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Annual Report of the Departments of Health and Human Services and Justice: Health Care Fraud and Abuse Control Program FY 2014

March 26, 2015 Comments off

Annual Report of the Departments of Health and Human Services and Justice: Health Care Fraud and Abuse Control Program FY 2014 (PDF)
Source: U.S. Department of Health and Human Services/U.S. Department of Justice

During Fiscal Year (FY) 2014, the Federal government won or negotiated over $2.3 billion in health care fraud judgments and settlements , and it attained additional administrative impositions in health care fraud cases and proceedings. As a result of these efforts, as well as those of preceding years, in FY 2014, approximately $3.3 billion returned to the Federal government or paid to private persons. Of this $3.3 billion, the Medicare Trust Funds3 received transfers of approximately $1.9 billion during this period, and over $523 million in Federal Medicaid money was similarly transferred separately to the Treasury as a result of these efforts. The HCFAC account has returned over $27.8 billion to the Medicare Trust Funds since the inception of the Program in 1997.

In FY 2014, the Department of Justice (DOJ) opened 924 new criminal health care fraud investigations. Federal prosecutors filed criminal charges in 496 cases involving 805 defendants. A total of 734 defendants were convicted of health care fraud-related crimes during the year. Also in FY 2014, DOJ opened 782 new civil health care fraud investigations and had 957 civil health care fraud matters pending at the end of the fiscal year. In FY 2014, the FBI investigative efforts resulted in over 605 operational disruptions of criminal fraud organizations and the dismantlement of the criminal hierarchy of more than 142 health care fraud criminal enterprises.

CRS — Mandatory Spending Since 1962 (March 18, 2015)

March 25, 2015 Comments off

Mandatory Spending Since 1962 (PDF)
Source: Congressional Research Service (via Federation of American Scientists)

Federal spending is divided into three broad categories: discretionary spending, mandatory spending, and net interest. Mandatory spending is composed of budget outlays controlled by laws other than appropriation acts, including federal spending on entitlement programs. Entitlement programs such as Social Security and Medicare make up the bulk of mandatory spending. Other mandatory spending programs include Temporary Assistance for Needy Families (TANF), Supplemental Security Income (SSI), unemployment insurance, some veterans’ benefits, federal employee retirement and disability, and Supplemental Nutrition Assistance Program (SNAP). In contrast to mandatory spending, discretionary spending is provided and controlled through appropriations acts. Net interest spending is the government’s interest payments on debt held by the public, offset by interest income that the government receives.

New Hepatitis C Treatments: Considerations and Potential Strategies for States

March 24, 2015 Comments off

New Hepatitis C Treatments: Considerations and Potential Strategies for States
Source: National Governors Association

The National Governors Association Center for Best Practices (NGA Center) convened an expert roundtable to discuss the opportunities and challenges presented by new hepatitis C virus (HCV) treatments and other pharmaceutical therapies known as high-impact drugs. Such drug treatments share the common characteristics of being more effective than prevailing drug therapies, often resulting in a change in clinical practice that includes treating many more people and being much more expensive. Experts participating in the roundtable included state health care leaders, scientists, national health care experts, subject-matter experts from insurance and pharmaceutical companies, Medicaid and corrections legal experts, and senior staff from the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Veterans Affairs (VA). This paper summarizes the expert roundtable discussion supplemented by NGA Center research to flesh out the background information and strategies discussed.

Transitioning from Medicaid Expansion Programs to Medicare: Making Sure Low-Income Medicare Beneficiaries Get Financial Help

March 12, 2015 Comments off

Transitioning from Medicaid Expansion Programs to Medicare: Making Sure Low-Income Medicare Beneficiaries Get Financial Help
Source: Urban Institute

The Affordable Care Act allows states to offer Medicaid coverage to low-income adults who would not have qualified under previous law. This population will face higher cost-sharing requirements when they transition to Medicare, although some may be eligible for traditional Medicaid benefits and/or Medicare Savings Programs (MSPs) that will reduce their costs. This report discusses how Medicare beneficiaries can qualify for traditional Medicaid and MSPs, provides new estimates of the number and characteristics of eligible individuals, and outlines policy options that would make it easier for Medicare beneficiaries to qualify for traditional Medicaid benefits and MSPs.

Medicare at 50—Origins and Evolution

March 9, 2015 Comments off

Medicare at 50—Origins and Evolution
Source: Commonwealth Fund

Since 1965, Medicare has provided millions of older and disabled Americans with guaranteed access to affordable health care. The broad popularity of the program, however, belies the intensely ideological struggle that preceded its creation and that continues in the debate over its future. In the first report of a two-part series published in the New England Journal of Medicine, David Blumenthal, M.D., Karen Davis, and Stuart Guterman trace the origins of Medicare and discuss its accomplishments, the changes it has undergone, and the challenges that remain.

CRS — Medicare Advantage (MA)–Proposed Benchmark Update and Other Adjustments for CY2016: In Brief (February 25, 2015)

March 5, 2015 Comments off

Medicare Advantage (MA)–Proposed Benchmark Update and Other Adjustments for CY2016: In Brief (PDF)
Source: Congressional Research Service (via Federation of American Scientists)

Medicare Advantage (Part C or MA) is an alternative way for Medicare beneficiaries to receive covered benefits. Under MA, private health plans are paid a per-person monthly amount to provide all Medicare-covered benefits (except hospice) to beneficiaries who enroll in their plan. Unlike under original Medicare, where providers are paid for each item or service provided to a beneficiary, the same capitated monthly payment is made to an MA plan regardless of how many or few services a beneficiary actually uses. The plan is at-risk if costs for all of its enrollees exceed program payments and beneficiary cost sharing; conversely, in general, the plan can retain savings if aggregate enrollee costs are less than program payments and cost sharing.

This report provides a brief background on how MA payments are determined through a comparison of a plan’s estimated cost (bid) and the maximum amount Medicare will pay a plan (benchmark). The report then discusses how the calculation of the benchmark (or maximum possible payment) has changed with the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended), and related administrative action. The report then describes some of the provisions in the Advance Notice of Methodological Changes for CY2016, which would either adjust the benchmarks or make other adjustments, some of which are statutorily specified and some of which are at the discretion of the Secretary. The report concludes with answers to a few questions on the CY2016 MA payments.

HHS OIG — Not All Children in Foster Care Who Were Enrolled in Medicaid Received Required Health Screenings

March 4, 2015 Comments off

Not All Children in Foster Care Who Were Enrolled in Medicaid Received Required Health Screenings
Source: U.S. Department of Health and Human Services, Office of Inspector General

Nearly a third of children in foster care who were enrolled in Medicaid did not receive at least one required health screening. Furthermore, just over a quarter of children in foster care who were enrolled in Medicaid received at least one required screening late. Moreover, ACF’s reviews do not ensure that children in foster care receive the required screenings according to State schedules.

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