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Medicare and Medicaid

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Justice Department Joins Lawsuit Alleging Massive Medicare Fraud by UnitedHealth
"The Justice Department has joined a California whistleblower's lawsuit that accuses insurance giant UnitedHealth Group of fraud in its popular Medicare Advantage health plans.... [The whistleblower] has accused the insurer of 'gaming' the Medicare Advantage payment system by 'making patients look sicker than they are' said his attorney ... [The attorney] said the combined cases could prove to be among the 'larger frauds' ever against Medicare, with damages that he speculates could top $1 billion." (Kaiser Health News)
What's in the Manager's Amendment to the American Health Care Act?
"It consists of two sets of amendments, labeled technical changes ([ with an accompanying summary]) and policy changes ([with an accompanying summary]).... The amendments add an additional year to the relief the AHCA offered from the 'Cadillac' plan excise tax ... and accelerate the repeal of all other ACA taxes from 2018 to 2017.... Another provision clarifies that the 30 percent of premium penalty imposed on consumers who seek coverage after a gap in coverage applies only in the individual and not in the small group market.... [M]uch of the $337 billion in deficit reduction that the CBO credited to the AHCA disappears under the manager's amendment." (Health Affairs)
House Republicans Announce Updates to Strengthen American Health Care Act
"To provide more immediate help, the amendment accelerates repealing the Obamacare taxes to 2017, rather than 2018.... Under current law, Americans can deduct from their taxes the cost of medical expenses that exceed 10 percent of their income. Our proposed amendment reduces this threshold to 5.8 percent of income.... This amendment would allow states to opt out of the per capita [Medicaid] allotment baseline and instead receive federal funds through a block grant.... [T]he amendment would prevent new states from opting in to Obamacare's Medicaid expansion." (Committee on Ways and Means, U.S. House of Representatives)
The Unfolding Medicaid Story: Congress, Governors, and the Trump Administration
"Over a half century, federal and state policymakers alike have turned to Medicaid because its flexible structure repeatedly has offered the ability to nimbly respond to social problems as they emerge ... Thus, how to change Medicaid's growth trajectory without weakening its unique and indispensable qualities represents perhaps the most significant of all U.S. health policy challenges. The rest of the nation's intensely market-driven system, as well as Medicare, rests on Medicaid's features and capabilities. The debate over Medicaid is now playing out on three fronts." (Health Affairs)
House GOP Health Plan Would Accelerate Depletion of Medicare Trust Fund by Four Years
"The House bill to repeal the [ACA] would move up the Medicare's Hospital Insurance trust fund's depletion from 2028 to 2024. Repealing a payroll tax on high earners would advance the depletion date by three years ... Additional Medicare payments to hospitals that serve many uninsured payments would advance it one more year[.]" (Center on Budget and Policy Priorities)
State Retirement Savings Initiatives Can Enhance Retirement Security for Private Sector Workers and Offset the Cost of Medicaid (PDF)
"The result of the analysis showed a positive correlation between increased retirement savings, sufficient to remove a percentage of currently vulnerable households from the poverty rolls by the time they retire, and a reduction in Medicaid spending. [A table] shows estimated savings in Medicaid payments by states and the District of Columbia for the first 10 years after a retirement savings program is introduced. Over that period, 15 states would save more than $100 million each, with total projected savings if available in all states approaching $5 billion in the first 10 years." (Segal Consulting)
House Panel Calls for Medicaid Work Requirement, Tax Credit Changes in Health Bill
"Three of the motions, which passed along party lines, were aimed at establishing requirements for Medicaid enrollment, while a fourth would allow more generous tax credits to help low-income people afford insurance. The motions were nonbinding recommendations that could be proposed on the House floor as amendments or incorporated into the bill, the American Health Care Act, when it goes before the Rules Committee ... The recommendations came after the committee at the outset of the meeting narrowly voted to advance the bill, 19-17[.]" (U.S. News & World Report)
Improvements in Access and Quality Nationwide Following ACA's Major Coverage Expansions
"The uninsured rate among low-income working-age adults dropped an average of 14.1 percentage points in states that expanded Medicaid, compared to 8.9 points in nonexpansion states. The percentage of low-income adults who said they went without care because of its cost dropped an average of 5.5 points in expansion states compared to 2.3 points in nonexpansion states.... Some Medicaid expansion states saw gains beyond coverage." (The Commonwealth Fund)
