Month: February 2018

Medicaid Integrity Contractor – The MICs are private companies that conduct audit-related activities under contract to the Medicaid Integrity Group (MIG), the component within CMS that is charged by the U.S. Department of Health & Human Services with carrying out the MIP.

There are three primary MICs:

1) the Review MICs, which analyze Medicaid claims data to determine whether provider fraud, waste, or abuse has occurred or may have occurred;

2) the Audit MICs, which audit provider claims and identify overpayments; and

3) the Education MICs, which provide education to providers and others on payment integrity and quality-of-care issues.

Further reading –

https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Provider-Audits/Downloads/MIP-Contractors-Presentation.pdf

The Mental Health Parity Act (MHPA) is legislation signed into United States law on September 26, 1996 that requires annual or lifetime dollar limits on mental health benefits to be no lower than any such dollar limits for medical and surgical benefits offered by a group health plan or health insurance issuer offering coverage in connection with a group health plan.[1] Prior to MHPA and similar legislation, insurers were not required to cover mental health care and so access to treatment was limited, underscoring the importance of the act.

The MHPA was largely superseded by the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA), which the 110th United States Congress passed as rider legislation on the Troubled Asset Relief Program (TARP), signed into law by President George W. Bush in October 2008.[2] Notably, the 2010 Patient Protection and Affordable Care Act extended the reach of MHPAEA provisions to many health insurance plans outside its previous scope.[3]

Further reading –

https://en.wikipedia.org/wiki/Mental_Health_Parity_Act

The Medicaid Eligibility Quality Control (MEQC) program at § 431.810 through § 431.822 implements section 1903(u) of the Social Security Act (the Act) and requires states to report to the Secretary the ratio of states’ erroneous excess payments for medical assistance under the state plan to total expenditures for medical assistance. Section 1903(u) of the Act sets a 3 percent threshold for eligibility-related improper payments in any fiscal year (FY) and generally requires the Secretary to withhold payments to states with respect to the amount of improper payments that exceed the threshold. The Act requires states to provide information, as specified by the Secretary, to determine whether they have exceeded this threshold.

Further reading –

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/PERM/downloads/PERM_Elig_MEQC_update_2010.pdf

The Medicare Payment Advisory Commission (MedPAC) is an independent congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program. The Commission’s statutory mandate is quite broad: In addition to advising the Congress on payments to private health plans participating in Medicare and providers in Medicare’s traditional fee-for-service program, MedPAC is also tasked with analyzing access to care, quality of care, and other issues affecting Medicare.

The Commission’s 17 members bring diverse expertise in the financing and delivery of health care services. Commissioners are appointed to three-year terms (subject to renewal) by the Comptroller General and serve part time. Appointments are staggered; the terms of five or six Commissioners expire each year. For more information on the commissioner appointment process, please click here. The Commission is supported by an executive director and a staff of analysts who typically have backgrounds in economics, health policy, public health, or medicine.

MedPAC meets publicly to discuss policy issues and formulate its recommendations to the Congress. In the course of these meetings, Commissioners consider the results of staff research, presentations by policy experts, and comments from interested parties. (Meeting transcripts are available on this website.) Commission members and staff also seek input on Medicare issues through frequent meetings with individuals interested in the program, including staff from congressional committees and the Centers for Medicare & Medicaid Services (CMS), health care researchers, health care providers, and beneficiary advocates.

Two reports—issued in March and June each year—are the primary outlet for Commission recommendations. In addition to these reports and others on subjects requested by the Congress, MedPAC advises the Congress through other avenues, including comments on reports and proposed regulations issued by the Secretary of the Department of Health and Human Services, testimony, and briefings for congressional staff.

Further reading –

http://www.medpac.gov/

The Medicare-Medicaid Data Match program (Medi-Medi program) enables program safeguard contractors (PSC) and participating State and Federal Government agencies to collaboratively analyze billing trends across the Medicare and Medicaid programs to identify potential fraud, waste, and abuse.

Further reading –

https://oig.hhs.gov/oei/reports/oei-09-08-00370.pdf

Minimum Essential Coverage – Under the Affordable Care Act, the federal government, state governments, insurers, employers and individuals each are given roles in reforming and improving the availability, quality and affordability of health insurance coverage in the United States. Starting January 1, 2014, the individual shared responsibility provision calls for each individual to have minimum essential health coverage (known as “minimum essential coverage”) for each month, qualify for an exemption, or make a payment when filing his or her federal income tax return.

Further reading –

https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/minimum-essential-coverage.html

Medicare Catastrophic Coverage Act – A government bill designed to improve acute care benefits for the elderly and disabled, which was to be phased in from 1989 to 1993. The Medicare Catastrophic Coverage Act of 1988 was meant to expand Medicare benefits to include outpatient drugs and limit enrollees’ copayments for covered services.

Further reading –

https://www.ncbi.nlm.nih.gov/pubmed/2672805

The Medicaid and CHIP Payment and Access Commission (MACPAC) is a non-partisan legislative branch agency that provides policy and data analysis and makes recommendations to Congress, the Secretary of the U.S. Department of Health and Human Services, and the states on a wide array of issues affecting Medicaid and the State Children’s Health Insurance Program (CHIP). The U.S. Comptroller General appoints MACPAC’s 17 commissioners, who come from diverse regions across the United States and bring broad expertise and a wide range of perspectives on Medicaid and CHIP.

MACPAC serves as an independent source of information on Medicaid and CHIP, publishing issue briefs and data reports throughout the year to support policy analysis and program accountability. The Commission’s authorizing statute, 42 U.S.C. 1396, outlines a number of areas for analysis, including:

payment;
eligibility;
enrollment and retention;
coverage;
access to care;
quality of care; and
the programs’ interaction with Medicare and the health care system generally.

MACPAC’s authorizing statute also requires the Commission to submit reports to Congress by March 15 and June 15 of each year. In carrying out its work, the Commission holds public meetings and regularly consults with state officials, congressional and executive branch staff, beneficiaries, health care providers, researchers, and policy experts.

Further reading –

https://www.macpac.gov/

Medicaid and CHIP Business Information Solutions – In 2010 CMS initiated the Medicaid and CHIP Business Information Solution (MACBIS) to meet mandates requiring reliable, comprehensive, and timely Medicaid and CHIP operational and programmatic data supported by leading edge technology and analytics solutions. MACBIS is an enterprise-wide initiative to ensure the Medicaid and CHIP data infrastructure and technology are commensurate to the programs’ role in evolving health care delivery reforms, access to coverage, and to enable proper monitoring and oversight. Aside from data needs to support the multi-billion dollar waiver negotiations, CMS will use MACBIS data for program integrity, evaluation of demonstrations, actuarial analysis, quality of care analysis, and to share this rich data set with states, stakeholders, and the research community.

MACBIS currently consists of four major projects: Medicaid and CHIP Program (MACPro), the Transformed Medicaid Statistical Information System (T-MSIS), the Medicaid Drug Rebate (MDR) program, the Medicaid and CHIP Financial program, the latter of which is the early planning in FY2017.

Further reading –

https://www.medicaid.gov/medicaid/data-and-systems/macbis/index.html

Medicare Advantage – You can get your Medicare benefits through Original Medicare, or a Medicare Advantage Plan (like an HMO or PPO). If you have Original Medicare, the government pays for Medicare benefits when you get them. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. Medicare pays these  companies to cover your Medicare benefits. If you join a Medicare Advantage Plan, the plan will provide all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage.

Further reading –

https://www.medicare.gov/Pubs/pdf/11474.pdf