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PubMed1983

Medicaid program; imposition of cost sharing charges under Medicaid--Health Care Financing Administration. Final rule with comment period.

This final rule revises regulations concerning imposition of cost sharing amounts on Medicaid recipients. Section 131 of the Tax Equity and Fiscal Responsibility Act of 1982 (Pub. L. 97-248) amended the Medicaid cost sharing requirements. This final rule revises the Medicaid regulations to remove the prohibition on States from imposing deductibles, coinsurance or copayments on categorically or medically needy individuals with certain exceptions. Under the law, States are precluded from imposing such charges with respect to services furnished to individuals under 18, services furnished to pregnant women, if the services relate to the pregnancy, or to any condition which may complicate the pregnancy, and services furnished to certain institutionalized patients who are required to spend all of their income for medical care costs except for a personal needs allowance. The law also prohibits imposition of deductions, cost sharing or similar charges on emergency services, and family planning services and supplies to any individual. Finally, services furnished by a health maintenance organization (HMO) to a categorically needy individual who is enrolled in the HMO are also exempt from cost sharing. States may also exempt medically needy HMO enrolees if they desire. The law also establishes a waiver authority under which cost-sharing amounts may be increased for nonemergency services in hospital emergency rooms. This rule reflects these changes in the law.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1983

Medicaid program; relation with other agencies and miscellaneous Medicaid definitions--Health Care Financing Administration. Proposed rule.

We proposed to amend the Medicaid regulations to allow States the option of paying cost sharing amounts for Medicaid beneficiaries who are covered under Medicare Part B "Buy-in" agreements. We also propose to revise several definitions and clarify ambiguities in existing Medicaid regulations. The proposed definition changes are related to private duty nursing services, inpatient psychiatric services, inpatient and outpatient and outpatient. All changes are a part of the Department's regulatory reform effort which targets for revision those regulations that are ambiguous or that have been identified as problematic.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1983

Medicaid program; reduction in error rate tolerance beginning October 1, 1983; Medicaid quality control program--HCFA. Proposed rule.

This proposed rule would revise current Medicaid regulations and establish new regulations concerning the disallowance of Federal financial participation to States whose eligibility payment error rate for Medicaid, as measured by the Medicaid quality control system, exceeds the 3-percent national standard. Specifically, the proposed rule would provide that the current regulations regarding the 3-percent national standard apply only to the period April 1, 1983 through September 30, 1983. The proposed rule would also establish regulations that would apply to periods beginning October 1, 1983. These modifications to the regulations are based on and implement the provisions of section 133 of the Tax Equity and Fiscal Responsibility Act of 1982 (Pub. L. 97-248).

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1983

Medicaid program; reduction in error rate tolerance; Medicaid quality control program--HCFA. Final rule.

This final rule revises current Medicaid regulations by establishing new regulations concerning the disallowance of Federal financial participation to States whose eligibility payment error rate for Medicaid, as measured by the Medicaid quality control system, exceeds the 3-percent tolerance level. Specifically, this rule provides that the current regulations regarding the method of projecting anticipated error rates apply only to the period April 1, 1983 through December 31, 1983. This rule also establishes new regulations that apply to periods beginning January 1, 1984. These modifications to the regulations are based on and implement the provisions of section 133 of the Tax Equity and Fiscal Responsibility Act of 1982 (Pub. L. 97-248), which enacted section 1903(u) of the Social Security Act.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1985

Medicaid program; Medicaid Management Information System; system requirements--HCFA. Final rule.

In this notice, we are informing State Medicaid agencies of three new system requirements for Medicaid Management Information Systems. These systems will be required to accept: (a) and use exclusively a uniform diagnostic coding system (the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM)), wherever diagnostic coding is used; (b) And use exclusively a common claim form for inpatient and outpatient hospital billing (HCFA-1450); and (c) A uniform electronic billing format for institutional billing. The purpose of these requirements is to improve the efficiency and effectiveness of the Medicaid program; the second and third requirements will reduce the paperwork burden by implementing a single claim form and a single electronic billing format for providers to bill multiple third party payers.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1985

Medicaid program; Medicaid Management Information System requirements for physician and supplier services--HCFA. Final notice.

In this notice, we are informing Medicaid state agencies of two new system requirements for Medicaid Management Information Systems. These systems will be required to accept and use exclusively: (a) A common claim form for physicians, durable medical equipment suppliers, laboratories, chiropractors, and podiatrists (the current version of the Health Insurance Claim Form, HCFA-1500); and (b) A uniform procedure coding system (HCFA Common Procedure Coding System). The purpose of these requirements is to improve the efficiency and effectiveness of the Medicaid program and to reduce the paperwork burden by implementing a single claim form for providers to bill multiple third party payers.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2001

Medicaid program; revision to Medicaid upper payment limit requirements for hospital services, nursing facility services, intermediate care facility services for the mentally retarded, and clinic services. Health Care Financing Administration (HCFA), HHS. Final rule.

