On February 20, 2024, the Centers for Medicare & Medicaid Services (CMS) released the final “Medicaid Program: Disproportionate Share Hospital Third-Party Payer Rule” to address legislative provisions in the Consolidated Appropriations Act, 2021 (CAA 2021), which makes changes to the hospital-specific limit on Medicaid disproportionate share hospital (DSH) payments.[1] The rule aims to provide more [...] Read More
On February 8, 2024, the Centers for Medicare & Medicaid Services (CMS) issued the proposed rule, Strengthening Oversight of Accrediting Organizations and Preventing Accrediting Organization Conflict of Interest, and Related Provisions. A Fact Sheet for the rule can be found here. Accrediting Organizations (AOs) are responsible for determining compliance for over 9,000 Medicare and Medicaid […]
Read MoreOn January 25 and 26, 2024, the Medicaid and CHIP Payment and Access Commission (MACPAC) held a virtual public meeting, which included the following sessions: Denials and Appeals in Medicaid Managed Care; Policy Options for Improving the Transparency of Medicaid Financing; Findings from Expert Roundtable on Evaluating the Effects of Medicaid Payment Changes on Access [...] Read More
On October 5, 2023, the Medicare Payment Advisory Commission (MedPAC) held a virtual public meeting. The meeting included the following sessions: Considering current law updates to Medicare’s payment rates for clinician services; Examining staffing ratios and turnover rates in nursing facilities; An alternative method to establish Medicare payments for select conditions treated in inpatient rehabilitation [...] Read More
On September 21 and 22, 2023, the Medicaid and CHIP Payment and Access Commission (MACPAC) held a virtual public meeting. The meeting included sessions on denials and appeals in Medicaid managed care, a panel discussion on unwinding the continuous coverage requirement, and eligibility and enrollment for Medicare Savings Programs. The full agenda for the meeting [...] 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
As noted last month, prior authorizations can be an important means of identifying clinically inappropriate or duplicative care. They are also increasingly employed as gatekeeping mechanisms to control healthcare spending by limiting utilization. This month, in the second installment of our conversation about prior authorizations, we examine how the U.S. healthcare system has given rise [...] Read More
Healthcare spending in the United States is expected to surpass $4.7 trillion in 2023. As Applied Policy has previously reported, some of that money may be spent on unproven, ineffective, unnecessarily expensive, or even harmful practices. Some of it will be spent on effective treatments for which there are less expensive alternatives. Some of it [...] Read More
We trust modern medicine to be evidence-based: grounded in the most current and reliable research available. But sometimes medicine gets it wrong, and clinicians engage in unproven, ineffective, expensive, and even harmful practices. Worse, these practices can become entrenched as standard protocols. Good intentions Clinicians are not immune from hope. And hope, bolstered by logic, [...] Read More