicare Evidence Development...

    Science.gov (United States)

    2010-12-16

    ... clinical medicine of all specialties, administrative medicine, public health, biologic and physical...: Clinical medicine of all specialties Administrative medicine Public health Patient advocacy Biologic...

  14. 75 FR 4095 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Science.gov (United States)

    2010-01-26

    ... stimulating agents (ESAs) to manage anemia in patients who have chronic kidney disease. This meeting is open... have chronic kidney disease. Background information about this topic, including panel materials, is... with expertise in renal insufficiency/kidney disease, anemia, and ESAs. II. Meeting Format This...

  15. 75 FR 43178 - Medicare Program; Solicitation for Proposals for the Medicare Imaging Demonstration

    Science.gov (United States)

    2010-07-23

    ... (for example, collated, tabulated color copies). Hard copies and electronic copies must be identical... test whether the use of decision support systems (DSSs) can improve quality of care and reduce... ordering of the specified services and test results, and provide feedback to physicians on...

  16. 75 FR 8982 - Medicare Program; Request for Nominations for Members for the Medicare Evidence Development...

    Science.gov (United States)

    2010-02-26

    ... evaluates medical literature, reviews technology assessments, and examines data and information on the... information management and analysis The economics of health care Medical ethics Other related professions such.... FOR FURTHER INFORMATION CONTACT: Maria Ellis, Executive Secretary for MEDCAC, Centers for...

  17. 76 FR 58514 - Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports

    Science.gov (United States)

    2011-09-21

    ... estimation involving economics and actuarial science. Panelists are not restricted, however, in the topics... on the actuarial and economic assumptions and methods by which Trustees might more accurately...

  18. 76 FR 52955 - Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports

    Science.gov (United States)

    2011-08-24

    ... highly technical aspects of estimation involving economics and actuarial science. Panelists are not... nature and will focus on the actuarial and economic assumptions and methods by which Trustees might...

  19. 77 FR 16841 - Medicare Program; Solicitation for Proposals for the Medicare Graduate Nurse Education...

    Science.gov (United States)

    2012-03-22

    ... hospital'' may apply to perform the responsibilities specified. Section 5509(e)(5) of the ACA defines an ``eligible hospital'' to mean a hospital (as defined in section 1861(e) of the Social Security Act (the Act... training. See section 5509(e) of the ACA for the definitions of the terms used in the preceding...

  20. 75 FR 58405 - Medicare Program; Meeting of the Advisory Panel on Medicare Education, October 13, 2010

    Science.gov (United States)

    2010-09-24

    ...., Partner, Sonora Advisory Group; Carmen R. Green, M.D., Professor, Anesthesiology and Associate Professor... browser, and Adobe Flash Player Version 8 or later to attend a Web conference. Connect Pro supports nearly...

  1. 76 FR 71573 - Medicare Program; Request for Nominations for Members for the Medicare Evidence Development...

    Science.gov (United States)

    2011-11-18

    ... representatives of professional associations or societies. We wish to ensure adequate representation of the interests of both women and men, members of all ethnic groups and physically challenged individuals... professional associations or societies. We wish to ensure adequate representation of the interests of both...

  2. 78 FR 63986 - Medicare Program; Request for Nominations for Members for the Medicare Evidence Development...

    Science.gov (United States)

    2013-10-25

    ... representation of the interests of both women and men, members of all ethnic groups and physically challenged... representatives of professional associations or societies. We wish to ensure adequate representation of the interests of both women and men, members of all ethnic groups and physically challenged individuals...

  3. 77 FR 50110 - Medicare Program; Request for Nominations for Members for the Medicare Evidence Development...

    Science.gov (United States)

    2012-08-20

    ... societies. We wish to ensure adequate representation of the interests of both women and men, members of all... representatives of professional associations or societies. We wish to ensure adequate representation of the interests of both ] women and men, members of all ethnic groups and physically challenged individuals...

  4. 75 FR 3742 - Medicare Program; Meeting of the Advisory Panel on Medicare Education; Cancellation of the...

    Science.gov (United States)

    2010-01-22

    ... Accommodations: Wednesday, March 17, 2010, 5 p.m., e.d.t. ADDRESSES: Meeting Location: Hilton Washington Hotel... Cancer Research, Whittingham Cancer Center at Norwalk Hospital; Dr. Carmen R. Green, Director, Pain...

  5. 75 FR 30043 - Medicare Program; Meeting of the Advisory Panel on Medicare Education

    Science.gov (United States)

    2010-05-28

    ... Accommodations: Tuesday, June 8, 2009, 5 p.m., e.d.t. ADDRESSES: Meeting Location: Hilton Washington Hotel... Advisory Group; Carmen R. Green, M.D., Professor, Anesthesiology and Associate Professor, Health...

  6. 75 FR 68790 - Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual Deductible...

    Science.gov (United States)

    2010-11-09

    ... has been set for a given year, a contingency reserve ratio in excess of 20 percent of the following... deductible is calculated by multiplying the 2010 deductible by the ratio of the 2011 aged actuarial rate over... larger Part B contingency reserve than would otherwise be necessary. The asset level projected for...

  7. 78 FR 64943 - Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual Deductible...

    Science.gov (United States)

    2013-10-30

    ... percent reserve ratio has been the normal target used to calculate the Part B premium. In view of the... physician update, a contingency reserve ratio in excess of 20 percent of the following year's expenditures... deductible by the ratio of the 2014 aged actuarial rate to the 2013 aged actuarial rate. The...

  8. 76 FR 67572 - Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual Deductible...

    Science.gov (United States)

    2011-11-01

    ... has been set for a given year, a contingency reserve ratio in excess of 20 percent of the following... deductible by the ratio of the 2012 aged actuarial rate over the 2011 aged actuarial rate. The amount... physician fees in 2012, it is appropriate to maintain a significantly larger Part B contingency reserve...

