Health Hippo: Managed Care
To do nothing is sometimes a good remedy.
There is little evidence that managed care has undermined the quality of health care services in America. Public outcry has waned, with more than 135 million people receiving their primary, preventive, and acute health services through a managed care plan. But does managed care really result in lower health care spending? Since the plans have become dominant over two decades of the most explosive growth of health care costs in history, it is a fair question.
The Affordable Care Act (ACA) eliminated certain subsidies used to establish Medicare’s managed care program (currently called “Medicare Advantage”) In 2008, the federal government spent 12 percent more on Medicare Advantage than it did for comparable care under traditional Medicare. These subsidies (which added an additional $14 billion to the Medicare program in 2009) were slated to be reduced to bring costs in line with traditional Medicare.
Shortly after the ACA passed, however, the government launched an $8.35 billion demonstration project to postpone the majority of Medicare Advantage program cuts. According to the Government Accountability Office, the Medicare Advantage Quality Bonus Payment Demonstration project costs more than the previous 85 demonstration projects combined and is not required by law to conform to principles of budget neutrality.
- Health Care and Education Reconciliation Act: Medicare Advantage
- Affordable Care Act: Medicare Advantage Provisions.
- Sec. 3201. Medicare Advantage payment.
- Sec. 3202. Benefit protection and simplification.
- Sec. 3203. Application of coding intensity adjustment during MA payment transition.
- Sec. 3204. Simplification of annual beneficiary election periods.
- Sec. 3205. Extension for specialized MA plans for special needs individuals.
- Sec. 3206. Extension of reasonable cost contracts.
- Sec. 3207. Technical correction to MA private fee-for-service plans.
- Sec. 3208. Making senior housing facility demonstration permanent.
- Sec. 3209. Authority to deny plan bids.
- Sec. 3210. Development of new standards for certain Medigap plans.
- Sec. 10318. Revisions to transitional extra benefits under Medicare Advantage.
- Sec. 10319. Revisions to market basket adjustments.
- Medicare Modernization Act: Medicare Advantage program.
- Sec. 201 Implementation of Medicare Advantage program.
- Sec. 211 Immediate improvements.
- Sec. 221 Establishment of MA regional plans.
- Sec. 222 Competition program beginning in 2006.
- Sec. 223 Effective date.
- Sec. 231 Specialized MA plans for special needs individuals.
- Sec. 232 Avoiding duplicative State regulation.
- Sec. 233 Medicare MSAs.
- Sec. 234 Extension of reasonable cost contracts.
- Sec. 235 Two-year extension of municipal health service demonstration projects.
- Sec. 236 Payment by PACE providers for medicare and medicaid services furnished by noncontract providers.
- Sec. 237 Reimbursement for federally qualified health centers providing services under MA plans.
- Sec. 238 Institute of Medicine evaluation and report on health care performance measures.
- Sec. 241 Comparative Cost Adjustment (CCA) program.
- Balanced Budget Act: Medicare+Choice Program
- Sec. 4001 Establishment of Medicare+Choice program.
- Sec. 1851 Eligibility, election, and enrollment.
- Sec. 1852 Benefits and beneficiary protections.
- Sec. 1853 Payments to Medicare+Choice organizations.
- Sec. 1854 Premiums.
- Sec. 1855 Organizational and financial requirements for Medicare+Choice organizations; provider-sponsored organizations.
- Sec. 1856 Establishment of standards.
- Sec. 1857 Contracts with Medicare+Choice organizations.
- Sec. 1859 Definitions; miscellaneous provisions.
- Sec. 4002 Transitional rules for current medicare HMO program.
- Sec. 4003 Conforming changes in medigap program.
- Sec. 4006 Medicare+Choice MSA.
- Sec. 4011 Medicare prepaid competitive pricing demonstration project.
- Sec. 4012 Administration through the Office of Competition; advisory committee.
- Sec. 4013 Project design based on FEHBP competitive bidding model.
- Sec. 4014 Social health maintenance organizations (SHMOs)
- Sec. 4015 Medicare subvention demonstration project for military retirees.
- Sec. 4016 Medicare coordinated care demonstration project.
- Sec. 4017 Orderly transition of municipal health service demonstration projects.
- Sec. 4018 Medicare enrollment demonstration project.
- Sec. 4019 Extension of certain medicare community nursing organization demonstration projects.
- Sec. 4021 National Bipartisan Commission on the Future of Medicare.
- Sec. 4022 Medicare Payment Advisory Commission.
- Sec. 4031 Medigap protections.
- Sec. 4032 Addition of high deductible medigap policies.
- Sec. 4041 Tax treatment of hospitals which participate in provider- sponsored organizations.