[Opinion] Sensible Medicare and Federal Employees Health Benefits Reform for All Annuitants
"The Postal Service Reform Act of 2017 (H.R. 756) would force postal annuitants to buy Medicare insurance they neither need nor want. The Postal Service does need to address a serious retiree health care prefunding obligation imposed by Congress over a decade ago. But the problem can be resolved without forcing seniors to purchase insurance they do not need or want." (The Heritage Foundation)
Medicare Premium Support Proposals Could Increase Costs for Today's Seniors, Despite Assurances
"[P]roponents would split Medicare into two parts: one for people now over age 55 who would be 'grandfathered' into the current Medicare program, and one for younger adults, now 55 or younger, who would get coverage under the new premium support system once they became eligible for Medicare.... Once the system is fully implemented, younger, healthier, and lower-cost beneficiaries, those now 55 and younger, would be cut off -- at least actuarially -- from older, sicker, and more expensive beneficiaries, those now 55 and older.... [T]he increased rate of cost growth in the current system would result in higher premiums, deductibles, and cost-sharing for those covered by it: today's seniors and near-seniors." (Health Affairs)
[Opinion] Why Living Longer Should Not Lead to Medicare Benefit Cuts
"[A] new report [analyzes] the impact of raising the Medicare eligibility age from 65 to 67 ... The findings are grim: soaring rates of uninsured people age 66 and 67, worsened health outcomes and rising use of expensive emergency medical services." (Reuters)
The American Health Care Act: House Energy and Commerce Committee Provisions (PDF)
"The legislation, part of House Republicans' American Health Care Act, ... [1] Creates a Patient and State Stability Fund -- This new and innovative fund give states broad flexibility to design programs that best serve their unique populations. They can also use funds to increase access to preventative services. [2] Responsibly unwinds Obamacare's Medicaid expansion -- By freezing new enrollment after 2 years and grandfathering in current enrollees, we protect patients and offer a stable transition. [3] Strengthens Medicaid -- Using a per capita allotment, our legislation ensures a fair funding formula for states while creating a viable financial future for the program." (Energy and Commerce Committee, U.S. House of Representatives)
[Opinion] Medicaid Caps: The Threat Below the Surface
"President Trump and Republican leaders are actively considering voucherizing Medicare and converting Medicaid financing into a block grant or per capita cap. This [article] focuses on the efforts to undermine Medicaid and the voucherization of Medicare." (National Health Law Program [NHeLP])
Justice Department Joins Whistleblower Suit Accusing UnitedHealth Group of Overcharging Medicare by 'Hundreds of Millions'
"The suit accuses United of operating an 'up-coding' scheme to receive higher payments under [Medicate Advantage's] risk adjustment program ... The complaint alleges that United fraudulently collected 'hundreds of millions -- and likely billions -- of dollars' by claiming patients were sicker than they really were." (Sheppard Mullin)
Creditable Coverage Disclosures Are Due to CMS by March 1
"Plan sponsors generally must disclose creditable coverage status to CMS within 60 days after the beginning of each plan year.... An entity that does not offer outpatient prescription drug benefits to any Part D-eligible individual on the first day of its plan year is not required to complete the CMS disclosure form for that plan year." (Society for Human Resource Management [SHRM])
How Much Should a Medicare Beneficiary Save for Health Expenses? Some Couples Need $350,000 (PDF)
"In 2016, a 65-year-old man would need $72,000 in savings and a 65 year-old woman would need $93,000 if each had a goal of having a 50 percent chance of having enough savings to cover health care expenses in retirement.... A couple with median prescription drug expenses would need $165,000 if they had a goal of having a 50 percent chance of having enough savings to cover health care expenses in retirement.... For a couple with drug expenses at the 90th percentile throughout retirement who wanted a 90 percent chance of having enough money saved for health care expenses in retirement by age 65, targeted savings would be $349,000 in 2016." (Employee Benefit Research Institute [EBRI])
[Guidance Overview] Medicare Updates Affect Employer Reporting Requirements
"[F]rom April 1, 2018 through December 31, 2019, CMS will begin issuing Medicare Beneficiary Identifiers (MBI) to replace the Social Security Number (SSN) based Health Insurance Claim Number (HICN) currently in use.... For all settlements with Medicare beneficiaries that have the impact of releasing medical care issues, employers and/or insurers should request the MBI to use when reporting the settlement to CMS or determining its potential reimbursement interests based on conditional payments." (Ice Miller LLP)
