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At least 19 recordsLinked to original sources
PubMed1991

Medicare program; explanation of enrollee rights and other provisions applicable to health maintenance organizations and competitive medical plans--HCFA. Final rule.

This rule revises current Medicare requirements relating to health maintenance organizations and competitive medical plans. It eliminates the requirement that an organization enroll two new Medicare beneficiaries for each present Medicare enrollee converted from a cost to a risk contract (the "two-for-one" rule), expands the amount and type of information which an organization must provide to enrollees, and requires annual notice of enrollees' rights under the plan. This rule also authorizes HCFA to terminate a contract with an organization for noncompliance with the composition of enrollment standard requiring that no more than 50 percent of an organization's membership be comprised of Medicare or Medicaid enrollees (hereinafter referred to as the "50/50 rule") and authorizes sanctions when an organization fails to comply with the 50/50 rule or the terms of any waiver or exception to that rule. These provisions conform our regulations with changes made by the Omnibus Budget Reconciliation Acts of 1986, 1987 and 1989.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1987

Medicare program; enrollment provisions concerning health maintenance organizations and competitive medical plans--HCFA. Final rule with comment period.

For health maintenance organizations (HMOs) and competitive medical plans (CMPs), this final rule clarifies the financial responsibility of HMOs and CMPs for inpatient stays in hospitals paid under the prospective payment system when the patient begins or ends enrollment in the HMO or CMP during the hospital stay; eliminates the one full calendar month period between a request to disenroll and the effective date of disenrollment and requires a written explanation to disenrolling beneficiaries of exactly when their enrollment ends; and requires HMOs and CMPs to submit marketing materials for HCFA's review before their distribution to the public. This rule implements statutory provisions of sections 9211(a), (b) and (c) of Pub. L. 99-272, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1994

Medicare and state health care programs: fraud and abuse, civil money penalties and intermediate sanctions for certain violations by health maintenance organizations and competitive medical plans--HHS. Final rule.

This final rule implements sections 9312(c)(2), 9312(f), and 9434(b) of Public Law 99-509, section 7 of Public Law 100-93, section 4014 of Public Law 100-203, sections 224 and 411(k)(12) of Public Law 100-360, and section 6411(d)(3) of Public Law 101-239. These provisions broaden the Secretary's authority to impose intermediate sanctions and civil money penalties on health maintenance organizations (HMOs), competitive medical plans, and other prepaid health plans contracting under Medicare or Medicaid that (1) substantially fail to provide an enrolled individual with required medically necessary items and services; (2) engage in certain marketing, enrollment, reporting, or claims payment abuses; or (3) in the case of Medicare risk-contracting plans, employ or contract with, either directly or indirectly, an individual or entity excluded from participation in Medicare. The provisions also condition Federal financial participation in certain State payments on the State's exclusion of certain prohibited entities from participation in HMO contracts and waiver programs. This final rule is intended to significantly enhance the protections for Medicare beneficiaries and Medicaid recipients enrolled in a HMO, competitive medical plan, or other contracting organization under titles XVIII and XIX of the Social Security Act.

Competitive Medical Plans↗
PubMed1997

Medicare program; establishment of an expedited review process for Medicare beneficiaries enrolled in health maintenance organizations, competitive medical plans, and health care prepayment plans--HCFA. Final rule with comment period.

This final rule with comment period establishes a new administrative review requirement for Medicare beneficiaries enrolled in health maintenance organizations (HMOs), competitive medical plans (CMPs), and health care prepayment plans (HCPPs). This rule implements section 1876(c)(5) of the Social Security Act, which specifies the appeal and grievance rights for Medicare enrollees in HMOs and CMPs. This rule requires that an HMO, CMP, or HCPP establish and maintain, as part of the health plan's appeals procedures, an expedited process for making organization determinations and reconsidered determinations when an adverse determination could seriously jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function. This rule also revises the definition of appealable determinations to clarify that it includes a decision to discontinue services.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1988

Restructuring quality assurance programs in HMOs and other competitive medical plans.

