Tag Archives: Medicaid

GAO Encourages More CMS Collaboration with States on Medicaid Program Integrity Efforts

The GAO has had ongoing concerns about the integrity of the Medicaid program due to its size, diversity, and recent rapid growth as a result of the Affordable Care Act. It is the second largest health insurance program in the U.S. based on expenditures ($576 billion combined federal and state spending projected for 2016).  At the … Continue Reading

CMS Clarifies Medicaid DSH Rules for Treatment of Third Party Payments in Calculating Uncompensated Care Costs

CMS has published a final rule intended to codify its existing interpretation of how third-party payments are considered in the calculation of Medicaid uncompensated care costs for the purpose of making Medicaid disproportionate share hospital (DSH) payments. Under the final rule, CMS specifies that uncompensated care costs for purposes of calculating hospital-specific DSH limits are … Continue Reading

House GOP Moving Ahead on Controversial ACA Repeal & Replace Bill; First of Three Planned Phases of Health Reform

The House of Representatives is moving ahead on the Republican plan -– the American Health Care Act (AHCA) – that would repeal and replace major provisions of the Affordable Care Act (ACA). On March 16, 2017, the House Budget Committee approved sending the bill to the full House as part of fiscal year 2017 budget … Continue Reading

Trump Administration Signals More Administrative Flexibility for State Medicaid Programs, with Emphasis on “Most Vulnerable Populations”

In her first act as CMS Administrator, Seema Verma joined HHS Secretary Tom Price in writing to the nation’s Governors to urge collaboration on improving the Medicaid program, with an emphasis on services for “truly vulnerable” populations. Price and Verma contend that the “expansion of Medicaid through the Affordable Care Act (ACA) to non-disabled, working-age … Continue Reading

House Panel Votes to Tighten Medicaid Income Standards

The House Energy and Commerce Subcommittee on Health has approved two bills that would modify Medicaid eligibility rules to consider additional sources of income. First, HR 829 would establish standards for states to consider lottery winnings and other lump sum payments for purposes of determining Modified Adjusted Gross Income (MAGI) for Medicaid and CHIP eligibility.  … Continue Reading

CMS Finalizes Tighter Rules for New Medicaid Managed Care Pass-Through Payments

CMS has finalized without change its proposed rule to block states from adopting or increasing Medicaid managed care “pass-through” payments to hospitals, nursing facilities, and physicians beyond those in place when pass-through payment transition periods were established in a May 6, 2016 final Medicaid managed care rule.  As we previously reported, CMS considers pass-through payments … Continue Reading

Medicare, Medicaid Payment Policies, Fraud Authorities Enacted as Part of 21st Century Cures Act

Included in the 21st Century Cures Act are numerous changes to Medicare and Medicaid policies, including provisions with significant reimbursement impacts for certain types of Medicare providers and suppliers, along with changes intended to reduce the regulatory and administrative burdens associated with the use of electronic health records.  Furthermore, the law once again expands the … Continue Reading

CMS Issues Additional ACA Medicaid and CHIP Eligibility, Appeals, Enrollment Regulations

CMS has published a final rule that implements various Medicaid and Children’s Health Insurance Program (CHIP) eligibility, appeals, and related administrative changes under the Affordable Care Act (ACA) that were proposed in January 22, 2013 but not included in a July 15, 2013 rule finalizing selected provisions. According to CMS, the rule will support “modernization … Continue Reading

CMS Proposes Restrictions on New Medicaid Managed Care Pass-Through Payments

CMS is proposing to prohibit states from adopting new or increased “pass-through” payments to hospitals, nursing facilities, and physicians under their Medicaid managed care contracts beyond those in place when the pass-through payment transition periods were established in a May 6, 2016 final Medicaid managed care rule. CMS considers pass-through payments to be amounts that … Continue Reading

FY 2018 Federal Financial Participation Matching Amounts Published

The Department of Health and Human Services (HHS) has published the FY 2018 Federal Medical Assistance Percentages (FMAP), Enhanced FMAP, and disaster-recovery FMAP adjustments.  These amounts will be used to determine federal matching amounts for state expenditures for Medicaid, the Children’s Health Insurance Program, and certain other medical and other social services, applicable from October … Continue Reading

Looking Ahead to a Trump Administration: Health Care and Life Sciences Industry Perspectives

Observers are digesting what the Trump Administration will mean for the health care and life sciences industry.  Forecasting is more challenging for this incoming Administration than most given the relatively sparse policy details released during the campaign and the lack of a government service record to examine for clues.  Today President-elect Trump’s transition team released … Continue Reading