How COBRA Intersects with Medicare and Retiree Health Plans
"If an employer offers retiree health coverage that is a non-COBRA alternative to COBRA coverage for eligible retirees, then the retirees are still considered 'covered employees' for COBRA purposes." (HR Daily Advisor)
State Retirement Savings Initiatives Do More Than Enhance Retirement Security for Private Sector Workers (PDF)
"As states look at programs to build retirement savings, they are also asking how a population better prepared for retirement would affect public safety-net programs.... [An] analysis showed a positive correlation between increased retirement savings sufficient to remove a percentage of currently vulnerable households off the poverty rolls by the time they retire, and a reduction in Medicaid spending." (Segal Consulting)
[Guidance Overview] Calendar Year Health Plans Must Complete Online CMS Disclosure by March 1
"The plan sponsor must complete the disclosure within 60 days after the beginning of the plan year if it has any employees or dependents eligible for and receiving Part D prescription drug benefits.... Employer plans that do not offer drug coverage to any Medicare-enrolled employee, retiree or dependent at the beginning of the plan year are exempt from filing." (Kushner & Company)
[Guidance Overview] Calendar Year Health Plans Must Complete Online CMS Disclosure by March 1 (PDF)
"The plan sponsor must complete the disclosure within 60 days after the beginning of the plan year. (Sponsors of insured plans may apparently choose to file within 60 days after the beginning of the insurance contract year, but whatever approach they adopt, they should use that approach consistently.) ... A CMS filing is also required within 30 days of termination of a prescription drug plan and for any change in a plan's creditable coverage status. Some plans are exempt from the filing requirement." (Lockton Benefit Group)
[Guidance Overview] Medicare Part D Disclosures Due By March 1 For Calendar Year Plans (PDF)
"This disclosure requirement applies when an employer-sponsored group health plan provides prescription drug coverage to individuals who are eligible for coverage under Medicare Part D. The plan sponsor must complete the online disclosure within 60 days after the beginning of the plan year. For calendar year health plans, the deadline for the annual online disclosure is March 1." (Cowden Associates, Inc.)
[Official Guidance] Text of CMS State Innovation Waiver Approval Letter for Hawai'i (PDF)
"Hawai'i's application sought waiver of the ACA requirement that a [SHOP] operate in Hawai'i and other related provisions relevant to SHOP Exchanges. Under this waiver ... [certain enumerated] provisions of the ACA are waived in Hawai'i ... The Departments deny Hawai'i's request to waive section 131 l(t)(3)(B) to seek flexibility to permit state agencies other than the State Medicaid Agency to have a role in an Exchange ... Given that a Federally-facilitated Marketplace operates in Hawai'i, this provision will not be a part of the waiver." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
How COBRA Intersects with Medicare and Retiree Health Plans
"If an employer offers retiree health coverage that is a non-COBRA alternative to COBRA coverage for eligible retirees, then the retirees are still considered 'covered employees' for COBRA purposes. Furthermore, the Medicare statutory rules allow employer-sponsored group health plans to reduce or terminate coverage if retired employees become entitled to Medicare. Thus, if a covered retiree becomes entitled to Medicare, and that entitlement would cause a loss of coverage for his or her spouse and dependents under the terms of the employer's retiree coverage, then a qualifying event has occurred." (HR Daily Advisor)
[Guidance Overview] CMS Acts on Premium Payments by Dialysis Facilities, Special Enrollment Period Eligibility
"Comments [received by CMS] suggested that facilities are paid four times as much by commercial than by public payers, allowing them to make as much as $100,000 to $200,000 more per year per patient. But premiums for individual market coverage only cost $4,200 per year; thus, there is an incentive for the providers to steer their patients to commercial coverage and pay the full premium.... CMS has concluded that this practice can be harmful to consumers." (Timothy Jost, in Health Affairs)
[Official Guidance] Text of CMS Interim Final Rule: Conditions for Third-Party Payment of Individual Health Plan Premiums by Medicare-Certified Dialysis Facilities
63 pages. "Dialysis facilities subject to the new standard will be required to make patients aware of potential coverage options and educate them about the benefits of each to improve transparency for consumers.... [F]acilities must ensure that issuers are informed of and have agreed to accept the payments.... [CMS is] considering whether it would be appropriate to prohibit third party premium payments for individual market coverage completely for people with alternative public coverage." [Fact Sheet also available.] (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