  9. 77 FR 69850 - Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual Deductible...

    Science.gov (United States)

    2012-11-21

    ... sequestration, a contingency reserve ratio in excess of 20 percent of the following year's expenditures would... legislation, then the Part B asset reserve ratio for December 31, 2013 would be approximately 9.3 percentage... reserve ratios at the end of 2013 would be reduced by approximately another 2 percentage points....

  10. 78 FR 13059 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Science.gov (United States)

    2013-02-26

    ... cancers of unknown primary site and for cervical cytology findings of uncertain clinical significance... PowerPoint presentation materials and writings that will be used in support of an oral presentation is 5... selected genetic tests for cancer diagnosis (for cancers of unknown primary site and for cervical...

  11. Adding a Prescription Drug Benefit to Medicare: An Analysis of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003

    Science.gov (United States)

    2004-09-01

    unpredictable and potentially high costs ( Marmor , 2000). The missing benefit was outpatient prescription drug coverage. On July 30th, President Johnson...Proposed Medicare Benefit At-a-Glance Chart. Retrieved September 12, 2004, from: http://www.kff.org/medicare/ medicarebenefitataglance.cfm Marmor , T.R

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

    Science.gov (United States)

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

    2010-07-01

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

  13. Medicare and State Health Care Programs: Fraud and Abuse; Revisions to the Safe Harbors Under the Anti-Kickback Statute and Civil Monetary Penalty Rules Regarding Beneficiary Inducements. Final rule.

    Science.gov (United States)

    2016-12-07

    In this final rule, OIG amends the safe harbors to the anti-kickback statute by adding new safe harbors that protect certain payment practices and business arrangements from sanctions under the anti-kickback statute. The OIG also amends the civil monetary penalty (CMP) rules by codifying revisions to the definition of "remuneration," added by the Balanced Budget Act (BBA) of 1997 and the Patient Protection and Affordable Care Act, Public Law 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010 (ACA). This rule updates the existing safe harbor regulations and enhances flexibility for providers and others to engage in health care business arrangements to improve efficiency and access to quality care while protecting programs and patients from fraud and abuse.

  14. Executive function, episodic memory, and Medicare expenditures.

    Science.gov (United States)

    Bender, Alex C; Austin, Andrea M; Grodstein, Francine; Bynum, Julie P W

    2017-07-01

    We examined the relationship between health care expenditures and cognition, focusing on differences across cognitive systems defined by global cognition, executive function, or episodic memory. We used linear regression models to compare annual health expenditures by cognitive status in 8125 Nurses' Health Study participants who completed a cognitive battery and were enrolled in Medicare parts A and B. Adjusting for demographics and comorbidity, executive impairment was associated with higher total annual expenditures of $1488 per person (P executive function, but not episodic memory ($584 higher for every 1 standard deviation decrement in executive function; P executive function is specifically and linearly associated with higher health care expenditures. Focusing on management strategies that address early losses in executive function may be effective in reducing costly services. Copyright © 2017 the Alzheimer's Association. Published by Elsevier Inc. All rights reserved.

  15. Health and Health Care of Medicare Beneficiaries in 2030

    Science.gov (United States)

    Gaudette, Étienne; Tysinger, Bryan; Cassil, Alwyn; Goldman, Dana P.

    2016-01-01

    On Medicare’s 50th anniversary, we use the Future Elderly Model (FEM) – a microsimulation model of health and economic outcomes for older Americans – to generate a snapshot of changing Medicare demographics and spending between 2010 and 2030. During this period, the baby boomers, who began turning 65 and aging into Medicare in 2011, will drive Medicare demographic changes, swelling the estimated US population aged 65 or older from 39.7 million to 67.0 million. Among the risks for Medicare sustainability, the size of the elderly population in the future likely will have the highest impact on spending but is easiest to forecast. Population health and the proportion of the future elderly with disabilities are more uncertain, though tools such as the FEM can provide reasonable forecasts to guide policymakers. Finally, medical technology breakthroughs and their effect on longevity are most uncertain and perhaps riskiest. Policymakers will need to keep these risks in mind if Medicare is to be sustained for another 50 years. Policymakers may also want to monitor the equity of Medicare financing amid signs that the program’s progressivity is declining, resulting in higher-income people benefiting relatively more from Medicare than lower-income people. PMID:27127455

  16. Effect of Medicare's Nonpayment for Hospital-Acquired Conditions Lessons for Future Policy

    Science.gov (United States)

    Waters, Teresa M.; Daniels, Michael J.; Bazzoli, Gloria J.; Perencevich, Eli; Dunton, Nancy; Staggs, Vincent S.; Potter, Catima; Fareed, Naleef; Liu, Minzhao; Shorr, Ronald I.

    2017-01-01

    Importance In 2008, Medicare implemented the Hospital-Acquired Conditions (HACs) Initiative, a policy denying incremental payment for 8 complications of hospital care, also known as never events. The regulation's effect on these events has not been well studied. Objective To measure the association between Medicare's nonpayment policy and 4 outcomes addressed by the HACs Initiative: central line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), hospital-acquired pressure ulcers (HAPUs), and injurious inpatient falls. Design, Setting, And Participants Quasi-experimental study of adult nursing units from 1381 US hospitals participating in the National Database of Nursing Quality Indicators (NDNQI), a program of the American Nurses Association. The NDNQI data were combined with American Hospital Association, Medicare Cost Report, and local market data to examine adjusted outcomes. Multilevel models were used to evaluate the effect of Medicare's nonpayment policy on never events. Exposures United States hospitals providing treatment for Medicare patients were subject to the new payment policy beginning in October 2008. Main Outcomes And Measures Changes in unit-level rates of HAPUs, injurious falls, CLABSIs, and CAUTIs after initiation of the policy. Results Medicare's nonpayment policy was associated with an 11% reduction in the rate of change in CLABSIs (incidence rate ratio [IRR], 0.89; 95% CI, 0.83-0.95) and a 10% reduction in the rate of change in CAUTIs (IRR, 0.90; 95% CI, 0.85-0.95), but was not associated with a significant change in injurious falls (IRR, 0.99; 95% CI, 0.99-1.00) or HAPUs (odds ratio, 0.98; 95% CI, 0.96-1.01). Consideration of unit-, hospital-, and market-level factors did not significantly alter our findings. Conclusions And Relevance The HACs Initiative was associated with improvements in CLABSI and CAUTI trends, conditions for which there is strong evidence that better hospital processes