- 42 U.S. Code Chapter 6A, Subchapter XI HEALTH MAINTENANCE ORGANIZATIONS
- 42 USC Sec. 300e Requirements of
health maintenance organizations
- 42 USC Sec. 300e-1 Definitions
- 42 USC Sec. 300e-4 Loans and loan
guarantees for initial operation costs
- 42 USC Sec. 300e-5 Application
- 42 USC Sec. 300e-6 Administration of
- 42 USC Sec. 300e-7 General
provisions relating to loan guarantees and loans
- 42 USC Sec. 300e-8 Authorization of
- 42 USC Sec. 300e-9 Employees’ health
- 42 USC Sec. 300e-10 Restrictive
State laws and practices
- 42 USC Sec. 300e-11 Continued
regulation of health maintenance organizations
- 42 USC Sec. 300e-12 Limitation on
source of funding for health maintenance organizations
- 42 USC Sec. 300e-13 Repealed
- 42 USC Sec. 300e-14 Annual report
- 42 USC Sec. 300e-14a Health
services for Indians and domestic agricultural migratory and seasonal workers
- 42 USC Sec. 300e-15 Repealed
- 42 USC Sec. 300e-16 Training and
- 42 USC Sec. 300e-17 Financial
- 42 USC Sec. 489.20 Basic commitments
- 42 USC Sec. 300e Requirements of
Code of Federal
- PART 422 MEDICARE ADVANTAGE PROGRAM (422.1 – 422.2276)
- SUBPART A General Provisions (422.1 – 422.6)
- SUBPART B Eligibility, Election, and Enrollment (422.50 – 422.74)
- SUBPART C Benefits and Beneficiary Protections (422.100 – 422.133)
- SUBPART D Quality Improvement (422.152 – 422.158)
- SUBPART E Relationships With Providers (422.200 – 422.220)
- SUBPART F Submission of Bids, Premiums, and Related Information and Plan Approval (422.250 – 422.270)
- SUBPART G Payments to Medicare Advantage Organizations (422.300 – 422.324)
- SUBPART H Provider-Sponsored Organizations (422.350 – 422.390)
- SUBPART I Organization Compliance With State Law and Preemption by Federal Law (422.400 – 422.404)
- SUBPART J Special Rules for MA Regional Plans (422.451 – 422.458)
- SUBPART K Application Procedures and Contracts for Medicare Advantage Organizations (422.500 – 422.527)
- SUBPART L Effect of Change of Ownership or Leasing of Facilities During Term of Contract (422.550 – 422.553)
- SUBPART M Grievances, Organization Determinations and Appeals (422.560 – 422.626)
- Sec. 422.560 Basis and scope.
- Sec. 422.561 Definitions.
- Sec. 422.562 General provisions.
- Sec. 422.564 Grievance procedures.
- Sec. 422.566 Organization determinations.
- Sec. 422.568 Standard timeframes and notice requirements for organization determinations.
- Sec. 422.570 Expediting certain organization determinations.
- Sec. 422.572 Timeframes and notice requirements for expedited organization determinations.
- Sec. 422.574 Parties to the organization determination.
- Sec. 422.576 Effect of an organization determination.
- Sec. 422.578 Right to a reconsideration.
- Sec. 422.580 Reconsideration defined.
- Sec. 422.582 Request for a standard reconsideration.
- Sec. 422.584 Expediting certain reconsiderations.
- Sec. 422.586 Opportunity to submit evidence.
- Sec. 422.590 Timeframes and responsibility for reconsiderations.
- Sec. 422.592 Reconsideration by an independent entity.
- Sec. 422.594 Notice of reconsidered determination by the independent entity.
- Sec. 422.596 Effect of a reconsidered determination.
- Sec. 422.600 Right to a hearing.
- Sec. 422.602 Request for an ALJ hearing.
- Sec. 422.608 Medicare Appeals Council (MAC) review.
- Sec. 422.612 Judicial review.
- Sec. 422.616 Reopening and revising determinations and decisions.
- Sec. 422.618 How an MA organization must effectuate standard reconsidered determinations or decisions.
- Sec. 422.619 How an MA organization must effectuate expedited reconsidered determinations.
- Sec. 422.620 Notifying enrollees of hospital discharge appeal rights.
- Sec. 422.622 Requesting immediate QIO review of the decision to discharge from the inpatient hospital.
- Sec. 422.624 Notifying enrollees of termination of provider services.
- Sec. 422.626 Fast-track appeals of service terminations to independent review entities (IREs)
- SUBPART N Medicare Contract Determinations and Appeals (422.641 – 422.696)
- SUBPART O Intermediate Sanctions (422.750 – 422.764)
- Sec. 422.750 Types of intermediate sanctions and civil money penalties.
- Sec. 422.752 Basis for imposing intermediate sanctions and civil money penalties.
- Sec. 422.756 Procedures for imposing intermediate sanctions and civil money penalties.
- Sec. 422.758 Collection of civil money penalties imposed by CMS.
- Sec. 422.760 Determinations regarding the amount of civil money penalties and assessment imposed by CMS.
- Sec. 422.762 Settlement of penalties.
- Sec. 422.764 Other applicable provisions.
- SUBPART P [Reserved]
- SUBPART T Appeal procedures for Civil Money Penalties (422.1000 – 422.1094)
- SUBPART V Medicare Advantage Marketing Requirements (422.2260 – 422.2276)
- 42 CFR Part 425 MEDICARE SHARED SAVINGS PROGRAM (AFFORDABLE CARE ORGANIZATIONS)
- SUBPART A General Provisions (425.10 – 425.20)
- SUBPART B Shared Savings Program Eligibility Requirements (425.100 – 425.114)
- Sec. 425.100 General.
- Sec. 425.102 Eligible providers and suppliers.
- Sec. 425.104 Legal entity.
- Sec. 425.106 Shared governance.
- Sec. 425.108 Leadership and management.
- Sec. 425.110 Number of ACO professionals and beneficiaries.
- Sec. 425.112 Required processes and patient-centeredness criteria.
- Sec. 425.114 Participation in other shared savings initiatives.
- SUBPART C Application Procedures and Participation Agreement (425.200 – 425.222)
- SUBPART D Program Requirements and Beneficiary Protections (425.300 – 425.316)
- Sec. 425.300 Compliance plan.