In Antitrust Trial, Justice Department Questions Aetna-Humana Asset Sale Plan
"The [DOJ], which is suing to block the merger, questioned the ability of the proposed asset buyer, California-based Molina Healthcare Inc., to keep the market for private Medicare plans for senior citizens competitive if Aetna and Humana combine.... Justice Department lawyer Ryan Kantor said Molina's own documents showed that its board members had concerns about the wisdom of buying assets from Aetna and Humana." (The Wall Street Journal; subscription may be required)
The Enrollees Who Actually Didn't Even Need Obamacare
"[A]bout 70 percent of the decline in the number of uninsured people [can be attributed to] three factors: the subsidies for buying insurance; the law's more generous criteria for Medicaid eligibility; and the 'woodwork effect,' in which people who were previously eligible for Medicaid 'came out of the woodwork' and signed up for the program in 2014.... The largest effect was due to that woodwork effect -- about 44 percent of the effect they can explain, or roughly 30 percent of the overall reduction in the number of uninsured in 2014. Call it 3.3 million people, out of the 11.6 million who gained insurance that year." (Bloomberg)
[Guidance Overview] CMS Announces 2017 Medicare Parts A & B Premiums and Deductibles
"Because of the low Social Security COLA, a statutory 'hold harmless' provision designed to protect seniors, will largely prevent Part B premiums from increasing for about 70 percent of beneficiaries. Among this group, the average 2017 premium will be about $109.00, compared to $104.90 for the past four years. For the remaining roughly 30 percent of beneficiaries, the standard monthly premium for Medicare Part B will be $134.00 for 2017, a 10 percent increase from the 2016 premium of $121.80. Because of the 'hold harmless' provision covering the other 70 percent of beneficiaries, premiums for the remaining 30 percent must cover most of the increase in Medicare costs for 2017 for all beneficiaries." For detailed official announcements of the 2017 amounts see: [1] Medicare Part A Premiums; [2] Medicare Part B Premiums and Deductibles; and [3] Medicare Inpatient Deductible and Coinsurance Amounts. (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
How Could a New Administration Tackle ACA Challenges? Look to Medicare
"The ACA marketplaces aren't the only health insurance markets to have faced turmoil.... [T]he Medicare Advantage markets were roiled with health plan exits in the late 1990s and early 2000s.... Key policy solutions included: [1] Throwing money at the problem ... [2] Authorizing a fallback 'public option' plan ... [3] Making risk mitigation programs permanent ... [4] Conducting aggressive enrollment outreach ... These same strategies could be adapted to help stabilize the ACA marketplaces." (Health Affairs)
Feds Block Medicare 'Seamless Conversions', Will Issue New Rules for Plans Who Make the Switches
"Under current rules, an insurer can transfer customers who have purchased policies through an [ACA] insurance exchange or other commercial plans when they become eligible for Medicare, typically at age 65. An insurer must give an individual 60 days' advance written notice of the switch; if a person doesn't opt out, that enrollment takes effect automatically. But some seniors and advocates say such notices can easily be missed in the deluge of mailings from companies trying to entice newly eligible seniors to join their Medicare Advantage plans." (Healthcare Finance News)
Medicare: Insolvency Projections (PDF)
15 pages. "Almost from its inception, the [Hospital Insurance (HI)] Trust Fund has faced a projected shortfall. The insolvency date has been postponed a number of times, primarily due to legislative changes that have had the effect of restraining growth in program spending. The 2016 Medicare trustees' report projects that, under intermediate assumptions, the HI Trust Fund will become insolvent in 2028, two years earlier than estimated in the prior year's report." [Report RS20946, Oct. 5, 2016] (Congressional Research Service [CRS])
[Guidance Overview] Medicare Creditable Coverage Disclosures Due before October 15th
"The disclosure requirement does not apply to account-based medical plans such as health savings accounts (HSAs), health flexible spending accounts (health FSAs), or Archer medical savings accounts (Archer MSAs). However, disclosures would be required for HDHPs and other non-account benefits available to participants with these account types, to the extent the HDHP or other non-account benefit offers prescription drug coverage." (Ice Miller LLP)
[Opinion] Designing a Medicare Buy-in and a Public Plan Marketplace Option: Policy Options and Considerations (PDF)