  17. Postoperative Staphylococcus aureus infections in Medicare beneficiaries.

    Directory of Open Access Journals (Sweden)

    Moaven Razavi

    Full Text Available Staphylococcus aureus (S. aureus infections are important because of their increasing frequency, resistance to antibiotics, and high associated rates of disabilities and deaths. We examined the incidence and correlates of S. aureus infections following 219,958 major surgical procedures in a 5% random sample of fee-for-service Medicare beneficiaries from 2004-2007. Of these surgical patients, 0.3% had S. aureus infections during the hospitalizations when index surgical procedures were performed; and 1.7% and 2.3%, respectively, were hospitalized with infections within 60 days or 180 days following admissions for index surgeries. S. aureus infections occurred within 180 days in 1.9% of patients following coronary artery bypass graft surgery, 2.3% following hip surgery, and 5.9% following gastric or esophageal surgery. Of patients first hospitalized with any major infection reported during the first 180 days after index surgery, 15% of infections were due to S. aureus, 18% to other documented organisms, and no specific organism was reported on claim forms in 67%. Patient-level predictors of S. aureus infections included transfer from skilled nursing facilities or chronic hospitals and comorbid conditions (e.g., diabetes, congestive heart failure, chronic obstructive pulmonary disease, and chronic renal disease. In a logarithmic regression, elective index admissions with S. aureus infection stayed 130% longer than comparable patients without that infection. Within 180 days of the index surgery, 23.9% of patients with S. aureus infection and 10.6% of patients without this infection had died. In a multivariate logistic regression of death within 180 days of admission for the index surgery with adjustment for demographics, co-morbidities, and other risks, S. aureus was associated with a 42% excess risk of death. Due to incomplete documentation of organisms in Medicare claims, these statistics may underestimate the magnitude of S. aureus infection

  18. The evolution of Medicare financing policy for graduate medical education and implications for PM&R: a commentary.

    Science.gov (United States)

    Verville, R; DeLisa, J A

    2001-04-01

    Currently, the only explicit payers for graduate medical education (GME) in the United States are the federal and state governments. Of these, Medicare is by far the largest and most predictable payer. Through the prospective payment system, Medicare reimburses teaching institutions for both their direct and indirect costs associated with their GME programs. Because a well-educated workforce benefits patients covered by private, as well as public insurance, various proposals have been advanced to establish an all-payer pool to distribute the financial burden more equitably. Furthermore, Medicare policy affects physician supply. There is increasing recognition of potential physician oversupply, raising policy questions about the government's longstanding support of GME. In comparison with other specialties, physical medical and rehabilitation (PM&R) may receive more favorable treatment under future GME funding plans, for 2 reasons. First, under the formulas used by Medicare, PM&R training slots typically bring in more indirect revenue to teaching hospitals than is consumed in indirect expenses. This makes PM&R a relatively more attractive program to retain in the face of mandated reductions in training slots. Second, in many parts of the country, PM&R is not threatened by oversupply, making cuts less likely. Nevertheless, the high percentage of non-US medical graduates entering PM&R training may make the specialty vulnerable to future reductions in funded training slots.

  19. Canadian political science and medicare: six decades of inquiry.

    Science.gov (United States)

    O'Neill, Michael A; McGuinty, Dylan; Teskey, Bryan

    2011-05-01

    Based on an extensive sample of the literature, this critical review dissects the principal themes that have animated the Canadian political science profession on the topic of medicare. The review considers the coincidence of economic eras and how these are reflected in the methodological approaches to the study of medicare. As is to be expected, most of the scholarly activity coincides with the economic era marked by fiscal restraint and decreases in social investments (1993-2003). At the same time, the review notes the prevalence of institutionalism as an approach to the topic and the scholarly community's near-consensus on medicare as a defining characteristic of the country and its people.

  20. The National Market for Medicare Clinical Laboratory Testing

    Data.gov (United States)

    U.S. Department of Health & Human Services — Current Medicare payment policy for outpatient laboratory services is outdated. Future reforms, such as competitive bidding, should consider the characteristics of...

  1. Cooperative Medicare System:A Boon for Farmers And Herders

    Institute of Scientific and Technical Information of China (English)

    SOINAMDAGYI

    2003-01-01

    Amedical system for farmers and herders has always been uppermost in the minds of the CentralGovernment and the people'sgovernment of the Tibet AutonomousRegion. The free medicare system introduced in Tibetan farming and pastoral areas

  2. Medicare Part D Prescriber Look-up Tool

    Data.gov (United States)

    U.S. Department of Health & Human Services — This look-up tool is a searchable database that allows you to look up a Medicare Part D prescriber by National Provider Identifier (NPI), or by name and location....

  3. Use of Hospitalists by Medicare Benes, A National Picture

    Data.gov (United States)

    U.S. Department of Health & Human Services — The number of physicians working as hospitalists is thought to have increased dramatically since the term emerged in 1990. In Use of Hospitalists by Medicare...

  4. Medicare Advantage-Part D Contract and Enrollment Data

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Medicare Advantage (MA) - Part D Contract and Enrollment Data section serves as a centralized repository for publicly available data on contracts and plans,...

  5. The National Market for Medicare Clinical Laboratory Testing

    Data.gov (United States)

    U.S. Department of Health & Human Services — Current Medicare payment policy for outpatient laboratory services is outdated. Future reforms, such as competitive bidding, should consider the characteristics of...

