Third-Party LiabilityState Medicaid programs are required to take all reasonable measures to identify and seek payment from liable third parties, such as commercial insurance companies, casualty coverage, and medical support provided under a court order, before billing Medicaid. Previously, CMS required states to review all claims paid under a range of International Classification of Diseases (“ICD”) diagnosis codes indicative of trauma to help states identify possible sources of third-party liability. CMS did allow states to request waivers for review of certain codes deemed to be unproductive in identifying third-party liability. With the upcoming transition to ICD-10, CMS must eliminate references to ICD-9. CMS now proposes to eliminate all references to a specific coding system and replace these with a general description of the types of trauma-related diagnoses that states are expected to review. The revision would allow states to revise the trauma code editing process … [Read more...] about CMS Issues Broad-Reaching Proposals to Better Align Medicaid Managed Care with the Commercial and Medicare Markets
Health law managed care
Boards and Hospital Governance and ComplianceThe Department of Justice is increasingly holding individual leaders responsible for the stewardship of their hospitals. Educating hospital boards is vital to effective compliance, especially related to financial arrangements and quality of care. … [Read more...] about Key Takeaways From FHA’s Health Law Summit
On June 1, 2015 the Centers for Medicare & Medicaid Services (“CMS”) issued a proposed rule, revising the provisions of the Medicaid managed care (“MMC”) program for the first time in over twelve years.  The effects of these new regulations, if adopted, will be far-reaching, because the vast majority of Medicaid beneficiaries, especially in Kentucky, receive services through managed care plans. Medicaid expansion under the Patient Protection and Affordable Care Act (“ACA”) has led to growth in the number of people eligible for Medicaid managed care. The 201-page proposed regulation attempts to modernize Medicaid managed care and Children’s Health Insurance Programs (“CHIP”) so that they align with rules for other payers, including Medicare Advantage (“MA”) and qualified health plans (“QHPs”). … [Read more...] about What Changes are in store with the new CMS Proposed Rule for Medicaid Managed Care?
The impact of the MLR requirements will turn on what activities and expenditures are ultimately included in the definition of medical costs. CMS notes that it intends for service coordination, case management, and activities supporting state goals for community integration of individuals with complex needs to fall within the purview of "expenditures on activities that improve health care quality" and is seeking comment on whether the language of the Proposed Rule is broad enough to reasonably include these activities. Moreover, unlike the Medicare Advantage and commercial insurer MLR requirements, the Proposed Rule includes a limited amount of fraud/abuse prevention expenditures in the definition of medical costs. Stakeholders must ensure that CMS' definition of medical costs does not include activities primarily aimed at controlling a plan's costs, but exclusively includes activities focused on improving quality of care. … [Read more...] about Proposed Rule’s Medicaid Managed Care Medical Loss Ratio Requirement Will Likely Impact Plans, Providers and Patients in New York
This changed in 2014, when the federal Centers for Medicare and Medicaid Services (CMS) told Ohio and other states that the Medicaid MCO sales tax would no longer qualify as a source of revenue by which Ohio is able to draw down the federal money. In addition to the losses at the state level, local governments will also feel the effect of the new rules by virtue of the loss of over $200 million in revenue due to the piggyback tax levied by local governments. … [Read more...] about Ohio Administration Proposes Changes to State’s Medicaid Managed Care Organization Sales Tax