In this article, the authors evaluate the cost and utilization effects of the SELECT implementations in 11 States. In particular they compare the before-and-after enrollment experiences of Medicare beneficiaries newly enrolled in SELECT plans with the experiences of those newly enrolled in traditional medigap plans. Using Medicare claims data for ...

On October 6, 1992, Congress passed the Departments of Commerce, Justice, and State, the Judiciary, and Related Agencies Appropriations Act of 1993, Pub. L. No. 102-395, 106 Stat. 1828 (1992) (codified at 21 U.S.C. 886a) (Act). In section 886a(3) of this Act, Congress directed that "fees charged by the DEA ...

This final rule duplicates in HCFA's regulations the content of two sections of the Social Security Administration's regulations concerning waiver of recovery of overpayments. In the past, regulations in 20 CFR part 404 were applicable to both the Federal Old-Age, Survivors and Disability Insurance program (OASDI), which provides monthly Social ...

This rule establishes requirements and procedures for advance payments to suppliers of Medicare Part B services. An advance payment will be made only if the carrier is unable to process a claim timely; the supplier requests advance payment; we determine that payment of interest is insufficient to compensate the supplier ...

This article presents results from a study of 119 hospice programs in the United States. Personal interviews and questionnaires were utilized to collect data about hospice programs, their directors, nurses, social workers, and chaplains. Specifically, this article describes reasons programs sought Medicare certification, and the perceived advantages and disadvantages to ...

This document corrects a technical error that appeared in 42 CFR part 1004 of the final rule published in the Federal Register on December 12, 1995 (60 FR 63634). The final rule was designed to revise and update the procedures governing the imposition and adjudication of program sanctions predicated on ...

Medicare beneficiaries face myriad rules, conditions, and exceptions under the Medicare program. As a result, State Information, Counseling, and Assistance (ICA) programs were established or enhanced with Federal funding as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. ICA programs utilize a volunteer-based and locally-sponsored support system to ...

This notice provides the updated adjusted standardized amounts, DRG relative weights, outlier thresholds, and beneficiary cost-share per diem rates to be used for FY 1996 under the CHAMPUS DRG-based payment system. It also describes the changes made to the CHAMPUS DRG-based payment system in order to conform to changes made ...

This technical regulation provides uniform simplified authority citations for most of the parts that pertain to the Medicare program, and revises the sections or paragraphs that explain the statutory basis for the substance of the rules. These changes are consistent with the use of authority citations and paragraphs identified as ...

This notice implements section 1833(i)(2)(C) of the Social Security Act, which mandates an automatic inflation adjustment to Medicare payment amounts for ambulatory surgical center (ASC) facility services during the years when the payment amounts are not updated based on a survey of the actual audited costs incurred by ASCs.

In large part due to the foregoing issues, Medicare program officials have focused on respiratory therapy as an area with great potential for abuse, and may well introduce significant reforms in the near future. Accordingly, any contractual arrangements for respiratory therapy programs of the type discussed above should be carefully ...

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 ...

This final rule revises regulations concerning Medicaid agencies' actions where third party liability (TPL) may exist for expenditures for medical assistance covered under the State plan. It allows the Medicaid agencies to request waivers from certain procedures in our regulations that are not expressly required by the Social Security Act. ...

The Clean Air Act, enacted in 1970, failed to provide for an enforceable regulatory scheme at any level of government. In late 1990, Congress passed the Clean Air Act Amendments, of which Title V is the focal point. This amendment includes the Operating Permit Program, which states that all "major ...

This final rule responds to comments on the May 25, 1994, final rule with comment period that implemented a standardized electronic cost reporting system for all hospitals under the Medicare program. In that rule, we solicited comments on the requirement that cost reporting software be able to detect changes made ...

This document sets forth a technical revision to OIG regulations on program integrity for Medicare and State Health Care programs, concerning the scope and effect of the OIG's program exclusion regulations. Prior to this revision, the regulations provided that a program exclusion imposed under title XI of the Social Security ...

In the long run, the impact of Guernsey will depend on the interpretation and application of the decision by HCFA, the Provider Reimbursement Review Board, and the courts. If HCFA interprets the decision as a signal that the Supreme Court is willing to grant federal agencies broad latitude to avoid ...