  6. Office of Medicare Hearings and Appeals (OMHA) - Receipts by Procedure

    Data.gov (United States)

    U.S. Department of Health & Human Services — This data set provides information about the appeals and claims received by the Office of Medicare and Hearings by procedure for Fiscal Year 2006 - 2012.

  7. Medicare Payment: Surgical Dressings and Topical Wound Care Products.

    Science.gov (United States)

    Schaum, Kathleen D

    2014-08-01

    Medicare patients' access to surgical dressings and topical wound care products is greatly influenced by the Medicare payment system that exists in each site of care. Qualified healthcare professionals should consider these payment systems, as well as the medical necessity for surgical dressings and topical wound care products. Scientists and manufacturers should also consider these payment systems, in addition to the Food and Drug Administration requirements for clearance or approval, when they are developing new surgical dressings and topical wound care products. Due to the importance of the Medicare payment systems, this article reviews the Medicare payment systems in acute care hospitals, long-term acute care hospitals, skilled nursing facilities, home health agencies, durable medical equipment suppliers, hospital-based outpatient wound care departments, and qualified healthcare professional offices.

  8. Characteristics of otolaryngology claims to Medicare in 2012.

    Science.gov (United States)

    Bhattacharyya, Neil; Lin, Harrison W

    2014-11-01

    The Medicare provider utilization and payment public use datafile for 2012 was analyzed with respect to otolaryngology specialty providers to characterize otolaryngology services billed to and reimbursed by Medicare, both overall and according to provider characteristics. Among 8450 otolaryngology specialty providers submitting claims, the top 5 billed services were (count in millions): 99213 (2.23), 95165 (1.81), 99203 (0.92), 99214 (0.83), and 69210 (0.71), and the top 5 total reimbursed services were (aggregate total reimbursements in millions): 99213 ($114), 99203 ($68), 99214 ($63), 31231 ($60), and 31575 ($47). There was a mean of 1567 services billed per provider with an average (yearly) total reimbursement from Medicare of $76,068 per provider. These data characterize the current level of provision of otolaryngology services to the Medicare population. © American Academy of Otolaryngology-Head and Neck Surgery Foundation 2014.

  9. Basic Stand Alone Medicare Prescription Drug Events PUF

    Data.gov (United States)

    U.S. Department of Health & Human Services — This is a Public Use File for Prescription Drug Events drawn from the 2008 Beneficiary Summary File of Medicare beneficiaries enrolled during the calendar year 2008,...

  10. Basic Stand Alone Medicare Claims Public Use Files

    Data.gov (United States)

    U.S. Department of Health & Human Services — CMS is committed to increasing access to its Medicare claims data through the release of de-identified data files available for public use. They contain...

  11. Basic Stand Alone Medicare Home Health Beneficiary PUF

    Data.gov (United States)

    U.S. Department of Health & Human Services — This release contains the Basic Stand Alone (BSA) Home Health Agency (HHA) Beneficiary Public Use Files (PUF) with information from Medicare HHA claims. The CMS BSA...

  12. Basic Stand Alone Medicare DME Line Items PUF

    Data.gov (United States)

    U.S. Department of Health & Human Services — This release contains the Basic Stand Alone (BSA) Durable Medical Equipment (DME) Line Items Public Use Files (PUF) with information from Medicare DME claims. The...

  13. The price sensitivity of Medicare beneficiaries: a regression discontinuity approach.

    Science.gov (United States)

    Buchmueller, Thomas C; Grazier, Kyle; Hirth, Richard A; Okeke, Edward N

    2013-01-01

    We use 4 years of data from the retiree health benefits program of the University of Michigan to estimate the effect of price on the health plan choices of Medicare beneficiaries. During the period of our analysis, changes in the University's premium contribution rules led to substantial price changes. A key feature of this 'natural experiment' is that individuals who had retired before a certain date were exempted from having to pay any premium contributions. This 'grandfathering' creates quasi-experimental variation that is ideal for estimating the effect of price. Using regression discontinuity methods, we compare the plan choices of individuals who retired just after the grandfathering cutoff date and were therefore exposed to significant price changes to the choices of a 'control group' of individuals who retired just before that date and therefore did not experience the price changes. The results indicate a statistically significant effect of price, with a $10 increase in monthly premium contributions leading to a 2 to 3 percentage point decrease in a plan's market share. Copyright © 2012 John Wiley & Sons, Ltd.

  14. Changing BMI Categories and Healthcare Expenditures Among Elderly Medicare Beneficiaries

    OpenAIRE

    Wilkins, Tricia Lee; Rust, George S.; Sambamoorthi, Usha

    2011-01-01

    To examine the association between changes in BMI categories and health-care expenditures among elderly Medicare beneficiaries using longitudinal data of the Medicare Current Beneficiary Survey (MCBS) 2000–2005. Changes in BMI were (i) Stayed Normal: individuals with a normal BMI at baseline and follow-up; (ii) Stayed Overweight individuals with overweight BMI at baseline and follow-up; (iii) Stayed Obese individuals with obese BMI at baseline and follow-up; (iv) Normal-Overweight: individual...

  15. General Revenue Financing of Medicare: Who Will Bear the Burden?

    OpenAIRE

    Johnson, Janet L.; Long, Stephen H.

    1982-01-01

    Two recent national advisory committees on Social Security recommended major shifts in Medicare financing to preserve the financial viability of the Social Security trust funds. This paper estimates the income redistribution consequences of the two proposals, in contrast to current law, using a micro-simulation model of taxes and premiums. These estimates show that while the current Medicare financing package is mildly progressive, the new proposals would substantially increase income redistr...

  16. Impact of Medicare's prospective payment system on hospitals, skilled nursing facilities, and home health agencies: how the Balanced Budget Act of 1997 may have altered service patterns for Medicare providers.