- Sec. 425.302 Program requirements for data submission and certifications.
- Sec. 425.304 Other program requirements.
- Sec. 425.306 Participation agreement and exclusivity of ACO participant TINs.
- Sec. 425.308 Public reporting and transparency.
- Sec. 425.310 Marketing requirements.
- Sec. 425.312 Notification to beneficiaries of participation in shared savings program.
- Sec. 425.314 Audits and record retention.
- Sec. 425.316 Monitoring of ACOs.
- SUBPART E Assignment of Beneficiaries (425.400 – 425.404)
- SUBPART F Quality Performance Standards and Reporting (425.500 – 425.506)
- SUBPART G Shared Savings and Losses (425.600 – 425.608)
- SUBPART H Data Sharing With ACOs (425.700 – 425.710)
- SUBPART I Reconsideration Review Process (425.800 – 425.810)
- Sec. 425.800 Preclusion of administrative and judicial review.
- Sec. 425.802 Request for review.
- Sec. 425.804 Reconsideration review process.
- Sec. 425.806 On-the-record review of reconsideration official’s recommendation by independent CMS official.
- Sec. 425.808 Effect of independent CMS official’s decision.
- Sec. 425.810 Effective date of decision.
- 42 CFR PART 417 HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS
- SUBPART A General Provisions (417.1 – 417.2)
- SUBPART B Qualified Health Maintenance Organizations: Services (417.101 – 417.106)
- SUBPART C Qualified Health Maintenance Organizations: Organization and Operation (417.120 – 417.126)
- SUBPART D Application for Federal Qualification (417.140 – 417.144)
- SUBPART E Inclusion of Qualified Health Maintenance Organizations in Employee Health Benefits Plans (417.150 – 417.159)
- SUBPART F Continued Regulation of Federally Qualified Health Maintenance Organizations (417.160 – 417.166)
- SUBPART G-I [Reserved]
- SUBPART J Qualifying Conditions for Medicare Contracts (417.400 – 417.418)
- SUBPART K Enrollment, Entitlement, and Disenrollment under Medicare Contract (417.420 – 417.464)
- Sec. 417.421 Basic rules on enrollment and entitlement.
- Sec. 417.422 Eligibility to enroll in an HMO or CMP.
- Sec. 417.423 Special rules: ESRD and hospice patients.
- Sec. 417.424 Denial of enrollment.
- Sec. 417.426 Open enrollment requirements.
- Sec. 417.427 Extending MA and Part D program disclosure requirements to section 1876 cost contract plans.
- Sec. 417.428 Marketing activities.
- Sec. 417.430 Application procedures.
- Sec. 417.432 Conversion of enrollment.
- Sec. 417.434 Reenrollment.
- Sec. 417.436 Rules for enrollees.
- Sec. 417.440 Entitlement to health care services from an HMO or CMP.
- Sec. 417.442 Risk HMO’s and CMP’s: Conditions for provision of additional benefits.
- Sec. 417.444 Special rules for certain enrollees of risk HMOs and CMPs.
- Sec. 417.446 [Reserved]
- Sec. 417.448 Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs.
- Sec. 417.450 Effective date of coverage.
- Sec. 417.452 Liability of Medicare enrollees.
- Sec. 417.454 Charges to Medicare enrollees.
- Sec. 417.456 Refunds to Medicare enrollees.
- Sec. 417.458 Recoupment of uncollected deductible and coinsurance amounts.
- Sec. 417.460 Disenrollment of beneficiaries by an HMO or CMP.
- Sec. 417.461 Disenrollment by the enrollee.
- Sec. 417.464 End of CMS’s liability for payment: Disenrollment of beneficiaries and termination or default of contract.
- SUBPART L Medicare Contract Requirements (417.470 – 417.500)
- SUBPART M Change of Ownership and Leasing of Facilities: Effect on Medicare Contract (417.520 – 417.520)
- SUBPART N Medicare Payment to HMOs and CMPs: General Rules (417.524 – 417.528)
- SUBPART O Medicare Payment: Cost Basis (417.530 – 417.576)
- SUBPART P Medicare Payment: Risk Basis (417.580 – 417.598)
- SUBPART Q Beneficiary Appeals (417.600 – 417.600)
- Sec. 417.600 Basis and scope.
- SUBPART R Medicare Contract Appeals (417.640 – 417.640)
- SUBPART S-T [Reserved]
- SUBPART U Health Care Prepayment Plans (417.800 – 417.840)
- SUBPART V Administration of Outstanding Loans and Loan Guarantees (417.910 – 417.940)
- Medicare Plus Choice: Interim Final Rule (replaced by Medicare Advantage)
- INTRODUCTION: Medicare benefits through enrollment in one of an array of managed care choices.