Medicare cost limits stem from 20-year-old legislation that determines "reasonable" rates for reimbursement. Although those rates have periodically been adjusted, they often do not represent a reasonable limitation on a provider's reimbursement. How can agencies challenge limits and appeal unfavorable rulings? What are the most successful means of appeal?

The federal government uses the Medicaid matching formula to distribute federal funds to states to finance various social welfare programs involving billions of dollars. How does the formula affect the distribution of federal money? How would that distribution change if a revised formula were used? This article presents the results ...

Between 1981 and the early 1990s, the Medicaid program grew substantially, in part because, for the first time in the program's history, eligibility for medical assistance was severed from eligibility for income-maintenance payments. Program participation had always been reserved for the "deserving poor," and these were originally defined as persons ...

From 1972 to 1990, the number of Postdoctoral General Dentistry (PGD) programs increased by 57% and enrollment increased by 57% and enrollment increased by 131% for a total of 118 PGD programs and 1,367 positions. Although there has been some increase in military and Veterans Affairs (VA) programs, the major ...

The Medicare program was first implemented to meet a critical need in American society, and over its thirty-year history it has evolved into an integral part of the U.S. health care system. This DataWatch provides a broad overview of the program, outlining both historical and current trends in coverage, financing, ...

The new federalism is now taking hold in Washington, with far-reaching implications for the role of the federal government in health, education, and welfare programs; financial support for such programs; and the shift of control to the states. For telemedicine, the implications of these changes include having to make do ...

The last 15 years have witnessed explosive growth in State Medicaid programs. This article demonstrates the equalizing impacts of greater spending and recent Federal mandates on the health care coverage of the poor. Large inequalities in generosity still remain, however. Inequalities in taxpayer burdens are also documented, and simulations of ...

The deficiencies of the Medicare program are rooted in its defined-benefit structure and in its use of price controls. Medicare should be transformed into a defined cash contribution made to beneficiaries' private plans or to the traditional Medicare program. The Federal Employees Health Benefits Program (FEHBP) is essentially such a ...

This article has three objectives: to estimate how many eligible elderly beneficiaries are participating in the Qualified Medicare Beneficiary (QMB) program; to determine the characteristics of participating and non participating eligibles; and to identify the most significant barriers to program participation. We used data from the Medicare Current Beneficiary Survey ...

This final rule contains provisions regarding both paternity establishment and the audit. The paternity establishment provisions implement the requirements of section 13721 of the Omnibus Budget Reconciliation Act of 1993 (OBRA '93) signed by the President on August 10, 1993, which amends title IV-D of the Social Security Act (the ...

This notice lists HCFA manual instructions, substantive and interpretive regulations and other Federal Register notices, and statements of policy that were published during April, May, and June of 1994 that relate to the Medicare and Medicaid programs. Section 1871(c) of the Social Security Act requires that we publish a list ...

This notice describes the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program beginning October 1, 1994. The results of these evaluations are considered whenever HCFA enters into, renews, or terminates an intermediary agreement or carrier contract ...

In the September 30, 1993 issue of the Federal Register, we published a general notice with comment period describing the criteria and standards for evaluating intermediary and carrier performance in administering the Medicare program during FY 1994. This notice amends that document to require that contractors certify the accuracy and ...

This final rule withdraws regulations setting forth a mandatory budgetary method for determining financial eligibility for individuals who are not receiving or deemed to be receiving Federal cash assistance but whose financial eligibility for Medicaid is being determined through the application of financial criteria of the Aid to Families with ...

This notice lists HCFA manual instructions, substantive and interpretive regulations and other Federal Register notices, and statements of policy that were published during January, February, and March of 1994 that relate to the Medicare and Medicaid programs. Section 1871(c) of the Social Security Act requires that we publish a list ...

This notice lists HCFA manual instructions, substantive and interpretive regulations and other Federal Register notices, and statements of policy that were published during October, November, and December of 1993 that relate to the Medicare and Medicaid programs. Section 1871(c) of the Social Security Act requires that we publish a list ...

Established in 1965 to provide medical care for the impoverished, the Medicaid program has pitted state governments against the federal government, and made adversaries of the providers. The authors examine the legislative history of the program and the rapid growth of expenditures that have led states to cut benefits, tighten ...