OIG “Investigative Advisory” Highlights Potential Medicaid Fraud, Patient Harm Stemming from Personal Care Services

The OIG has issued an “Investigative Advisory on Medicaid Fraud and Patient Harm Involving Personal Care Services” that identifies various “fraud schemes” it has encountered involving personal care services (PCS) — nonmedical assistance typically provided by an attendant working for a personal care agency.  PCS is an optional Medicaid benefit offered in certain states.  According … Continue Reading

OIG Cautions that States May Be Claiming Matching Funds for Privately-Operated Hospitals

The OIG has issued a memo to CMS suggesting that some states may be claiming matching funds for government-owned but privately-operated hospitals, where no state or local government funds are used to operate the hospital. The OIG suggests that CMS consider requiring that an entity be operated by a unit of government in order to … Continue Reading

CMS Proposes Changes to Payment Error Rate Measurement (PERM) & Medicaid Eligibility Quality Control (MEQC) Programs

CMS has issued a proposed rule to make changes to the PERM and MEQC programs to align with changes to state adjudication of Medicaid and Children’s Health Insurance Program (CHIP) eligibility under the Affordable Care Act. The proposed rule also includes revisions to PERM and MEQC policies that are intended to reduce state burdens associated … Continue Reading

OIG Examines State Implementation of Correct Coding Edits for Medicaid Payments

The HHS Office of Inspector General (OIG) recently issued a report examining implementation of Medicaid National Correct Coding Initiative (NCCI) edits, as required by the Affordable Care Act since October, 2010.  The report finds that several problems have limited the success of these edits (medically unlikely edits and procedure-to-procedure edits), which are designed to encourage … Continue Reading

CMS Delays Deadline for State Medicaid Access Monitoring Review Plans

CMS has published a notice giving states more time to submit state access monitoring review plans under a November 2015 rule intended to assure access to covered Medicaid services.  By way of background, the final rule required states to develop and submit to CMS an access monitoring review plan for the following service categories: primary … Continue Reading

House Unanimously Approves Legislation to Remove Terminated Providers from Medicaid, CHIP

The House of Representatives has unanimously approved H.R. 3716, the Ensuring Access to Quality Medicaid Providers Act. The bill, which still awaits Senate consideration, would implement several OIG recommendations to improve CMS oversight of terminated providers and state screening of providers. Among other things, H.R. 3716 would require states and Medicaid managed care plans to … Continue Reading

Energy & Commerce Committee Advances Medicaid/CHIP Legislation with Lower Provider Tax Limit

The House Energy & Commerce Committee has voted to approve H.R. 4725, Common Sense Savings Act of 2016, which includes a number of Medicaid and Children’s Health Insurance Program (CHIP) reforms. Among other things, the bill would: reduce the limit on Medicaid provider taxes from 6% to 5.5% of net patient revenues; reduce federal Medicaid … Continue Reading

House Budget Committee Clears FY 2017 Budget Resolution with Medicare, Medicaid Cuts

The House Budget Committee has approved the budget resolution providing instructions to Congressional committees on the federal spending framework for FY 2017. The resolution calls for the adoption of major reforms to the Medicare program that would cut spending by $449 billion over 10 years, while Medicaid and other health care spending would be reduced … Continue Reading

CMS Finalizes Medicaid Home Health and Medical Equipment Policy Changes, Including Face-to-Face Encounter Requirements

CMS published a final rule on February 2, 2016 to implement statutory requirements regarding documentation of face-to-face encounters with Medicaid beneficiaries within certain timeframes as a condition of Medicaid coverage of home health services and certain medical equipment.  The rule also makes several clarifications to Medicaid policies related to coverage of home health services, including … Continue Reading

Government Reports Compile Medicaid, Dual Eligible Beneficiary Spending, Enrollment Data

The Government Accountability Office (GAO) has issued a report on trends in Medicaid managed care spending, enrollment, and oversight.  Notably, the GAO reports that over 10 years (FY 2004 through 2014), federal Medicaid managed care spending grew from $27 billion to $107 billion, representing 38% of total federal Medicaid spending in 2014.  The report also … Continue Reading

CMS Issues Final Rule on Enhanced Funding for Certain Medicaid Eligibility & Enrollment Systems

On December 4, 2015, CMS published a final rule that extends enhanced federal funding for the design, development, installation, or enhancement of Medicaid eligibility and enrollment systems. The rule also updates standards for Medicaid Management Information Systems (MMIS). According to CMS, the final rules will help states automate the application and renewal process, improve the … Continue Reading
LexBlog