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Monthly Archives: April 2012

Medicaid Upper Payment Limits: Understanding Federal Limits on Medicaid Fee-For-Service Reimbursement of Hospitals and Nursing Homes

Medicaid financing is extremely complex.  Federal upper payment limits on hospitals, nursing facilities, and other healthcare providers are a case in point.  Here is a quick primer. Origins of Upper Payment Limit: The Upper Payment Limit (UPL) is a federal limit placed on fee-for-service reimbursement of Medicaid providers.  Specifically, the Upper Payment Limit is the maximum a given State Medicaid program...

Medicaid Expansion under ACA: New CMS Rules on Medicaid Eligibility Expansion and Streamlined Enrollment

Medicaid enrollment is expected to increase dramatically starting in 2014 under the Affordable Care Act (ACA).  New final and interim final rules from the Centers for Medicare and Medicaid Services (CMS) significantly expand Medicaid eligibility for adults under age 65 and streamline existing Medicaid eligibility and enrollment processes. These new federal policies will increase Medicaid enrollment by 15 million in...

Health Reform Implementation: Milestones for State Implementation of Health Insurance Exchanges, Medicaid Expansion, and Health Insurance Market Reforms

Under the Affordable Care Act (ACA), states are responsible for implementing a complex array of health reforms, most notably Health Insurance Exchanges, Medicaid expansion, and health insurance market regulations.  ACA presents states, particularly state Medicaid agencies and insurance departments, with unprecedented policy, fiscal, programmatic, operational, and systems challenges. A helpful new policy brief from RWJF’s State Health Reform Assistance Network identifies...

Health IT and Care Coordination: Role of Health Information Technology in Care Coordination

Care coordination is a process that ensures a patient’s health services and information sharing preferences and needs are met. Care coordination, a critical component during the nation’s current shift from a fragmented system toward one that stresses accountability and continuity, is primarily accomplished by people as opposed to technology. This demands effective collaboration between the providers and organizations caring...

Medical Devices and the FDA: FDA Taking Longer to Approve New Medical Devices for U.S. Market

The Food and Drug Administration (FDA) reviews the safety and effectiveness of new medical devices sold in the United States, and The Medical Device User Fee and Modernization Act of 2002 (MDUFMA) authorizes FDA to collect user fees to support the device submission review process. MDUFMA also establishes performance goals for the FDA including time frames for action on...

Comparative Effectiveness Research: How Agency for Healthcare Research and Quality Spent $474 Million in ARRA Funds

As part of the $1.1 billion provided to the Department of Health and Human Services (HHS) earmarked for comparative effectiveness research (CER) under the American Recovery and Reinvestment Act (ARRA or Recovery Act) of 2009, $474 million went to HHS’s Agency for Healthcare Research and Quality (AHRQ) to support and disseminate comparative effectiveness research results. Comparative effectiveness research is...

Health Insurance Administrative Expenses: Details on Administrative Expenses of Health Plans in Large Group, Small Group, and Individual Markets

Health insurance plans are required to report their administrative expenses.  For health plans in the for the large group, small group, and individual insured markets, an new report from Milliman details insurers’ administrative expenses in five categories: Expenses for improving healthcare quality Claims adjustment expenses Agents and brokers fees and commissions Direct sales salaries and benefits expenses Other general and administrative expenses Milliman’s research report,...

Medicaid Program Integrity: Federal Investigations, Audits, and Evaluations to Combat Medicaid Waste, Fraud, and Abuse

In its latest Medicaid Integrity Program Report, the HHS Office of Inspector General (OIG) outlines Medicaid program integrity activities for FY 2011, including Medicaid-related audits and evaluations and Medicaid-related legal and investigative outcomes. Funding was employed in 2011 to oversee the integrity of Medicaid activity from the Health Care Fraud and Abuse Control program, the Medicaid Integrity Program, and the...

Health Plans and Quality Improvement Reporting Under the Affordable Care Act: Recommendations for Implementing Reporting of Quality Improvement Strategies

The Affordable Care Act (ACA) requires the Centers for Medicare and Medicaid Services (CMS) issue employer group health plan quality improvement reporting requirements. Reports shall cover specified quality improvement activities regarding plan or coverage benefit and provider reimbursement structures. Those requirements shall include efforts to improve health outcomes, ensure patient safety and reduce medical errors, prevent hospital readmissions, and...

Health Insurer Fee Impact on Medicaid: Financial Impact of ACA Health Insurer Fee on State Medicaid Programs and Medicaid Health Plans

A new federally mandated tax on health insurers will increase costs for state Medicaid programs and Medicaid health plans. In an excellent new report, PPACA Health Insurer Fee Estimated Impact on State Medicaid Programs and Medicaid Health Plans, Milliman, retained by the Medicaid Health Plans of America (MHPA), conducted an independent analysis of the new federal health insurer fee’s effect on...

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