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EBSA and Centers for Medicare & Medicaid Services Announces Meeting of CHIP Working Group, Addressing Employer-Sponsored Group Health Plan Coverage Coordination

2 pages. Excerpt: The CHIP Working Group will meet ... to develop a model coverage coordination disclosure form for group health plan administrators to send to States upon request regarding benefits available under the plan.... The CHIP Working Group will identify and report on the impediments to the effective coordination of coverage available to families that include employees of employers that maintain group health plans and members who are eligible for medical assistance under title XIX of the [Social Security] Act or child health assistance or other health benefits coverage under title XXI of the [Social Security] Act.

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Text of White Paper by Centers for Medicare & Medicaid Services: Retiree Drug Coverage (PDF)

10 pages. Excerpt: CMS is presenting multiple options for employers and unions to offer enhanced drug coverage to retirees at a lower cost ... [W]e are interested in hearing what employers are likely to do under the various proposed options.... Employers and unions can choose between two broad options in offering additional retiree drug coverage: offering coverage that qualifies for the retiree drug subsidy, or enhancing the basic Medicare drug benefit.  MORE >>

Centers for Medicare and Medicaid Services Delays Medicare Secondary Payer Mandatory Reporting, Which Was to Begin April 1, to Jan. 1, 2011

Excerpt: Medicare Secondary Payer reporting requirements are intended to ensure that Medicare remains the secondary payer when a Medicare beneficiary has medical expenses that should be paid primarily by a liability, no-fault or workers compensation plan.  MORE >>

Centers for Medicare & Medicaid Services' Report Says 1.4M Fewer Americans to be in Employer Health Plans as of 2019

Excerpt: Made public by U.S. Representative John Kline (R-Minnesota), the report also asserted that seven million seniors would no longer be covered by Medicare Advantage and that the nation's health care spending would increase by $331 billion over the next 10 years.

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Centers for Medicare and Medicaid Services Updates HRA Coverage Reporting

Excerpt: Among the issues addressed in the updated guide are references to changes in reporting for Health Reimbursement Arrangements (HRAs). CMS has removed all references from the updated guide that previously referred to reporting only for 'free-standing' HRAs.  MORE >>

Turbulent Times for Center for Medicare and Medicaid Innovation

"As lawmakers debate and discuss ways to repeal the [ACA], they will weigh the fate of the [Center for Medicare & Medicaid Innovation], funded through the health law with $10 billion for 2011 to 2019, and another $10 billion for each subsequent decade. [CBO] estimates the center would increase federal spending initially, but ultimately result in lower costs and save up to $34 billion over the next 10 years."

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CBO Presentation: Costs Under Medicare's Prescription Drug Benefit and a Comparison with the Cost of Drugs Under Medicaid Fee-For-Service

23 presentation slides. Topics include: [1] Background on Medicare Part D; [2] Comparing actual Part D costs to CBO's original estimate; [3] Growth in Part D drug costs and plan payments; [4] Comparing costs of drugs under Part D and Medicaid Fee-for-Service.

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CMS Examines Inappropriate Steering of People Eligible for Medicare or Medicaid Into Marketplace Plans

"[CMS is] seeking public comment on concerns that some health care providers and provider-affiliated organizations may be steering people eligible for, or receiving, Medicare and/or Medicaid benefits into [ACA]-compliant individual market plans, including Health Insurance Marketplace plans, for the purpose of obtaining higher reimbursement rates. CMS also sent letters to all Medicare-enrolled dialysis facilities and centers informing them of this announcement."  MORE >>

Compliance with Mandatory Reporting Requirements Under Medicare, Medicaid and SCHIP Extension Act of 2007 (PDF)