- SUBPART A: General Provisions
- SUBPART B: Eligibility, Election, and Enrollment
- SUBPART C: Benefits and Beneficiary Protections
- SUBPART D: Quality Assurance
- SUBPART E: Relationships With Providers
- SUBPART F: Payments to Medicare+Choice Organizations
- SUBPART G: Premiums and Cost-Sharing
- SUBPART H: Requirements concerning provider-sponsored organizations
- SUBPART I: Organization compliance with State law and preemption by Federal law
- SUBPART K: General contract and enrollment requirements
- SUBPART L: Effect of change of ownership or leasing of facilities during term of contract
- SUBPART M: Grievances and organization determinations and appeals
- SUBPART N: Contractor appeals of nonrenewals or terminations of contracts
- SUBPART O: Intermediate sanctions
- MEDICAL SAVINGS ACCOUNTS
- FEE FOR SERVICE PLANS
- REGULATORY IMPACT STATEMENT
- In the Case of Network Health Insurance Corp. (MAC 2012) (a Medicare Advantage Plan must provide enrollees with coverage where the evidence shows the supplies are reasonable and necessary in accordance with Medicare coverage criteria, including applicable NCDs)
- In the Case of E.T. (MAC 2012) (finding that the enrollee, at the time of review, met the NCD and LCD criteria for coverage of lap band surgery)
- In the Case of San Joaquin Valley Rehabilitation Hospital (MAC 2011) (the medical evidence reveals the required level of medically reasonable and necessary care could have been provided in a less intense setting, rather than in an extended inpatient rehabilitation hospital stay)
- In the Case of F.M. for the Estate of A.M. (MAC 2011) (the notice of non-coverage in this case met all requirements for delivery of a valid telephone notice)
- In the Case of G.S. (MAC 2011) (the MA plan is not required to authorize surgery which is not available to beneficiaries residing in a plan’s service area)
- In the Case of S.W. (MAC 2011) (the MA plan covers lenses in accordance with traditional Medicare Part B coverage guidelines, which allow for coverage of standard lenses after cataract surgery, not for coverage of upgraded lenses)
- In the Case of D.C. (MAC 2011) (while a Tempur-pedic bed may be beneficial or even medically necessary for the enrollee, the bed is available to the general population, is primarily and customarily used for a non-medical purpose, and does not meet Medicare’s definition of covered DME)
- In the Case of Kaiser Permanente Senior Advantage (MAC 2011) (the copayments at issue are the contractual obligations of an enrollee whenever an enrollee receives care under the plan and are not dependent on the degree of the enrollee’s satisfaction with, or outcome of, the services rendered)
- In the Case of B.V. (MAC 2011) (the enrollee has a legal liability to pay for the non-covered dentures)
- In the Case of G.S. (MAC 2011) (the MAO’s Evidence of Coverage for dental services is consistent with the coverage criteria under original Medicare and the MA plan is not required to cover the outpatient dental services at issue)
- In the Case of K.B. (MAC 2011) (the MA plan is not required to provide coverage for any of the home health aide services provided to the enrollee by a non-licensed provider)
- In the Case of Kaiser Foundation Health Plan (MAC 2011) (the record demonstrates that the MA plan’s providers could provide the necessary programming services for the enrollee’s cochlear implants)
- In the Case of Evercare by United Healthcare (MAC 2011) (the ALJ failed to consider the MA plan’s policy regarding “out-of-network” providers and suppliers)
- In the Case of D.K. (MAC 2011) (the enrollee’s obligation to pay the copayment for ambulance services is not eliminated based on the fact that the second transport occurred on the same day as the first transport, was to the same hospital, and needed generally for the same condition)
- In the Case of P.B.S., D.O., o/b/o P.A.S. (MAC 2011) (the enrollee has shown that the MA plan’s in-network providers are unavailable or inadequate to meet her medical needs and therefore a referral to an out-of-network surgeon is medically reasonable and necessary)
- In the Case of United Healthcare/Secure Horizons (MAC 2011) (the application of LCD L26109 to this case allows for only one conclusion, that prostate cancer is not a covered indication for coverage of CyberKnife stereotactic radiotherapy)
- In the Case of Secure Horizons (MAC 2011) (placement for court-ordered detention and competency treatment is not equivalent to the temporary unavailability of plan providers under unusual and extraordinary circumstances for purposes of coverage)
- In the Case of J.B. (MAC 2010) (The MA plan was not required to pay for out-of-network services provided to enrollee when enrollee failed to establish that an urgent situation existed particularly where the MA plan offered two treatment programs which enrollee refused, the enrollee was not outside of the MA plan’s service area when the need for the care arose, and the enrollee did not suffer from an unforeseen illness or injury)
- In the case of Kaiser Foundation Health Plan, Inc. (MAC 2010) (the MAO’s denial of an out-of-plan referral for surgery and subsequent administrative determination that it could cover the removal of the an implant if an in-plan doctor confirms the rupture of that specific implant despite the recommendations of two doctors that both implants be removed, was a denial of basic covered benefits in accordance with the EOC’s reconstructive surgery coverage provisions)
- In the case of A.M.R. (MAC 2010) (because the enrollee provided evidence that the network providers were unavailable or inadequate to meet her medical needs, a referral by her primary care physician to an out-of-network provider is medically reasonable and necessary and covered by the MA plan)
- In the case of Care Improvement Plus (MAC 2010) (brief inpatient care of MA enrollee was medically necessary after attending physician considered the enrollee’s medical status and foreseeable adverse consequences in light of the enrollee’s pre-existing cardiac condition)
- In the case of United HealthCare d/b/a Evercare (MAC 2010) (on remand, the ALJ properly considered the IRE doctor consultant’s opinion, whose identity remained anonymous, and the written interrogatories and interrogatory answers provided by an independent medical expert in reaching his decision)