The Health Care Financing Administration recently established a new set of regulations for health maintenance organizations (HMOs) and other competitive medical plans (CMPs). These regulations require quality assurance (QA) programs in HMOs and CMPs to include a system for collecting data on provider performance and patient outcomes, ensuring that physicians and other health professionals review the processes involved in service delivery, and taking corrective action when inappropriate care is delivered. As a result of these new requirements, QA programs in HMOs and other CMPs have come under greater scrutiny than ever before by numerous external review organizations. This article describes a model for restructuring QA plans to meet the demands of the current regulatory environment.

Health Maintenance Organizations↗
PubMed1994

Medicare and state health care programs: fraud and abuse, civil money penalties and intermediate sanctions for certain violations by health maintenance organizations and competitive medical plans--HHS. Correction to final regulations.

This document corrects technical errors that appeared in 42 CFR part 1003 of the final rule published in the Federal Register on July 15, 1994 (59 FR 36072). Specifically, the final rule set forth the Secretary's authority to impose sanctions and civil money penalties on health maintenance organizations, competitive medical plans and other prepaid health plans contracting under Medicare and Medicaid. This correction notice sets forth the corrected text for sections 1003.100, 1003.103 and 1003.106, some of which was inadvertently omitted or amended.

Competitive Medical Plans↗
PubMed1986

Medicare program; payment to health maintenance organizations and competitive medical plans--HCFA. Final rule.

This final rule makes several changes to the regulations that implement legislation regarding Medicare reimbursement for health care services provided by eligible health maintenance organizations and competitive medical plans. The changes involve rules governing supervision of clinical psychologists, continuing membership for non-residents, and administration of the benefit stabilization fund. We are also responding to the comments we received on the final rule with comment period published on January 10, 1985 (50 FR 1314).

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1986

Medicare program; standardized per capita rates of payments for health maintenance organizations and competitive medical plans for 1986--HCFA. Notice.

This notice sets forth the standardized per capita rates of payments and demographic cost factors that will be applied in calculating payment rates for health maintenance organizations and competitive medical plans for contract periods beginning in calendar year 1986. It also explains the methodology that is used in calculating the adjusted average per capita cost.

Capitation Fee↗
PubMed1987

Medicare and Medicaid programs; entities performing quality of care review of services provided by risk-basis health maintenance organizations and competitive medical plans--HCFA. Final rule with comment period.

This final rule provides for review by Utilization and Quality Control Peer Review Organizations (PROs) of the quality of care furnished by risk-basis health maintenance organizations and competitive medical plans under 42 CFR Part 417, Subpart C. It also provides for this same review by non-PRO entities and identifies the requirements that these non-PRO entities must meet. This rule is necessary for the timely implementation of section 1154(a)(4) of the Social Security Act, as amended by section 9353(a)(2) of the Omnibus Budget Reconciliation Act of 1986 (Pub. L. 99-509).

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

Medicare program; payment to health maintenance organizations and competitive medical plans--HCFA. Final rules with comment period.

These regulations implement section 114 of the Tax Equity and Fiscal Responsibility Act of 1982 by authorizing Medicare reimbursement for health care services to eligible health maintenance organizations (HMOs) and competitive medical plans (CMPs) on a prospective basis for those entities that have a risk contract or on a reasonable cost basis for those that have a cost contract. The regulations set forth the requirements that an entity must meet in order to be: Eligible to enter into a Medicare contract (either risk or reasonable cost) as an eligible organization; and Reimbursed by Medicare on a capitation basis (either prospectively or retrospectively) for items and services furnished to Medicare enrollees. In addition, these regulations implement sections 2322 and 2350 (b) and (c) of Pub. L. 98-369 (Deficit Reduction Act of 1984), which further amended the Social Security Act concerning payments to HMOs and CMPs.

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

Competitive medical plans: why be first?

In the face of numerous external pressures and federal regulations, hospitals and physicians must decide whether they will wait for government to hand down the next change in health care financing policy or begin developing a solution themselves to the problem of how to provide high-quality care at an affordable cost. One such solution is the competitive medical plan (CMP), regulations for which were published in the Jan. 10, 1985, Federal Register. The CMP, though it may be perceived as a threat to both hospitals and physicians, has been shown to effect significant cost savings in the enrollment of senior citizens. In ensuring care for the elderly within the national budget's constraints, the CMP represents a singular step beyond diagnosis-related group payment. Institutions and their medical staffs that seize the opportunity to develop a CMP will be able to define the marketplace by specifying services, costs, premiums, and coverage for seniors. As the first CMP in the region, they will be able to establish an image of effectiveness in the minds of the public. They also can help to create a sense of ownership among the community's senior citizens by involving them in marketing and consumer service efforts.