Excerpt: The Medicare, Medicaid and SCHIP Extension Act of 2007 ('MMSEA') took effect July 1, 2009. One of the purposes of MMSEA is to allow the federal government to recover payments made under Medicare when Medicareincorrectly acted as a primary payer or when a Medicare beneficiary receives payments from both an insurer and Medicare for the same injury. To that end, MMSEA requires group health plan arrangements ('GHPs') and liability insurers, no-fault insurers, workers' compensation insurers, and self-insurers (collectively, 'non-GHPs') to report any settlement, award, judgment, or other payment that they make involving a Medicare beneficiary to the Centers for Medicare & Medicaid Services ('CMS'), the federal agency within the U.S. Department of Health and Human Services that is responsible for administering Medicare.  MORE >>

Text of CMS Final Regs Requiring Drug Pricing Transparency for Medicare and Medicaid Programs

102 pages. "This final rule [amends] regulations for the Medicare Parts A, B, C and D programs, as well as the Medicaid program, to require direct-to-consumer (DTC) television advertisements of prescription drugs and biological products for which payment is available through or under Medicare or Medicaid to include the Wholesale Acquisition Cost (WAC or list price) of that drug or biological product. This rule is intended to improve the efficient administration of the Medicare and Medicaid programs by ensuring that beneficiaries are provided with relevant information about the costs of prescription drugs and biological products so they can make informed decisions that minimize their out-of-pocket (OOP) costs and expenditures borne by Medicare and Medicaid, both of which are significant problems." [Editor's note: Includes over 80 pages of summary, analysis and response to the 147 comments received on the proposed regs. Also available: CMS Drug Pricing Transparency Fact Sheet.]

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Text of CMS Proposed Regs: Medicare and Medicaid Programs -- Drug Pricing Transparency

45 pages. "This proposed rule would ... [amend] the Medicare Parts A, B, C and D programs, as well as the Medicaid program, to require direct-to-consumer (DTC) television advertisements of prescription drugs and biological products for which payment is available through or under Medicare or Medicaid to include the Wholesale Acquisition Cost (WAC, or 'list price') of that drug or biological product.... [CMS seeks] comment on [1] [W]hether Wholesale Acquisition Cost is the amount that best reflects the 'list price' for the stated purposes of price transparency and comparison shopping under this proposed regulation.... [2] [W]hether 30-day supply and typical course of treatment are appropriate metrics for a consumer to gauge the cost of the drug.... [3] [H]ow to treat an advertised drug that must be used in combination with another non-advertised drug or device.... [4] [W]hether the cost threshold of $35 to be exempt from compliance with this rule is the appropriate level and metric for such an exemption."  MORE >>

Text of CMS ANPRM on Civil Money Penalties Under the Medicare, Medicaid, and SCHIP Extension Act of 2007

"This advance notice of proposed rulemaking (ANPRM) solicits public comment on specific practices for which civil money penalties (CMPs) may or may not be imposed for failure to comply with Medicare Secondary Payer reporting requirements for certain group health and non-group health plans arrangements.... We are interested in comments and proposals to specifically define 'noncompliance' in the context of the phrase, 'for each day of noncompliance with respect to each claimant' in sections 1862(b)(7) or (b)(8) of the Act. We are seeking public comment and proposals on mechanisms and criteria that we would employ to evaluate whether and when the agency would impose CMPs. In addition, we are we are soliciting comments and proposals for methods to determine the dollar amount of a CMP that would be levied for each day that NGHP is a responsible reporting entity noncompliance under section 1862(b)(8) of the Act. We are also soliciting comments on how we might devise a method(s) and criteria to determine which actions would constitute 'good faith effort(s)' taken by an entity to identify a Medicare beneficiary for the purposes of reporting under section 1862(b)(8) of the Act. We are specifically soliciting comments and proposals from insurers, third party administrators for GHPs, other applicable plans, and the public."  MORE >>

Employer Sponsored Insurance Paid Twice as Much as Medicare for Services at Ambulatory Surgical Centers

