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Medicare, Medicaid, Health Reform

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Monthly Archives: September 2012

Risk Adjustment of Health Plans Under ACA: Methods and Complications for Individual and Small Group Markets

The Affordable Care Act (ACA) will prohibit health insurers from denying coverage and from excluding coverage of pre-existing coverage.  It will also limit how much more in premiums insurers can charge to high-cost groups compared to low-cost groups.  For example, a consumer's health status and sex may not be used to set premiums, even though unhealthy consumers and women tend to have higher per capita...

All-Payor Claims Database: A Useful Tool to Increase Transparency and Reduce Costs

States might find it useful to have a database replete with health care service claims data to identify Medicaid fraud, evaluate disease trends, establish cost and utilization rates, and share price information with consumers. Typically such comprehensive data is difficult to gather because it comes from various public and private sector sources. A recent white paper from Milliman gives...

Medicaid Prescription Drugs: National Survey of Average Drug Acquisition Costs

The Centers for Medicare and Medicaid Services (CMS) is working to help state Medicaid programs get the best deal possible when purchasing prescription drugs. The second phase of CMS’s Medicaid retail drug price survey will poll pharmacies on a monthly basis to create a National Average Drug Acquisition Cost (NADAC) pricing file. States will have access to the file...

Medicaid Eligibility Expansion: Arguments For and Against States Opting for ACA Medicaid Expansion

In deciding whether to expand Medicaid eligibility under the Affordable Care Act (ACA), governors and state legislatures face a complex, politically and fiscally challenging choice.  The decision on Medicaid eligibility expansion is already a hot topic in state capitals and state election campaigns.  Expect the politics and policy of Medicaid to reach a fever pitch after the November elections.  In this post,...

Electronic Health Records: Profile of Physicians Using EHRs

One objective of the 2009 Health Information for Economic and Clinical Health (HITECH) Act is to encourage more physicians and hospitals to adopt electronic health record (EHR) systems. Physicians and hospitals that effectively use electronic health records will play an important role in preventing medical errors, reducing costs, and providing higher-quality and evidence-based care. To help modernize U.S. health information...

Medicare Value-Based Payment Modifier: CMS Discusses Proposed Rules with Physicians

Medicare’s new value-based payment method for reimbursing physicians will begin in 2015 to affect physician groups with at least 25 eligible professionals. Groups will have the option to participate in a tiered payment system, which would adjust Medicare Part B fee schedule payment rates by an as-yet undetermined amount or could decrease reimbursements by up to 1 percent. Groups can...

Medicaid Managed Long-Term Care: Policy Recommendations from State Medicaid Directors

State Medicaid directors need greater flexibility and faster federal approval to maintain or establish new managed long-term supports and services (MLTSS) programs in Medicaid. A growing number of states are implementing such programs, from 8 states in 2004 to 16 states in 2012. “A strong and effective federal-state partnership with clearly aligned goals is critical to the success of these efforts,” says an...

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