- In the case of Desert Valley Hospital (MAC 2010) (the medical opinion by a treating physician that an enrollee is stabilized for transfer or discharge triggers an emergency provider’s obligation to notify the MAO, reasonably within an hour of the point at which the enrollee is stabilized, as well as the MAO’s financial responsibility for the post-stabilization care of the enrollee)
- In the Case of PacifiCare (MAC 2009) (a maintenance exercise program is an unskilled service that does not require the special skills of a licensed therapist and the Medicare Advantage plan is not required to cover the skilled nursing facility services)
- In the Case of G.L. (MAC 2009) (the facts of the case do not warrant an exception and the Medicare Advantage plan is not required to provide coverage for services provided by a skilled nursing facility that is not a plan provider)
- In the Case of D.C. (MAC 2009) (the Medicare Advantage plan is not required to provide coverage of, or reimbursement for, air ambulance services furnished to the enrollee from Mexico to the United States after he suffered a fall while on vacation)
- In the Case of R.C. (MAC 2009) (a Medicare Advantage plan must comply with local coverage determinations but policy articles are not binding)
- In the Case of Kaiser Foundation Health Plan Hawaii (MAC 2008) (the Medicare Advantage plan is not required to cover the enrollee’s out-of-plan liver resection surgery and associated post-surgery hospitalization expenses as the enrollee did not qualify for urgently needed care and the plan did not make their providers unavailable, inaccessible or inadequate to meet her needs)
- In the Case of Blue Cross of Idaho (MAC 2009) (the Medicare Advantage plan is required to reimburse the skilled nursing facility for the covered services instead of directly paying the enrollee’s estate)
- In the Case of Connecticut Dept. of Social Services (MAC 2009) (a Medicare Advantage plan must provide enrollees with all items and services covered by Medicare Part A and Part B available to beneficiaries residing in the plan’s service area and the plan is required to cover skilled nursing services as defined by regulation)
- In the Case of M.D. (MAC 2009) (a Medicare Advantage plan must provide necessary specialty care or arrange for specialty care outside the plan provider network when network providers are unavailable or inadequate to meet the enrollee’s medical needs)
- MedPac: Medicare Advantage Program The Medicare Advantage (MA) program allows Medicare beneficiaries to receive their Medicare benefits from private plans rather than from the traditional fee-for-service (FFS) program. Under the MA program, Medicare buys insurance coverage for its beneficiaries from private plans with payments made monthly. The coverage must include all Medicare Part A and Part B benefits except hospice. All plans, except PFFS plans, must also offer an option that includes the Part D drug benefit. Plans may limit enrollees’ choices of providers more narrowly than under the traditional fee-for-service (FFS) program.
- MedPac: Medicare Advantage Benchmarks And Payments Compared With Average Medicare Fee-For-Service Spending The combined Medicare Advantage Program benchmarks were set at an average of 115 percent of Fee for Service Medicare in 2006. After taking into account the amount that plans return to the trust fund through the bidding process, the 115 percent figure falls to 111 percent. In sum, this 111 percent includes all three factors we have discussed: the relationship of the MA benchmarks to FFS rates, the effect of bidding and returning funds to the trust funds, and the hold-harmless provisions.
- MedPac: M+C payment rates compared with county Medicare per capita fee-for-service spending Across all counties, Medicare is paying M+C plans an average of 107 percent of what it would cost to cover the current mix of M+C enrollees under the traditional fee-for-service Medicare program. This estimate (along with all the other estimates in this report) assumes that the average health risk of the M+C and traditional enrollees are the same, other than those differences accounted for by demographic characteristics. If, as CMS has found, M+C plans enroll a less costly population than would be accounted for by demographics, Medicare would be paying M+C plans more than 107 percent of Medicare’s spending under FFS.
- State Standards for Access to Care in Medicaid Managed Care (OIG 2014) Most States provide Medicaid services through managed care. The Office of Inspector General received a congressional request to evaluate the adequacy of access to care for enrollees in Medicaid managed care. This report describes the standards that States establish for access to care in their Medicaid managed care programs and how States determine compliance with these standards.
- CMS Regularly Reviews Part C Reporting Requirements Data, But Its Followup and Use of the Data Are Limited (OIG 2014) CMS contracted with Acumen to review and analyze all Part C Reporting Requirements data submitted by MA organizations, identify data issues, and notify affected MA organizations. The Part C Reporting Requirements data are a significant resource for oversight and improvement of the MA program because they pertain to the performance of MA organizations and often are not available to CMS from other sources.
- Medicare Advantage: Special Needs Plans Were More Profitable, on Average, than Plans Available to All Beneficiaries in 2011 (GAO 2013) Special needs plans (SNP) reported having higher profit margins and spending a lower percentage of total revenues on medical expenses, on average, than Medicare Advantage (MA) plans available to all beneficiaries in 2011. For instance, SNPs’ average profit margin was 4.0 percentage points higher than plans available to all beneficiaries–8.6 percent vs. 4.6 percent. SNPs also had a higher plan-level median profit margin compared to MA plans available to all beneficiaries–7.1 percent vs. 3.2 percent.
- Medicare Advantage: Substantial Excess Payments Underscore Need for CMS to Improve Accuracy of Risk Score Adjustments (GAO 2013) GAO’s findings underscore the importance for CMS to implement the recommendation from GAO’s January 2012 report that the agency improve the accuracy of its MA risk score adjustments by taking steps such as using the most current data available and incorporating adjustments for additional beneficiary characteristics.