12 pages. "A Medicare-related proposal could provide more plan choice for those eligible, which would have a significant effect where few or even only one insurer offers coverage in the nongroup insurance market. Depending upon how the proposal is structured, it could reduce costs for younger adults in the private insurance market as older adults leave the risk pool. However, designing such programs raises myriad issues, each with specific implications for costs and benefits to different age groups." (Urban Institute)
Medicare Advantage Premiums Remain Stable in 2017; Beneficiaries Have Saved Over $23.5 Billion on Prescription Drugs
"CMS estimates that the average Medicare Advantage monthly premium will decrease by $1.19 (about 4 percent) in 2017, from $32.59 on average in 2016 to $31.40. This would be 13 percent lower than the average Medicare Advantage premium prior to passage of the [ACA].... Since the enactment of the [ACA] ... more than 11 million seniors and people with disabilities have received savings and discounts in the coverage gap of over $23.5 billion on prescription drugs, an average of $2,127 per beneficiary[.]" (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
[Opinion] ERIC Comment Letter to CMS: Inappropriate Steering of Individuals to Individual Market Plans (PDF)
"[ERIC believes] that similar practices and problems are adversely affecting those enrolled in, and sponsoring, plans outside of Medicare and Medicaid. As such, we request that HHS considers what policies and strategies might provide relief to those individuals outside of public programs as well.... These comments will detail several examples of situations in which we believe increased oversight and possibly new regulations are needed to protect the rights and care of beneficiaries in both public programs and private health insurance." (The ERISA Industry Committee [ERIC])
Five Medicare Tips for New Retirees
"Moving to Medicare from employer health insurance can be a difficult transition.... [1] There is no family plan in Medicare.... [2] A cap on out-of-pocket costs isn't automatic.... [3] Be strategic in scheduling some procedures.... [4] Wellness features may be different.... [5] A little research may help limit your drug costs under Medicare." (TIME)
[Guidance Overview] October 15 Deadline Approaching for Medicare Part D Notices
"[I]f you as an employer offer prescription coverage to any Medicare Part D eligible employees (whether or not retired), or Medicare Part D Medicare-eligible spouses or dependents, you must provide those individuals with a [notice] to advise them whether your drug plan's total gross value is at least as valuable as the standard Part D coverage ... [T]here are five instances in which such notice must be provided: [1] prior to an individual's initial enrollment period for Part D; [2] prior to the effective date of enrollment in your company's prescription drug coverage; [3] upon any change in your plan's creditable status; [4] prior to the annual election period for Part D (which begins each October 15); and [5] upon the individual's request." (Fraser Trebilcock)
[Guidance Overview] Employee Classifications, Employer Shared Responsibility Tax and Medicare Collide
"[Information Letter 2016-0030] restated [the IRS] position that the employer shared responsibility tax is assessed based on the facts and circumstances of how many hours the employees work in a particular month, and that the employer's policies or classifications provide no protection from the tax assessment.... [T]he fact the employee was in fact eligible for and receiving Medicare did not change whether the employer might be subject to the employer shared responsibility tax for this individual if he or she worked 30 or more hours per week." (Winstead PC)
[Opinion] Postal Service Health Benefits and the FEHBP: The Urgent Case for Getting Reform Right
"The 2016 Postal Service Reform Act proposes shifting postal retirees' primary health care coverage from the Federal Employees Health Benefits Program (FEHBP) to Medicare.... The proposal's impact on both postal retirees and taxpayers could be substantial.... This arrangement drives excessive Medicare use, and thus imposes ever higher costs on both Medicare beneficiaries and taxpayers. Postal annuitants would be forced to enroll in Medicare Part B while continuing premium payments to the FEHBP if they want to maintain any FEHBP benefits or choice among FEHBP plans." (The Heritage Foundation)
Earnings and Employment Data for Workers Covered Under Social Security and Medicare, by State and County, 2013
"The data show, by sex and age, the number of wage and salary workers and self-employed persons, the amount of their taxable earnings, and the amount they paid in Social Security and Medicare contributions." (U.S. Social Security Administration [SSA])
Medicare Accountable Care Organization Results for 2015: The Journey to Better Quality and Lower Costs Continues
"Overall, 31 percent of the MSSP and Pioneer ACOs received shared savings bonuses for their 2015 performance, an increase over the 27 percent that earned a bonus in 2014. While more ACOs are succeeding under the program, there continues to be substantial variation in financial performance and quality results." (Health Affairs)
Taxpayers Foot 70 Percent of California's Health Care Tab