Hospitals, Community↗
PubMed1984

Medicare program; payment to health maintenance organizations and competitive medical plans--HCFA. Proposed rule.

These proposed regulations would implement section 114 of the Tax Equity and Fiscal Responsibility Act of 1982. This provision of the law amended section 1876 of the Social Security Act, which authorizes Medicare reimbursement to eligible organizations on a prospective basis for those organizations that have a risk contract or on a reasonable cost basis for those that have a cost contract. The definition of an eligible organization includes both health maintenance organizations (HMOs) that meet the definition of a qualified HMO under the Public Health Service Act and competitive medical plans (CMPs). The purpose of this proposal is to set forth the requirements that an entity must meet in order to be (1) eligible to enter into a Medicare contract (either risk or reasonable cost) as an eligible organization and (2) reimbursed by Medicare on a capacitation basis (either prospectively or retrospectively) for items and services furnished to Medicare enrollees.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1995

Full reporting by health maintenance organizations (HMOs) and competitive medical plans (CMPs) paid on a cost basis--HCFA. Correction notice.

Federal Register document No. 95-16411, beginning on page 34885 of the issue of July 5, 1995 amended part 417 of the HCFA regulations to require full reporting by HMOs and CMPs of the costs of all services furnished to their Medicare enrollees. In that final rule we amended section 417.546 to remove paragraph (b). However, we failed to remove, from the introductory text of the section, a reference to the paragraph (b) that we removed. This notice corrects our oversight.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1995

Medicare program; contracts with health maintenance organizations (HMOs) and competitive medical plans (CMPs)--HCFA. Final rule with comment period.

This rule clarifies and updates portions of the HCFA regulations that pertain to the following: The conditions that an HMO or CMP must meet to qualify for a Medicare contract (Subpart J). The contract requirements (Subpart L). The rules for enrollment, entitlement, and disenrollment of Medicare beneficiaries in a contracting HMO or CMP (Subpart K). How a Medicare contract is affected when there is change of ownership or leasing of facilities of a contracting HMO or CMP (Subpart M). These are technical and editorial changes that do not affect the substance of the regulations. They are intended to make it easier to find particular provisions, to provide overviews of the different program aspects, and to better ensure uniform understanding of the rules.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1995

Full reporting by health maintenance organizations (HMOs) and competitive medical plans (CMPs) paid on a cost basis--HCFA. Final rule.

This rule affects HMOs and CMPs that contract with HCFA to furnish services to Medicare beneficiaries and be paid on a cost basis. It requires a cost HMO or CMP to include in its cost report the costs of hospital and skilled nursing facility (SNF) services even if it has elected (under section 417.532(c) of the HCFA regulations) to have HCFA's intermediary process those claims and pay the hospital or SNF directly. This change is necessary so that HCFA can determine and compare the cost of all services furnished by HMOs and CMPs with the cost of equivalent services paid for under the fee-for-service system. This rule also adds a definition and makes technical changes to clarify and update certain related provisions of subparts O and U of part 417 of the HCFA rules.

Accounting↗
PubMed1994

Medicare program; appeal rights and procedures for beneficiaries enrolled in prepaid health care plans--HCFA. Final rule.

This final rule modifies or establishes administrative review procedures for Medicare beneficiaries enrolled in health maintenance organizations (HMOs), competitive medical plans (CMPs), and health care prepayment plans (HCPPs). Specifically, it requires that an HMO or CMP complete a reconsideration, requested by a Medicare enrollee for denied services or claims, within 60 days from the date of receipt of the reconsideration request; extends to HMO and CMP enrollees the right to request immediate review by a Utilization and Quality Control Peer Review Organization of an HMO's, CMP's, or hospital's determination that an inpatient hospital stay is no longer necessary; and requires an HCPP to establish administrative review procedures for its Medicare enrollees who are dissatisfied with decisions on denied services or claims.

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