This final notice with comment period provides that there will be no changes in the skilled nursing facility (SNF) cost limits for cost reporting periods beginning during Federal fiscal years 1994 and 1995 and that the add-on for administrative and general costs of hospital-based SNFs is eliminated. This notice announces ...

This rule issues technical amendments to Medicare regulations intended to simplify and improve our system for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program. Currently, we evaluate intermediaries using performance criteria and standards announced in an annual notice in the Federal Register. We ...

Utilization review practices, innovations and trends for the 21 states using diagnosis-related groups for Medicaid during 1992 are described. According to this descriptive survey, Medicaid inpatient utilization review programs vary widely in authority, approach and focus, reflecting state payment system incentives, health and hospital system characteristics, and provider practice norms. ...

In recent years the growth of Medicaid spending has been a serious state budgetary problem. Between 1988 and 1992, state Medicaid expenditures increased at an average annual rate of 21 percent. Even when accounting for funds from special revenue programs, such as provider tax and donation programs, state Medicaid spending ...

Although prescription drugs do not appear to be a primary source of recent surges in Medicaid spending, their share of Medicaid expenditures has risen despite efforts to control costs. As part of a general concern with prescription drug policy, Congress mandated a study of the adequacy of Medicaid payments to ...

Recombinant human erythropoietin (rHuEPO) is a new drug for treating anemia associated with end stage renal disease (ESRD). In a study of rHuEPO diffusion, costs, and effectiveness, we analyze ESRD program data and all claims submitted to Medicare for reimbursement of rHuEPO administered to ESRD dialysis patients. Access to rHuEPO ...

The Medicare population remains largely unmanaged despite its increasing cost burden. With a few notable exceptions, health maintenance organizations (HMOs) have historically avoided serving this expensive segment. In many cases, the inability to control costs results from failing to understand the importance of specialist reimbursement mechanisms. This article examines the ...

This notice lists HCFA manual instructions, substantive and interpretive regulations and other Federal Register notices, and statements of policy that were published during July, August, and September of 1993 that relate to the Medicare and Medicaid programs. Section 1871(c) of the Social Security Act requires that we publish a list ...

The Federal Percentages and Federal Medical Assistance Percentages for Fiscal Year 1995 have been calculated pursuant to the Social Security Act (the Act). These percentages will be effective from October 1, 1994 through September 30, 1995. This notice announces the calculated "Federal percentages" and "Federal medical assistance percentages" that we ...

This rule implements section 1865(a) of the Social Security Act, as amended by sections 2345 and 2346 of the Deficit Reduction Act of 1984 and section 6019 of the Omnibus Budget Reconciliation Act of 1989. The amendments expand the types of providers and suppliers of services that we may consider ...

This notice provides the updated adjusted standardized amounts, DRG relative weights, outlier thresholds, and beneficiary cost-share per diem rates to be used for FY 1994 under the CHAMPUS DRG-based payment system. It also describes the non-regulatory changes made to the CHAMPUS DRG-based payment system in order to conform to changes ...

This final rule responds to public comments on the August 25, 1989, interim final rule with comment period that established a demonstration project to develop a uniform cost reporting system for hospitals under the Medicare program. Under that rule, all hospitals in the States of California and Colorado were required ...

Governmentally-mandated programs are a fact of life in health care. Such programs are often considered "hassles" by health care providers, who sometimes question whether such programs can justify themselves. The South Dakota Drug Evaluation and Education Program (DEEP) is a federally-mandated program of drug use review for Medicaid patients. While ...

This final rule implements provisions of the Department of Defense Appropriations Act, 1993, section 9011, which limits increases in maximum allowable payments to physicians and other individual professional providers (including clinical laboratories), authorizes reductions in such amounts for overpriced procedures, provides special procedures to assure beneficiary access to care, and ...

OBJECTIVE: To assess the increased public assistance costs resulting from Michigan's 1988 ban on Medicaid funding of abortions. METHODS: The increased number of births resulting from the Medicaid abortion funding ban was estimated. The costs of this increase in births to the state and federal governments were then calculated. RESULTS: ...

This notice describes the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program beginning October 1, 1993. The results of these evaluations are considered whenever HCFA enters into, renews, or terminates an intermediary agreement or carrier contract ...