"ESI reimbursement for vascular procedures were 3.1 times higher than the Medicare FFS payment rates. At the same time, ESI reimbursement for skin procedures were 1.4 times higher than Medicare FFS payment rates. The vast majority of (76%) of ASC procedures studied have ESI payments that are greater than the corresponding median Medicare reimbursed amounts."  MORE >>

Shutdown Effect on Medicare, Medicaid, and ACA Programs

"The HHS shutdown contingency plan for FY2012 stated that, 'Operations of the Center for Consumer Information and Insurance Oversight would continue as funding was provided through the [ACA].' This includes insurance rate reviews, assessment of a portion of insurance premiums that are used on medical services, establishment of exchanges, operation of the pre-existing condition insurance program and the early retiree reinsurance program."

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New Medicare and Medicaid Demonstration Projects Focused on Addressing the Costs of Medications

"[T]he Center for Medicare & Medicaid Innovation (CMMI), the research arm of [CMS], will implement three demonstration models ... [1] generic medications used to treat common chronic conditions. [2] A Medicaid project focused on the emerging field of cell and gene therapies. [3] A Medicare Part B model that would reduce payments for medications approved via the [FDA] Accelerated Approval pathway while the sponsors generate evidence from confirmatory trials."  MORE >>

Medicare and Medicaid: Savings Opportunities from Health Care Modernization (PDF)

"Taking into account overlapping effects, [the authors] estimate a strategic combination of these initiatives could yield $542 billion in federal savings over the 2013 to 2022 period, helping to reduce Medicare and federal Medicaid spending by about 4.4 percent.... While much of the recent debate on Medicare and Medicaid savings has centered on either cutting consumers' benefits or providers' payments, the options [assessed in this working paper] favor a different approach: better care coordination and support for beneficiaries so as to unleash greater value from the health care system. These estimates, while inherently uncertain, help to illustrate the size of the potential modernization dividend."

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GAO Report: The Transition of Dual-Eligible Beneficiaries from Medicaid to Medicare Drug Coverage

48 pages. "The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) established a voluntary outpatient prescription drug benefit, known as Medicare Part D.... [D]rug coverage for dual-eligible beneficiaries will transition from Medicaid to Medicare Part D. This transition will occur for approximately 6 million full-benefit dual-eligible beneficiaries -- Medicare beneficiaries who receive full Medicaid benefits for services not covered by Medicare.... We identified three potential problems that may leave some dual-eligible beneficiaries facing difficulties immediately obtaining necessary drugs beginning January 1, 2006. " [GAO-06-278R, Dec. 16, 2005]

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CRS Report: Consolidated Appropriations Act, 2024 Medicaid and Medicare Provisions (PDF)

32 pages. "With regard to Medicaid and CHIP, the CAA 2024 includes numerous provisions related to mental health and substance use disorder.... With regard to Medicare, the CAA 2024 extends funding for quality measure endorsement, input, and selection for Medicare quality programs and for outreach and assistance to low-income beneficiaries. " [R48075 May 24, 2024]  MORE >>

Accountable Health Communities: Addressing Social Needs through Medicare and Medicaid

"By some estimates, more than 95% of the trillion dollars spent on health care in the United States each year funds direct medical services, even though 60% of preventable deaths are rooted in modifiable behaviors and exposures that occur in the community.... CMS recently announced a 5-year, $157 million program to test a model called Accountable Health Communities (AHC).... [T]he test will assess whether systematically identifying and addressing health-related social needs can reduce health care costs and utilization among community-dwelling Medicare and Medicaid beneficiaries."  MORE >>

As Medicare and Medicaid Turn 50, Use of Private Health Plans Surges

"More than 30 percent of the 55 million Medicare beneficiaries and well over half of the 66 million Medicaid beneficiaries are now in private health plans run by insurance companies like the UnitedHealth Group, Humana, Anthem and Centene. Enrollment has soared as the government, in an effort to control costs and improve care, pays private insurers to provide and coordinate medical services for more and more beneficiaries."

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