    Science.gov (United States)

    Kulesher, Robert R

    2006-01-01

    The prospective payment system is one of many changes in reimbursement that has affected the delivery of health care. Originally developed for the payment of inpatient hospital services, it has become a major factor in how all health insurance is reimbursed. The policy implications extend beyond the Medicare program and affect the entire health care delivery system. Initially implemented in 1982 for payments to hospitals, prospective payment system was extended to payments for skilled nursing facility and home health agency services by the Balanced Budget Act of 1997. The intent of the Balanced Budget Act was to bring into balance the federal budget through reductions in spending. The decisions that providers have made to mitigate the impact are a function of ownership type, organizational mission, and current level of Medicare participation. This article summarizes the findings of several initial studies on the Balanced Budget Act's impact and discusses how changes in Medicare reimbursement policy have influenced the delivery of health care for the general public and for Medicare beneficiaries.

  17. Gallbladder surgery for Medicare patients in Mississippi.

    Science.gov (United States)

    Cobb, A B; Sanchez, N; Miller, D

    1994-10-01

    Mississippi Foundation for Medical Care (MFMC) conducted a review of gallbladder surgery performed on Mississippi Medicare Patients using hospital claims files and limited record review for verification of claims file data. Significant error rates in the surgeon identification number were found in the claims files. It should also be noted that the current ICD-9-CM coding system does not allow for identification of laparoscopic cholecystectomies converted to open procedures. Past studies have attempted to use claims data alone for these types of analyses. These findings demonstrate the importance of using caution by those attempting to use claims data (without verification) to define patterns of hospital utilization, clinical outcomes and/or physician profiling. Claims data must be tested for validity for reliable pattern analysis. In addition, considerable variation was found among providers in elements such as conversion rates, complication and readmission rates. A few surgeons showed patterns for critical variables that were quite different from the universe. There was however, no statistically significant differences associated between volume of cases performed and outcomes. Time frame comparisons over several years show significant (> 80%) increase in gallbladder surgery since the introduction of the laparoscopic procedure.

  18. Medicare Program; End-Stage Renal Disease Prospective Payment System, Coverage and Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program, Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding Program Bid Surety Bonds, State Licensure and Appeals Process for Breach of Contract Actions, Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding Program and Fee Schedule Adjustments, Access to Care Issues for Durable Medical Equipment; and the Comprehensive End-Stage Renal Disease Care Model. Final rule.

    Science.gov (United States)

    2016-11-04

    This rule updates and makes revisions to the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for calendar year 2017. It also finalizes policies for coverage and payment for renal dialysis services furnished by an ESRD facility to individuals with acute kidney injury. This rule also sets forth requirements for the ESRD Quality Incentive Program, including the inclusion of new quality measures beginning with payment year (PY) 2020 and provides updates to programmatic policies for the PY 2018 and PY 2019 ESRD QIP. This rule also implements statutory requirements for bid surety bonds and state licensure for the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP). This rule also expands suppliers' appeal rights in the event of a breach of contract action taken by CMS, by revising the appeals regulation to extend the appeals process to all types of actions taken by CMS for a supplier's breach of contract, rather than limit an appeal for the termination of a competitive bidding contract. The rule also finalizes changes to the methodologies for adjusting fee schedule amounts for DMEPOS using information from CBPs and for submitting bids and establishing single payment amounts under the CBPs for certain groupings of similar items with different features to address price inversions. Final changes also are made to the method for establishing bid limits for items under the DMEPOS CBPs. In addition, this rule summarizes comments on the impacts of coordinating Medicare and Medicaid Durable Medical Equipment for dually eligible beneficiaries. Finally, this rule also summarizes comments received in response to a request for information related to the Comprehensive ESRD Care Model and future payment models affecting renal care.

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

    Science.gov (United States)

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

    2013-01-01

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

  20. 76 FR 61103 - Medicare Program; Comprehensive Primary Care Initiative

    Science.gov (United States)

    2011-10-03

    ... improvement, and meaningful use of health information technology can achieve the three-part aim of better care... Center's approach to supporting comprehensive primary care. Learning systems will support participating... savings will not be a part of the payment methodology for Medicaid fee-for-service. III. Collection...

  1. Medicare incentive payments for meaningful use of electronic health records: accounting and reporting developments.

    Science.gov (United States)

    2012-02-01

    The Healthcare Financial Management Association through its Principles and Practices (P&P) Board publishes issue analyses to provide short-term practical assistance on emerging issues in healthcare financial management. In a new issue analysis excerpted in this article, HFMA's P&P Board provides some clarity to the healthcare industry on certain accounting and reporting issues resulting from incentive payments under the Medicare program for the meaningful use of electronic health record (EHR) technology. Consultation on these matters with independent auditors is highly recommended.

  2. Medicare-VHA dual use is associated with poorer chronic wound healing.

    Science.gov (United States)

    Bouldin, Erin D; Littman, Alyson J; Wong, Edwin; Liu, Chuan-Fen; Taylor, Leslie; Rice, Kenneth; Reiber, Gayle E

    2016-09-01

    Veterans who use Veterans Health Affairs (VHA) have the option of enrolling in and obtaining care from other non-VA sources. Dual system use may improve care by increasing options or it may result in poorer outcomes because of fragmented care. Our objective was to assess whether dual system use of VHA and Medicare for wound care was associated with chronic wound healing. We conducted a retrospective cohort study of 227 Medicare-enrolled VHA users in the Pacific Northwest who had an incident, chronic lower limb wound between October 1, 2006 and September 30, 2007 identified through VHA chart review. All wounds were followed until resolution or for up to one year. Dual system wound care was identified through Medicare claims during follow-up. We used a proportional hazards model to compare wound healing among VHA-exclusive and dual wound care users, using a time-varying measure of dual use and treating amputation and death as competing risks. About 18.1% of subjects were classified as dual wound care users during follow-up. After adjustment using propensity scores, dual use was associated with a significantly lower hazard of wound healing compared to VHA-exclusive use (HR = 0.63, 95%CI: 0.39-0.99, p = 0.047). Hazards for the competing risks, amputation (HR = 4.23, 95% CI: 1.61-11.15, p = 0.003) and death (HR = 3.08, 95%CI: 1.11-8.56, p = 0.031), were significantly higher for dual users compared to VHA-exclusive users. Results were similar in inverse probability of treatment weighted analyses and in sensitivity analyses that excluded veterans enrolled in a Medicare managed care plan and that used a revised wound resolution date based on Medicare claims data, but were not always statistically significant. Overall, dual wound care use was associated with substantially poorer wound healing compared to VHA-exclusive wound care use. VHA may need to design programs or policies that support and improve care coordination for veterans needing chronic