- State and CMS Oversight of the Medicaid Managed Care Credentialing Process (OIG 2013) All six States credentialing policies and MCE contract provisions met Federal standards. However, five of six States did not monitor MCEs compliance with the Federal provider nondiscrimination contract provision. This provision requires that MCEs not discriminate against providers that serve high-risk populations or that specialize in conditions requiring costly treatment. Also, CMS oversight to ensure the compliance of State contracts was inconsistent.
- Medicare Advantage: Quality Bonus Payment Demonstration Has Design Flaws and Raises Legal Concerns (GAO 2012) Notably, the bonus payments are based largely on plan performance that predates the demonstration. All of the performance data used to determine the 2012 bonus payments and nearly all of the data used to determine the 2013 bonus payments were collected before the demonstrations final specifications were published. The demonstrations incentives to improve quality can have a full impact only in 2014. Therefore, we are concerned about the demonstrations ability to provide additional incentives to increase the efficiency and economy of Medicare services.
- Medicare Advantage: Quality Bonus Payment Demonstration Undermined by High Estimated Costs and Design Shortcomings (GAO 2012) The MA Quality Bonus Payment Demonstration does not and is not required by law to conform to the principles of budget neutrality. OMB officials told us that they considered the costs of the demonstration in the context of other administrative actions in the Medicare program that are expected to generate savings. However, they did not confirm whether specific offsets were identified to account for the total costs of the demonstration.
- Medicare Advantage: CMS Actions Regarding Plans’ Health Reform Communications (GAO 2010) In August and September 2009, Humana–a large private health insurer–sent a letter to the approximately 930,000 beneficiaries enrolled in its Medicare Advantage (MA) plans, advising that leading health reform proposals could adversely affect MA beneficiaries. Signed by Humana’s Chief Medical Officer, the letter stated that if proposed funding cuts became law, “millions of seniors and disabled individuals could lose many of the important benefits and services that make MA health plans so valuable,” and encouraged beneficiaries to contact their members of Congress and ask them to protect MA funding.
- Medicare Advantage: Relationship between Benefit Package Designs and Plans’ Average Beneficiary Health Status (GAO 2010) GAO examined (1) MA plan benefit packages by average health status of plans’ enrolled beneficiaries, (2) distribution and characteristics of MA plans by average beneficiary health status, and (3) CMS’s process for ensuring that benefit packages do not discriminate with respect to health status.
- Medicare Advantage: CMS Assists Beneficiaries Affected by Inappropriate Marketing but Has Limited Data on Scope of Issue (GAO 2009) CMS took compliance and enforcement actions for inappropriate marketing against at least 73 organizations that sponsored MA plans from January 2006 through February 2009. While the number of MA organizations varied during that time period, 192 MA organizations offered MA plans as of March 2009. Actions taken ranged from initial notices of noncompliance and warning letters to more punitive measures, such as civil money penalties and suspensions of marketing and enrollment.
- Medicaid Managed Care Encounter Data: Collection and Use (OIG 2009) From 2000 to 2006, combined Federal and State Medicaid expenditures increased from $207 billion to $322 billion. In response to this growth, States have increasingly used Medicaid managed care to deliver services to beneficiaries. Encounter data are the primary records of Medicaid services provided to beneficiaries enrolled in capitated Medicaid managed care.
- Fee-For-Service Payments for Services Covered by Capitated Medicaid Managed Care (OIG 2008) To determine the extent to which Medicaid programs in five States paid noninstitutional fee-for-service claims for services provided to beneficiaries enrolled in capitated Medicaid managed care plans during the first quarter of fiscal year (FY) 2005.
- Medicare Advantage: Increased Spending Relative to Medicare Fee-for-Service May Not Always Reduce Beneficiary Out-of-Pocket Costs GAO-08-359: Feb 22, 2008. Although health plans were originally envisioned in the 1980s as a potential source of Medicare savings, such plans have generally increased program spending. Payments to MA plans have been estimated to be 12 percent greater than what Medicare would have spent in 2006 had MA beneficiaries been enrolled in Medicare FFS.
- Medicare Advantage: Required Audits of Limited Value (GAO 2007) In fiscal year 2006, the Centers for Medicare & Medicaid Services (CMS) estimated it spent over $51 billion on the Medicare Advantage program, which serves as an alternative to the traditional fee-for-service program. Under the Medicare Advantage program, CMS approves private companies to offer health plan options to Medicare enrollees that include all Medicare-covered services. Many plans also provide supplemental benefits. The Balanced Budget Act (BBA) of 1997 requires CMS to annually audit the financial records supporting the submissions (i.e., adjusted community rate proposals (ACRP) or bids) of at least one-third of participating organizations. BBA also requires that GAO monitor the audits.
- Medicare Managed Care: HMO Rates, Other Factors Create Uneven Availability of Benefits (GAO 2007) GAO discussed aspects of Medicare managed care, including greater choice and equity across the program.
- Dispute Resolution for Medicaid Managed Care Enrollees (OIG 2001) The Supreme Court established Medicaid beneficiaries right to due process in 1970 in Goldberg v. Kelly (397, U.S. 254, 1970). Due process rights were extended to Medicaid managed care beneficiaries in 1993 in J.K. v. Dillenberg (836 F Supp. 694, 699 D AZ 93). To fulfill due process requirements, States must guarantee all Medicaid beneficiaries access to State fair hearings when their benefits are adversely affected by a government action.
- Managed Care Organization Nonreporting to the National Practitioner Data Bank: A Signal for Broader Concern (OIG 2001) In this study we examine the extent to which managed care organizations are reporting adverse actions they take against health care practitioners to the National Practitioner Data Bank and the factors that influence their level of reporting.