This final rule modifies the Medicaid upper payment limits for inpatient hospital services, outpatient hospital services, nursing facility services, intermediate care facility services for the mentally retarded, and clinic services. For each type of Medicaid inpatient service, existing regulations place an upper limit on overall aggregate payments to all facilities and a separate aggregate upper limit on payments made to State-operated facilities. This final rule establishes an aggregate upper limit that applies to payments made to government facilities that are not State government-owned or operated, and a separate aggregate upper limit on payments made to privately-owned and operated facilities. This rule also eliminates the overall aggregate upper limit that had applied to these services. With respect to outpatient hospital and clinic services, this final rule establishes an aggregate upper limit on payments made to State government-owned or operated facilities, an aggregate upper limit on payments made to government facilities that are not State government-owned or operated, and an aggregate upper limit on payments made to privately-owned and operated facilities. These separate upper limits are necessary to ensure State Medicaid payment systems promote economy and efficiency. We are allowing a higher upper limit for payment to non-State public hospitals to recognize the higher costs of inpatient and outpatient services in public hospitals. In addition, to ensure continued beneficiary access to care and the ability of States to adjust to the changes in the upper payment limits, the final rule includes a transition period for States with approved rate enhancement State plan amendments.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2002

Medicaid program; modification of the Medicaid upper payment limit for non-state government-owned or operated hospitals. Final rule.

This final rule modifies the Medicaid upper payment limit (UPL) provisions to remove the 150 percent UPL for inpatient hospital services and outpatient hospital services furnished by non-State government-owned or operated hospitals. This final rule is part of this Administration's efforts to restore fiscal integrity to the Medicaid program and reduce the opportunity for abusive funding practices based on payments unrelated to actual covered Medicaid services.

Hospitals, Public↗
PubMed2002

Medicaid program; Medicaid managed care. Withdrawal of final rule with comment period.

This document withdraws all provisions of the final rule with comment period on Medicaid managed care that we published in the Federal Register on January 19, 2001 (66 FR 6228) with an initial effective date of April 19, 2001. This January 19, 2001 final rule, which has never taken effect, would have combined Medicaid managed care regulations in a new part 438, implemented Medicaid managed care requirements of the Balanced Budget Act of 1997 (Pub. L. 105-33), and imposed new requirements on entities currently regulated as "prepaid health plans'' (PHPs). The regulations set forth in the final rule being withdrawn have been superseded by regulations promulgated in a subsequent rulemaking initiated on August 20, 2001 (66 FR 43613). In addition, this document addresses comments received in response to an interim final rule with comment period that we published on August 17, 2001 in the Federal Register (66 FR 43090) that further delayed, until August 16, 2002, the effective date of the January 19, 2001 final rule with comment period.

Humans↗
PubMed1998

Medicaid estate planning: practices and perceptions of Medicaid workers, elder law attorneys, and certified financial planners.

This study examined Medicaid estate planning (MEP) through the experiences and perceptions of three groups in Connecticut: Medicaid eligibility workers (n = 128), elder law attorneys (n = 41), and certified financial planners (n = 29). Respondent groups varied significantly with regard to their perceptions of prevalence and magnitude of MEP, the nature of transferred assets, mechanisms for transfers, and characteristics of the "typical" client participating in asset divestiture for the purpose of qualifying for Medicaid. This substantial lack of concordance among those professionals most closely involved with MEP poses challenges for policy and research in this area.

Aged↗
PubMed1999

Medicaid eligibility workers discuss Medicaid estate planning for nursing home care.

This study was part of a multiphase project examining the perceptions of elder law attorneys, certified financial planners, and Medicaid eligibility workers regarding Medicaid estate planning (MEP) for nursing home care. Focus group methodology (5 groups, N = 32 participants) was used to explore the perspectives and experiences of Medicaid eligibility workers, who are responsible for interpreting, administering, and enforcing federal and state regulations. Findings describe factors influencing MEP, enforcement of regulations, and potential policy responses to MEP. Participants identified numerous impediments to effective implementation of current regulations. Recommendations for improved policy include redefinition of spousal assessment policies, other valuable consideration determinations, and penalty period formulas.

Aged↗
PubMed2002

Rural-urban differences in health risks, resource use and expenditures within three state medicaid programs: implications for medicaid managed care.

This study uses Medicaid claims data for income-eligible enrollees in California, Georgia and Mississippi to compare expenditures, resource usage and health risks between residents of rural and urban areas of the states. Resource use is measured using the Resource Based Relative Value Scale (RBRVS) system for professional services, hospital days and outpatient facility visits; it also is valued at private insurance reimbursement rates for the states. Health risks are measured using the diagnosis-based Adjusted Clinical Group system. Resource use is compared on a risk-adjusted basis with the use of urban Medicaid enrollees as the benchmark. We find that actual expenditures for rural care users are lower than for urban care users. However, because the proportion of Medicaid enrollees who use care is higher in rural than in urban areas in all three states, expenditures per rural enrollee are not consistently lower. Case mix is more resource intensive for rural compared to urban residents in all three states. Although resource usage is not systematically lower overall for rural enrollees, on a risk-adjusted basis they tend to use less hospital resources than urban enrollees. Capitation rates based on historical per enrollee expenditures would not appear to under-reimburse managed care organizations for the care of rural as opposed to urban residents in the study states.