  3. TRICARE; constructive eligibility for TRICARE benefits of certain persons otherwise ineligible under retroactive determination of entitlement to Medicare Part A hospital insurance benefits. Final rule.

    Science.gov (United States)

    2012-06-27

    The Department is publishing this final rule to implement section 706 of the National Defense Authorization Act (NDAA) for Fiscal Year 2010, Public Law 111-84. Specifically, section 706 exempts TRICARE beneficiaries under the age of 65 who become disabled from the requirement to enroll in Medicare Part B for the retroactive months of entitlement to Medicare Part A in order to maintain TRICARE coverage. This statutory amendment and final rule only impact eligibility for the period in which the beneficiary's disability determination is pending before the Social Security Administration. Eligible beneficiaries are still required to enroll in Medicare Part B in order to maintain their TRICARE coverage for future months, but are considered to have coverage under the TRICARE program for the retroactive months of their entitlement to Medicare Part A. This final rule also amends the eligibility section of the TRICARE regulation to more clearly address reinstatement of TRICARE eligibility following a gap in coverage due to lack of enrollment in Medicare Part B.

  4. Epidemiology of Medicare abuse: the example of power wheelchairs.

    Science.gov (United States)

    Goodwin, James S; Nguyen-Oghalai, Tracy U; Kuo, Yong-Fang; Ottenbacher, Kenneth J

    2007-02-01

    To determine the effect of neighborhood ethnic composition on power wheelchair prescriptions. The 5% noncancer sample of Medicare recipients in the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database, from 1994 to 2001. SEER regions. Individuals covered by Medicare living in SEER regions without a cancer diagnosis. Individual characteristics (age, sex, ethnicity, justifying diagnosis, and comorbidity), primary diagnoses, neighborhood characteristics (percentage black, percentage Hispanic, percentage with multilevel, multivariate analyses, individuals living in neighborhoods with higher percentages of blacks or Hispanics were more likely to receive power wheelchairs (odds ratios=1.09 for each 10% increase in black residents and 1.23 for each 10% increase in Hispanic residents) after controlling for ethnicity and other characteristics at the individual level. These results support allegations that marketers promoting power wheelchairs have specifically targeted minority neighborhoods.

  5. Clinician feedback on using episode groupers with Medicare claims data.

    Science.gov (United States)

    Thomas, Fred; Caplan, Craig; Levy, Jesse M; Cohen, Marty; Leonard, James; Caldis, Todd; Mueller, Curt

    2010-01-01

    CMS is investigating techniques that might help identify costly physician practice patterns. One method presently under evaluation is to compare resource use for certain episodes of care using commercially available episode grouping software. Although this software has been used by the private sector to classify insured individuals' medical claims into episodes of care, it has never been used with fee-for-service Medicare claims except in the studies by the Medicare Payment Advisory Commission (MedPAC) and CMS. This study reviews and reports on clinician feedback on the most obvious and important decisions that must be faced by Medicare to use grouped claims data as the foundation for a physician performance measurement system. The panel reactions show the importance of bringing persons with clinical knowledge into the development process. The clinician feedback confirms that additional research is needed.

  6. Peer-to-peer interprofessional health policy education for Medicare part D.

    Science.gov (United States)

    Lipton, Helene L; Lai, Cindy J; Cutler, Timothy W; Smith, Amanda R; Stebbins, Marilyn R

    2010-08-10

    To determine whether a peer-to-peer education program was an expedient and effective approach to improve knowledge and promote interprofessional communication and collaboration. Trained pharmacy students taught nursing students, medical students, and medical residents about the Medicare Part D prescription drug benefit (Part D), in 1- to 2-hour lectures. Learners completed a survey instrument to assess the effectiveness of the presentation and their attitudes toward the peer-to-peer instructional format. Learners strongly or somewhat agreed that the peer-to-peer format was effective in providing Part D education (99%) and promoted interprofessional collaboration (100%). Qualitative data highlighted the program's clinical relevance, value in promoting interprofessional collaboration, and influence on changing views about the roles and contributions of pharmacists. The Part D peer educator program is an innovative way to disseminate contemporary health policy information rapidly, while fostering interprofessional collaboration.

  7. Medicare and Other Health Benefits: Your Guide to Who Pays First

    Science.gov (United States)

    ... ready to retire and enroll in Medicare. Harry’s wife Jane, 63, works for a large company with ... IEQ. He reports he has coverage through his wife’s employment. After Harry becomes entitled to Medicare, his ...

  8. Justice implications of a proposed Medicare prescription drug policy.

    Science.gov (United States)

    Larkin, Heather

    2004-07-01

    Social justice is a core value to the mission of social work. Older people are among the most vulnerable populations for whom social workers are called on to advocate. Although Medicare prescription drug coverage has been a top legislative issue over the past few years, such a benefit expansion has yet to be implemented. This article examines the historical context of Medicare and reviews the proposals for prescription drug coverage, identifying the concerns raised. Literature critiquing the justice dimensions of health care for the elderly population is reviewed. Justice claims are identified and refined, and social justice theories are used in the analysis of the proposed policies.