- Federally Funded Health Centers and Low Income Children’s Health Care: Improving SCHIP Enrollmentand Adapting to a Managed Care Environment (OIG 2000) For health centers, emergence of the SCHIP provides a significant additional funding source as they continue to make health care available to uninsured children. Thus, the mutual needs of both States and health centers can be well-served through their stronger collaboration. However, the health centers must also be prepared for changes in reimbursement methods.
- Medicare Managed Care: Goals of National Marketing Guide (OIG 2000) Our findings from this report provide evidence that the Medicare Managed Care National Marketing Guide, while improving some aspects of the marketing-material review process, was not very successful at meeting its most important goal. That goal is to provide Medicare beneficiaries with accurate and consumer friendly marketing materials. Inaccurate and confusing materials may affect beneficiaries ability to make informed health-care choices.
- Medicare Managed Care: Marketing Materials (OIG 2000) Medicare beneficiaries are exposed to marketing materials through different media, including literature, billboards, radio, television, informational meetings, and the Internet. Regardless of the medium used, plans must get approval from HCFA prior to distributing the information.
- Public Health and Managed Care: Opportunities for Collaboration (OIG 1999) Based on the findings of our study, we come to one central conclusion: Collaborations that address public health population-based strategies have barely begun. In fact, the current environment may mean that opportunities for realizing the potential of collaboration are fading.
- Medicaid Managed Care Fraud and Abuse (OIG 1999) Fraud and abuse in Medicaid programs threatens States’ capability to pay for services and provide quality care for beneficiaries. To address this, Medicaid State agencies are required to have an integrity program dedicated to detecting and reviewing suspected fraud and abuse cases. Because abuse can entail patient abuse or egregious forms that may represent fraudulent activity, we have referenced fraud and abuse cases together in this study.
- Medicare’s Oversight of Managed Care: Monitoring Plan Performance (OIG 1998) The scope and speed of growth in Medicare managed care places stress on traditional tools for oversight. As of February, 1998,439 plans counted over 6 million beneficiaries as members, a 90 percent increase since December 1994. Ideally, managed care’s capitated payment leads to innovation in providing cost-effective, high quality health care. However, the economic incentives of operating within a fixed budget may encourage plans to limit access to needed care in the interest of increasing profits.
Managed Care: Challenge of Holding Plans Accountable Requires Greater State Effort (GAO 1997) Pursuant to a congressional request, GAO reviewed state efforts to hold managed care plans accountable for meeting Medicaid program goals and for providing beneficiaries enrolled in capitated managed care plans the care they need.
- Medicare Managed
Care: HMO Rates, Other Factors Create Uneven Availability of Benefits (GAO 1997) GAO discussed aspects of Medicare managed care, including greater choice and equity across the program.
- Medicare HMO
Enrollment: Area Differences Affected by Factors Other Than Payment Rates (GAO 1997) Pursuant to a congressional request, GAO reviewed the factors affecting Medicare risk health maintenance organization (HMO) enrollment.
- Medicare HMOs:
HCFA Can Promptly Eliminate Hundreds of Millions in Excess Payments (GAO 1997) Pursuant to a congressional request, GAO provided information on Medicare’s rate-setting method for paying risk contract health maintenance organizations.
Managed Care: HCFA Missing Opportunities to Provide Consumer Information (GAO 1997) GAO discussed: (1) Medicare beneficiaries’ need for comparative information on health maintenance organizations (HMO); and (2) steps the Health Care Financing Administration (HCFA) could take to meet that need promptly.
- Medicare HMOs:
Potential Effects of a Limited Enrollment Period Policy (GAO 1997) Pursuant to a congressional request, GAO reviewed how a limited enrollment period would affect the Medicare program, private health plans, beneficiaries, and employers who provide Medicare supplemental benefits to retirees.
- Retooling State Medicaid Agencies for Managed Care (OIG 1997) For the Medicaid agencies, this transition is fundamental. They are faced with retooling themselves, much like private corporations do when entering new markets or introducing new product lines. This inquiry defines the key challenges these agencies face in making this adaptation and offers feedback on how they are meeting them. It is based on a review of the experiences of 10 State Medicaid agencies strongly committed to managed care.
- Medicaid Managed Care: Use of Surveys as a Beneficiary Protection Tool (OIG 1997) To date, surveys provided little useful information about plan performance to
Medicaid agencies. Agency leadership found them to be of questionable value with regard to the technical quality of care and were reluctant to base corrective actions on survey data. Surveys have yet to provide beneficiaries with information to help them choose a plan. In one groundbreaking survey, Medicaid beneficiaries found the survey data to be “unwieldy.” In general, little is known about what information beneficiaries would like to have when faced with a choice of plans.
- Medicaid Managed Care and Early Periodic, Diagnostic, Screening and Treatment (OIG 1997) Under EPSDT, State Medicaid agencies must provide eligible children services that include comprehensive, periodic health assessments beginning at birth and continuing through age 20. All medically appropriate immunizations are required. Age appropriate assessments must be provided at intervals following defined periodicity schedules.
- Medicare HMOs:
Potential Effects of a Limited Enrollment Period Policy (GAO 1996) Pursuant to a congressional request, GAO reviewed how a limited enrollment period would affect the Medicare program, private health plans, beneficiaries, and employers who provide Medicare supplemental benefits to retirees.