California↗
PubMed1981

Medicaid program; offset based on third party liability recoveries against reductions in Medicaid payments--Health Care Financing Administration. Notice of proposed rulemaking.

Section 2161 of the Omnibus Budget Reconciliation Act (Pub L. (7-35) imposes reductions in Federal matching payments for fiscal years 1982 through 1984, but also provides for offsets against the reductions if a State meets certain conditions. One of the conditions in a specific level of fraud and abuse recoveries by a State or, for fiscal year 1981 only, a combination of fraud and abuse and third party liability recoveries. Interim final rules, published elsewhere in this issue of the Federal Register, amend Medicaid regulations to implement section 2161, except for the provisions relating to third party liability recoveries. We are proposing here that, for purposes of implementing these provisions, recoveries from Medicare would be- . Excluded in situations in which the State had knowledge of the dual entitlement of individuals to Medicare and Medicaid before a Medicaid claim was paid; and . Included in situations in which the State had to make a special effort to determine that an individual's claim should be paid by Medicare.

Crime↗
PubMed1981

Medicaid program; miscellaneous Medicaid provisions--increased state flexibility--Health Care Financing Administration. Interim final rule with comment period.

This rule amends current Medicaid regulations to implement several provisions of the Omnibus Budget Reconciliation Act of 1981 (Pub. L. 97-35). Those provisions give State agencies increased flexibility in the administration of their Medicaid programs. The following subjects and sections of the law are included in these amendments: I. Removal of reasonable charge limits that apply to reimbursement for the services of practitioners such as physicians, and for other noninstitutional services and items such as medical supplies and laboratory services (Section 2174); II. Removal of the requirement for collection of third party payments when the amount of reimbursement that the State expects to recover exceeds the cost of recovery (Section 2182); III. Permitting physician assistants and nurse practitioners to recertify the need for continued inpatient care for patients in institutions and extending the period of time for recertification from 60 days to 12 months in certain facilities for the mentally retarded or persons with related conditions (section 2183). In addition, this rule includes technical amendments that add the Northern Mariana Islands to the States and territories participating in the Medicaid program (Section 2162).

Insurance, Health, Reimbursement↗
PubMed1987

Medicaid program; withholding of Medicaid payments for fraud or willful misrepresentation--HHS. Final rule.

This final rule specifically encourages State Medicaid agencies to whithhold program payments to providers without first granting administrative review where the State agency has reliable evidence of fraudulent activity by the provider. These changes serve both to reinforce and strengthen existing State Medicaid agency responsibilities in the withholding of program funds, and to bring Medicaid program regulations in line with existing Medicare policy in this area.

Crime↗
PubMed2000

Effect of method of defining the active patient population on measured immunization rates in predominantly Medicaid and non-Medicaid practices.

OBJECTIVE: To examine the effect of patient selection criteria on immunization practice assessment outcomes. METHODS: In 3 high- (50%-85%) and 7 low- (<25%) Medicaid pediatric practices in urban eastern Virginia, we assessed immunization rates of children 12 and 24 months old comparing the standard criteria (charts in the active files excluding those that documented the child moved or went elsewhere) with 3 alternative criteria for selecting active patients: 1) follow-up: the chart contained a complete immunization record or the patient was found to be active in the practice through follow-up contact by phone or mail; 2) seen in the past year: the chart indicated that the patient was seen in the practice in the past year; 3) consecutive: patients that were seen consecutively for any reason. RESULTS: Of the 1823 charts assessed in the high- and low-Medicaid practices, follow-up identified 61% and 83% as active patients; 78% and 95% were ever seen in the past year. At 24 months, mean practice immunization rates were lower for standard (70%) than all 3 alternative criteria (78%-86%). Immunization rate differences between standard and alternative criteria were greater in high- (17%-23%) than low-Medicaid practices (5%-13%). CONCLUSION: The standard for practice assessment should be based on a consistent definition of active patients as the immunization rate denominator.

Ambulatory Care↗
PubMed2000

Medicaid and indigent care issue brief: Medicaid: access to health services.

Medicaid provides health insurance coverage to low-income children, parents meeting specific income thresholds, pregnant women, the elderly and people with disabilities. According to the U.S. Census Bureau, Medicaid provided health insurance for approximately 14 million people in 1998. In that same year, however, 11.2 million poor people had no health insurance at all. In order to reduce the number of people without health insurance, states have expanded or clarified their eligibility standards to allow more people to enroll in Medicaid.

Forecasting↗
PubMed2002

Medicaid and indigent care issue brief: Medicaid: access to health services: year end report-2002.

Medicaid provides health insurance coverage to low-income children, parents meeting specific income thresholds, pregnant women, the elderly and people with disabilities. In 1999, Medicaid provided health care insurance to approximately 32 million low-income Americans. However, in that same year, 42 million Americans had no health insurance at all. In order to reduce the number of people without health insurance, states have expanded or clarified their eligibility standards to allow more people to enroll in Medicaid and other medical assistance programs.

Adult↗