The Medicaid Disproportionate Share Hospital (DSH) program is an important component of the United States' broader effort to provide healthcare to its most disadvantaged citizens. Initiated to offset the financial burdens faced by hospitals delivering care to uninsured and low-income patients, DSH payments have become a cornerstone of funding for many safety-net hospitals. However, while [...] Read More
The counterpart to Medicaid’s Disproportionate Share Hospital (DSH) program, Medicare’s DSH program was established with the shared objective of providing financial support to hospitals that serve a large number of low-income patients. Yet, despite this common purpose, the two programs differ significantly in terms of operational frameworks, eligibility criteria, and policy issues. Background The impetus [...] Read More
On March 11, 2024, the White House released the President’s fiscal year (FY) 2025 budget, which builds upon the priorities included in the Infrastructure Investment and Jobs Act (Bipartisan Infrastructure Law),[1] CHIPS and Science Act,[2] and the Inflation Reduction Act (IRA).[3] For the Department of Health and Human Services (HHS), the Administration is requesting $130.7 [...] Read More
As the Centers for Medicare & Medicaid Services (CMS) has contracted with private health insurance plans for the provision of managed care options under the Medicare Advantage (MA) program, these plans have not unexpectedly brought commercial insurance’s utilization management practices to Medicare. Chief among these is prior authorization, the process under which health plans can [...] Read More
Step therapy is the process under which a health insurance plan requires a patient to try one or more alternative—typically lower cost— drugs or treatment options before they can access the prescription which their physician has identified as the optimal treatment option for their diagnosis. For AHIP, the association representing America’s health plans, the stepwise [...] Read More
On April 29, 2022, the Centers for Medicare & Medicaid Services (CMS) released its final rule and a fact sheet, containing policies for Medicare Advantage (MA) and Medicare Part D plans in CY (contract year) 2023. The rule includes the following changes: Redefining ‘negotiated price’ for Part D drugs so prices at point of sale [...] Read More
On April 22, 2020, the Medicare trustees released their annual report on the status of the two separate trust funds, the Hospital Insurance (HI) Trust Fund and the Supplementary Insurance (SMI) Trust Fund. The Board reports annually on the financial operation and actuarial status of the program in a combined report that covers Medicare Part [...] Read More
Recent announcements from two giants in the healthcare field offer important insights into the growing focus on the social determinants of health, or SDOH, as they are widely known. According to the CDC, these social determinants are “economic and social conditions that influence the health of people and communities” and are shaped by the amount [...] Read More
On July 16, 2019, Centers for Medicare and Medicaid Services (CMS) released proposed changes to requirements for Long Term Care facilities. Comments are due September 16, 2019. CMS proposes changes to Long Term Care (LTC) facility requirements and estimates administrative cost savings of $616 million annually over five years. As part of the Administration's [...] Read More
At the end of June, the Alliance for Aging Research (the “Alliance”) announced the results of a Medicare claims study which found that families and state Medicaid programs, not Medicare, are burdened with the majority of costs associated with Alzheimer’s disease (Alzheimer’s) The study, conducted by the Alliance and Milliman, was published in the July issue of Journal of [...] Read More