"Many people assume that the U.S. health care system is primarily supported by private dollars, such as insurance premiums from employer-based coverage ... But that's no longer the case, at least in California -- mostly because of its massive expansion of Medi-Cal, the state's version of Medicaid ... Nationwide, public funds paid for about 45 percent of the country's $3 trillion in health care expenditures in 2014 through public insurance programs ... according to federal data. But that estimate may be too low -- it's probably closer to 65 percent[.]" (Kaiser Health News)
Speak Now or Forever Hold Your Peace on Third-Party Payment of Marketplace Insurance Premiums
"CMS is concerned that the private plans issuing the QHPs offer higher rates than Medicare or Medicaid, and that hospitals (or other third-party payors) are attempting to make more money (rather than just attempting to be paid at all).... The CMS request for information contains many detailed questions, including descriptions of whether the practice is happening now, how enrollees are affected, what remedies could deter this practice, whether this practice tends to be associated with bad care, and whether CMS should require providers to report this practice." (Quarles & Brady LLP)
[Guidance Overview] 2016 Deadline for Medicare Part D Creditable/Non-Creditable Coverage Notices Nears (PDF)
"[P]lan sponsors that offer prescription drug coverage must provide notices of creditable or non-creditable coverage to Medicare-eligible individuals. The required notices may be provided in annual enrollment materials, separate mailings or electronically.... [P]lan sponsors ... must provide the required disclosures no later than October 14, 2016." (Xerox HR Services)
Medicare Part D Spending Up More Than 17% in 2014
"Drug costs increased more than 17 percent from 2013 to 2014, compared to a 3.3 percent increase in the total cost of claims, according to Medicare Part D data released by [CMS] ... Insulin products Lantus Solostar and Lantus led the way in having the highest increased rates of 47 and 32 percent, respectively. Drugs Abilify (to treat depression, schizophrenia and bipolar disorder), Januvia (Type 2 diabetes) and Revlimid (anemia and myeloma) followed with rates of 20 percent or higher." (Healthcare Finance News)
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." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
How Income Affects Your Medicare Premiums (PDF)
"The amount of premium you pay is based on your income tax return from two years ago. So the premium you will pay for 2017 will be based on your 2015 income tax return, 2018 premiums will be based on your 2016 income tax return, and so on. Taxpayers with a modified adjusted gross income (MAGI) over certain income brackets pay a higher Medicare premium than others....In April 2015, legislation was passed to reduce the income brackets for Levels 3-5 starting in 2018, with inflation adjustments in subsequent years. This means that more taxpayers will be subject to the higher IRMAA Medicare premiums beginning in 2018. (Meld Financial, Inc.)
CMS Releases New Prescription Drug Cost Data
"The 2014 data set contains information from over one million distinct health care providers who collectively prescribed approximately $121 billion in prescription drugs paid for under the Medicare Part D program. This represents a 17 percent increase compared to the 2013 data set." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
[Guidance Overview] CMS Announces 2018 Changes to Medicare Advantage Value-Based Insurance Design Model
"In the second year of the model, beginning January 1, 2018, CMS will: [1] open the model test to new applicants; [2] conduct the model test in three new states -- Alabama, Michigan, and Texas; [3] add rheumatoid arthritis and dementia to the clinical categories for which participants may offer benefits; [4] make adjustments to existing clinical categories; and [5] change the minimum enrollment size for some MA and MA-PD plan participants." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
GAO Says Medicaid 'Innovation' Waivers Should Expand, Not Restrict Health Coverage
"Under the ACA, states can use 1332 Medicaid waivers starting in 2017 to tinker with some of the law's core provisions, including the individual mandate, employer penalties, rules governing exchanges and covered benefits, as well as premium tax credits. However, the GAO report states that as a practical matter, proposals cannot upend the need for the IRS and the federal exchange,, to administer a consistent program across states, one that does not unduly burden the government to make state-specific IT changes, for example." (American Journal of Managed Care)
Spending for Social Security and Major Health Care Programs in the Long-Term Budget Outlook
"CBO projects that spending for Social Security would increase noticeably as a share of the economy -- from 4.9 percent of gross domestic product (GDP) in 2016 to 6.3 percent in 2046 -- if current laws generally remained unchanged. Spending for the major health care programs is projected to grow even faster: Net outlays for those programs would increase from 5.5 percent of GDP now to 8.9 percent in 2046." (Congressional Budget Office [CBO])