  9. How Medicare could get better prices on prescription drugs.

    Science.gov (United States)

    Outterson, Kevin; Kesselheim, Aaron S

    2009-01-01

    Congress may reform drug pricing policies under Medicare Part D as part of a larger health reform effort. Currently, the "noninterference" provision prevents the government from negotiating drug prices on behalf of Medicare Part D prescription drug plans. Commonly considered reform proposals borrow ideas from Medicaid, either through returning dual eligibles to Medicaid drug pricing or by imposing mandatory rebates across the Part D population. We examine a menu of other options, including value-based pricing; expansion of generic and therapeutically equivalent substitution; increased formulary diversity; importation; and limited antitrust waivers. These latter options may reduce federal spending without direct government price negotiations.

  10. Part C and Part D - Program Audits

    Data.gov (United States)

    U.S. Department of Health & Human Services — The purpose of this Web page is to increase transparency related to the Medicare Advantage and Prescription Drug Plan program audits, and other various types of...

  11. Attitudes of Medicare-eligible Americans toward mail service pharmacy.

    Science.gov (United States)

    Rupp, Michael T

    2013-09-01

    For many years, community pharmacies provided mail delivery as a convenience for a small segment of special circumstance patients who requested it. Fueled by a movement among plan sponsors and prescription benefit managers to encourage or require its use, growth in mail service pharmacy began to accelerate in the 1980s and now accounts for nearly 25% of the market in the general population and a much higher percentage of seniors. To assess the attitudes of Medicare-eligible Americans toward concerns that have been raised about mail service pharmacy and its mandated use in the prescription benefit plans of public and private insurance programs. Existing published literature was reviewed, and interviews were conducted with Medicare-eligible persons aged 65 and older to identify potential areas of concern with mail order pharmacy services. A survey was constructed and mailed to a nationally representative random sample of 6,500 persons between the ages of 65 and 79 in July 2012. By the cutoff date, 669 completed surveys had been received, and an additional 221 had been returned as undeliverable, resulting in an overall response rate of 10.7%. Nearly half of respondents listed chain pharmacy as their primary source of prescription medications (47.7%) followed by mail service (34.1%), independent pharmacy (13.1%), and other (5.1%). Responses of seniors residing in rural zip codes compared with those in nonrural zip codes demonstrated significantly higher agreement with several concerns, including lost or stolen medications, receiving the exact medication the physician prescribed, and the effects of exposure to heat, cold, or moisture. Two additional concerns approached statistical significance: the ability to speak with a pharmacist face-to-face and the ability to obtain medications quickly if needed. A total of 533 (83.7%) indicated they would oppose mandated mail order in their current benefit plan if it would cause the local community pharmacy they rely on for

  12. Historical Trend of Racial and Ethnic Disparities in Meeting Medicare Medication Therapy Management Eligibility Criteria in Non-Medicare Population

    Science.gov (United States)

    Wang, Junling; Surbhi, Satya; Zhang, Zhiping; Spivey, Christina A.; Chisholm-Burns, Marie

    2014-01-01

    Background Prior research examining racial and ethnic disparities in meeting Medicare medication therapy management (MTM) eligibility criteria among the non-Medicare population suggests minorities have lower likelihood of being eligible than non-Hispanic Whites (Whites). However, such research has not examined trends in disparities and whether these disparities may be expected to decrease over time based on historical data. Objectives To examine trends in MTM eligibility disparities among the non-Medicare population from 1996-1997 to 2009-2010. Methods This retrospective observational analysis used Medical Expenditure Panel Survey data from the study periods. The MTM eligibility criteria used by health insurance plans in 2008 and 2010 were analyzed. Trends in disparities were examined by including interaction terms between dummy variables for 2009-2010 and non-Hispanic Blacks (Blacks)/Hispanics in a logistic regression. The effect of interaction was estimated on both the multiplicative and additive terms. Main and sensitivity analyses were conducted to represent the ranges of the Medicare MTM eligibility thresholds used by health insurance plans. Results According to the main analysis, Blacks and Hispanics were less likely to be eligible than Whites for both sets of eligibility criteria in 1996-1997 and in 2009-2010. Trend analysis for both sets of criteria found that on the multiplicative term, there were generally no significant changes in disparities between Whites and Blacks/Hispanics from 1996-1997 to 2009-2010. Interaction on the additive term found evidence that disparities between Whites and Blacks/Hispanics may have increased from 1996-1997 to 2009-2010 (e.g., in the main analysis between Whites and Hispanics for 2010 eligibility criteria: difference in odds= -0.03, 95% CI: [-0.03]-[-0.02]). Conclusions Racial and ethnic minorities in the non-Medicare population experience persistent and often increasing disparities in meeting MTM eligibility criteria

  13. Big Data, Little Data, and Care Coordination for Medicare Beneficiaries with Medigap Coverage.

    Science.gov (United States)

    Ozminkowski, Ronald J; Wells, Timothy S; Hawkins, Kevin; Bhattarai, Gandhi R; Martel, Charles W; Yeh, Charlotte S

    2015-06-01

    Most healthcare data warehouses include big data such as health plan, medical, and pharmacy claims information for many thousands and sometimes millions of insured individuals. This makes it possible to identify those with multiple chronic conditions who may benefit from participation in care coordination programs meant to improve their health. The objective of this article is to describe how large databases, including individual and claims data, and other, smaller types of data from surveys and personal interviews, are used to support a care coordination program. The program described in this study was implemented for adults who are generally 65 years of age or older and have an AARP(®) Medicare Supplement Insurance Plan (i.e., a Medigap plan) insured by UnitedHealthcare Insurance Company (or, for New York residents, UnitedHealthcare Insurance Company of New York). Individual and claims data were used first to calculate risk scores that were then utilized to identify the majority of individuals who were qualified for program participation. For efficient use of time and resources, propensity to succeed modeling was used to prioritize referrals based upon their predicted probabilities of (1) engaging in the care coordination program, (2) saving money once engaged, and (3) receiving higher quality of care. To date, program evaluations have reported positive returns on investment and improved quality of healthcare among program participants. In conclusion, the use of data sources big and small can help guide program operations and determine if care coordination programs are working to help older adults live healthier lives.