- Medicare: HCFA
Should Release Data to Aid Consumers, Prompt Better HMO Performance (GAO 1996) Until recent years, nearly all Medicare beneficiaries received care through a fee-for-service arrangement, with benefits and cost-sharing provisions standardized nationwide.
- Medicaid Managed
Care: Serving the Disabled Challenges State Programs (GAO 1996) Pursuant to a congressional request, GAO examined state efforts to include disabled Medicaid beneficiaries in prepaid managed care programs.
- Medicare HMOs: Rapid Enrollment Growth Concentrated in Selected States (GAO 1996) Pursuant to a congressional request, GAO provided information on the: (1) number of Medicare beneficiaries enrolling in health maintenance organizations (HMO); and (2) factors that influence beneficiaries’ decisions to enroll in HMO.
- Medicare HMOs:
Rapid Enrollment Growth Concentrated in Selected States (GAO 1996) Pursuant to a congressional request, GAO provided information on the: (1) number of Medicare beneficiaries enrolling in health maintenance organizations (HMO); and (2) factors that influence beneficiaries’ decisions to enroll in HMO.
- Medicare HMO Appeals and Grievance Processes: Overview Report (OIG 1996) The goals of managed care are to provide preventive and coordinated medical care, offer comprehensive benefits, and contain costs by using the most cost-efficient methods of treatment and preventing unnecessary care.
- Medicare HMO Appeals and Grievance Processes: Beneficiary Understanding (OIG 1996) Beneficiaries may join a risk HMO through the Medicare program. For a predetermined monthly amount, theHMO provides Medicare- covered medically necessary services. The goals of this coverage are to provide coordinated medical care, offer comprehensive benefits, and contain costs by using the most cost-efficient methods of treatment and preventing unnecessary care.
- Medicare HMO Appeals and Grievance Processes: Survey of HMOs (OIG 1996) Fifty percent of the HMOS responding to our sumey categorized appealable issues as grievances, while 36 percent categorized grievance issues as appeals, and 10 percent reported using incorrect processes for cases involving both appealable and grievable issues. The distinction between appeals and grievances is important to beneficiaries.
- Medicare HMO Appeals and Grievance Processes: Review of Cases (OIG 1996) In 1995, HCFNs Office of Managed Care retised guidelines used by HCFA Regional Offices in their annual review of HMOS. In addition, HCFA in conjunction with Netsvork Design Group, has conducted training sessions, provided technical assistance, and issued publications to improve HMOS’ understanding and processing of appeals and grievances. HCFA plans to revise the HMO/CMP Manual and has received funds to evaluate problems in the area of appeals and grievances.
- Beneficiary Perspectives of Medicare Risk HMOs (OIG 1995) Overall, HMO beneficiaries seemed relatively healthy. However, disenrollees repoited a much greater decline in health status during their HMO stay and were much more likely to biame their HMO care for their declining health.
- Medicaid Managed
Care: More Competition and Oversight Would Improve California’s Expansion Plan (GAO 1995) Pursuant to a congressional request, GAO reviewed California’s Medicaid managed care program, focusing on: (1) state oversight of managed care contractors; (2) state plans for expansion; and (3) key issues in implementing the expanded program.
- Medicare: Increased HMO Oversight Could Improve Quality and Access to Care (GAO 1995) The Congress is considering ways to attract Medicare beneficiaries to health organizations (HMO) and other forms of managed care in hopes of containing cost growth while preserving or improving quality and access to care.
- Health Care: Employers and Individual Consumers Want Additional Information on Quality (GAO 1995) Pursuant to a congressional request, GAO provided information on health care quality issues, focusing on: (1) how consumers use health care performance reports that contain comparative data on the quality of health care providers; and (2) what information consumers consider most important.
- Medicare Managed Care: Growing Enrollment Adds Urgency to Fixing HMO Payment Problem (GAO 1995) Pursuant to a congressional request, GAO reviewed Medicare payments to health maintenance organizations.
- Health Care:
Employers and Individual Consumers Want Additional Information on Quality (GAO 1995) Pursuant to a congressional request, GAO provided information on health care quality issues, focusing on: (1) how consumers use health care performance reports that contain comparative data on the quality of health care providers; and (2) what information consumers consider most important.
- Medicaid: State
Flexibility in Implementing Managed Care Programs Requires Appropriate Oversight (GAO 1995) Requiring states to obtain waivers to broaden use of managed care may hamper their efforts to
aggressively pursue cost-containment strategies.
Changes to HMO Rate Setting Method Are Needed to Reduce Program Costs (GAO 1994) During the 1980s, the per capita costs of providing health care to the elderly under Medicare increased 59 percent, even after adjusting for inflation.
Care Reform: “Report Cards” Are Useful but Significant Issues Need to Be Addressed (GAO 1994) As part of the debate over health care reform, Congress is considering requiring health plans to provide prospective purchasers with information on the quality of care they furnish.
Health Care: Effect on Employers’ Costs Difficult to Measure (GAO 1993) Many employers believe that, in principle, managed care plans save money, but little empirical evidence exists to support this view.
- Medicaid Managed Health Care Programs (OIG 1987) The Omnibus Budget Reconciliation Act of 1981 (Public Law 97-35) provides States with the flexibility to develop managed care programs in which Medicaid recipients can enroll voluntarily. In order to be approved by the Health Care Financing Administration (HCFA), these programs cannot exceed the cost of fee-for-service, or restrict emergency care, or substantially impair access to and quality of medical care.
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