[Guidance Overview] Medicare-Enrolled Employees' Impact on the ACA Employer Mandate Penalty
"[E]mployers with 50 or more full-time equivalent employees are subject to one of two penalties if they fail to comply with the ACA's employer shared responsibility provisions.... The IRS confirmed that for purposes of determining whether an employer is liable for the first penalty all full-time employees are counted, regardless of whether they are enrolled in Medicare or another type of coverage. Conversely, the IRS noted that an employer is liable for the second penalty only for employees who enroll in Marketplace coverage and receive a premium tax credit subsidy." (The Wagner Law Group)
The Partisan Divide on Health Care
"Now that the party platforms for the 2016 campaign are written and posted online, we can see that Republicans and Democrats are as far apart on health care as they have been for quite some time. Platforms are never implemented as written, and not all candidates endorse every plank in them. However, they signal which issues are important to the parties and, broadly speaking, what candidates aim to do about them." (JAMA Forum)
[Opinion] Orszag and Emanuel Do Not Seem to Understand Bundled Payments
"The clinical course of a heart attack is highly variable and could involve only a few or a great many interventions. Under a bundled payment, the physicians and hospital are bearing the risk of the high costs of a potentially complicated, protracted course. Isn't it the role of the insurer, in this case Medicare, to pool risk? Shifting that risk to the health care delivery system creates the potential for either a reduction in important beneficial health care services, or exposing the delivery system to potential monetary losses and the risk of insolvency -- neither of which are desirable." (Physicians for a National Health Program [PNHP])
CMS Proposes Mandatory Cardiac Bundled-Payment Pilot
"A new mandatory program [proposed by CMS] would make hospitals in 98 markets financially accountable for the cost and quality of all care associated with bypass surgery and heart attacks.... n 2014, hospitalizations for heart attacks for more than 200,000 beneficiaries cost Medicare over $6 billion ... Yet for every treatment, the cost could vary by as much as 50%, the agency said.... The CMS also plans to expand its first and mandatory bundled-payment model -- which took effect in January and covers total hip and knee replacements -- to include surgeries repairing hip and femur fractures." (Modern Healthcare Online; free registration required)
[Opinion] Medicare Is Not 'Bankrupt'
"Although Medicare faces financing challenges, the program is not on the verge of bankruptcy or ceasing to operate. Such charges represent misunderstanding (or misrepresentation) of Medicare's finances.... Health reform, along with other factors, has significantly improved Medicare's financial outlook, boosting revenues and making the program more efficient." (Center on Budget and Policy Priorities)
National Health Spending Will Surpass $10,000 per Person This Year
"National health spending will average more than $10,000 a person this year for the first time ... a milestone that heralds somewhat faster growth in health spending after several years of exceptionally low growth. By 2025 ... health care will represent 20 percent of the total economy, up from 17.8 percent last year. By 2025, one of every five Americans will be on Medicare, and the program will spend an average of nearly $18,000 a year for each beneficiary. Medicare spent about $12,000 per beneficiary in 2015." (The New York Times; subscription may be required)
Younger Seniors Amass More Costs for End-of-Life Care Than Oldest Americans
"Medicare claims data for 2014 for beneficiaries who died the same year shows that average Medicare spending per person peaked at age 73 -- at $43,353 ... That compared with $33,381 per person for 85-year-olds and among 90-year-olds, $27,779 per person.... researchers said their findings suggest that providers, patients and their families may favor more costly, lifesaving care for younger seniors, and turn to hospice care when patients are older." (Kaiser Health News)
[Guidance Overview] CMS Finalizes Rule Giving Providers and Employers Improved Access to Information for Better Patient Care
"The new rules, as required by the Medicare Access and CHIP Reauthorization Act (MACRA), allow organizations approved as qualified entities to confidentially share or sell analyses of Medicare and private sector claims data to providers, employers, and other groups who can use the data to support improved care.... The rule also includes strict privacy and security requirements for all entities receiving patient identifiable and beneficiary de-identified analyses or data, as well as expanded annual reporting requirements." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])

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