  14. Hearings by administrative law judges of certain Medicare claims--HCFA, SSA. General notice.

    Science.gov (United States)

    1988-06-01

    This notice is to advise the public that the Social Security Administration's Office of Hearings and Appeals (SSA, OHA) has recently been given temporary jurisdiction over Medicare Part B, Supplementary Medical Insurance, Administrative Law Judge (ALJ) hearings. Medicare Part A, Hospital Insurance, ALJ hearings and Medicare entitlement matters continue under SSA, OHA's jurisdiction.

  15. 42 CFR 403.322 - Termination of agreements for Medicare recognition of State systems.

    Science.gov (United States)

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Termination of agreements for Medicare recognition of State systems. 403.322 Section 403.322 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES... Reimbursement Control Systems § 403.322 Termination of agreements for Medicare recognition of State systems....

  16. 42 CFR 411.204 - Medicare benefits secondary to LGHP benefits.

    Science.gov (United States)

    2010-10-01

    ... or her own or a family member's current employment status. (b) Individuals entitled to Medicare on... 42 Public Health 2 2010-10-01 2010-10-01 false Medicare benefits secondary to LGHP benefits. 411.204 Section 411.204 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND...

  17. Strategic planning for Medicare coverage and payment of new diabetes technologies.

    Science.gov (United States)

    Spurgin, Elizabeth A

    2004-12-01

    This article reviews the process for gaining Medicare coverage and payment for new technologies and suggests factors to consider when developing a reimbursement strategy. Integrating Medicare reimbursement planning within the broader product commercialization strategy builds efficiencies and may enhance product uptake across both Medicare and private payer segments.

  18. Geographic variations in heart failure hospitalizations among medicare beneficiaries in the Tennessee catchment area.

    Science.gov (United States)

    Ogunniyi, Modele O; Holt, James B; Croft, Janet B; Nwaise, Isaac A; Okafor, Henry E; Sawyer, Douglas B; Giles, Wayne H; Mensah, George A

    2012-01-01

    Although differences in heart failure (HF) hospitalization rates by race and sex are well documented, little is known about geographic variations in hospitalizations for HF, the most common discharge diagnosis for Medicare beneficiaries. Using exploratory spatial data analysis techniques, the authors examined hospitalization rates for HF as the first-listed discharge diagnosis among Medicare beneficiaries in a 10-state Tennessee catchment area, based on the resident states reported by Tennessee hospitals from 2000 to 2004. The age-adjusted HF hospitalization rate (per 1000) among Medicare beneficiaries was 23.3 [95% confidence interval (CI), 23.3-23.4] for the Tennessee catchment area, 21.4 (95% CI, 21.4-21.5) outside the catchment area and 21.9 (95% CI, 21.9-22.0) for the overall United States. The age-adjusted HF hospitalization rates were also significantly higher in the catchment area than outside the catchment area and overall, among men, women and whites, whereas rates among the blacks were higher outside the catchment area. Beneficiaries in the catchment area also had higher age-specific HF hospitalization rates. Among states in the catchment area, the highest mean county-level rates were in Mississippi (30.6 ± 7.6) and Kentucky (29.2 ± 11.5), and the lowest were in North Carolina (21.7 ± 5.7) and Virginia (21.8 ± 6.6). Knowledge of these geographic differences in HF hospitalization rates can be useful in identifying needs of healthcare providers, allocating resources, developing comprehensive HF outreach programs and formulating policies to reduce these differences.

  19. Geographic disparities in chronic obstructive pulmonary disease (COPD hospitalization among Medicare beneficiaries in the United States

    Directory of Open Access Journals (Sweden)

    Holt JB

    2011-06-01

    Full Text Available James B Holt, Xingyou Zhang, Letitia Presley-Cantrell, Janet B CroftNational Center for Chronic Disease Prevention and Health Promotion, US Centers for Disease Control and Prevention, Atlanta, GA, USABackground: Hospitalizations for persons with chronic obstructive pulmonary disease (COPD result in significant health care resource use and excess expenditures. Despite well-documented sociodemographic disparities in COPD outcomes, no study has characterized geographic variations in COPD hospitalization across the US.Methods: Almost 3.8 million COPD hospitalization records were extracted from Medicare claims for 1995–2006, and the total population of eligible Medicare beneficiaries was extracted from the Medicare enrollment records to calculate COPD hospitalization rates by Health Service Area (HSA, (n = 949. Spatial cluster analysis and Bayesian hierarchical spatial modeling were used to characterize the geography of COPD hospitalizations.Results: The overall COPD hospitalization rate was 11.30 per 1,000 beneficiaries for the aggregated period 1995–2006. HSA-level COPD hospitalization rates had a median of 11.7 and a range of 3.0 (Cache, UT to 76.3 (Pike, KY. Excessive hospitalization risk was concentrated in Appalachia, the southern Great Lakes, the Mississippi Delta, the Deep South, and west Texas. In the Bayesian spatial mixture model, 73% of variability of COPD hospitalization relative risk was attributed to unidentified regional social and physical environments shared by HSAs rather than to unique local HSA factors (27%.Conclusion: We discovered distinct geographic patterns in COPD hospitalization rates and risks attributed to both regionally-shared environmental risk factors and HSA-unique environmental contexts. The correlates of these geographic patterns remain to be determined. Geographic comparisons of COPD hospitalization risk provide insights for better public health practice, policies, and programs for COPD prevention

  20. 42 CFR 457.618 - Ten percent limit on certain Children's Health Insurance Program expenditures.

    Science.gov (United States)

    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...