Medicare managed care manual chapter 2
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- Medicare Managed Care Manual Chapter 2 | Guidance Portal
Medicare Enrollment Technology – Compliance Must-Haves
DRG Exempt Hospital:. Same benefit as Medicare except that there is no limitation to the number of days of coverage. Benefit includes semiprivate room, regular nursing services, meals including special diets, physical, occupational and speech therapy, drugs furnished by the facility, necessary medical supplies, and appliances. Including residential treatment for children and adolescents See Note 8.
See Note 9. Inpatient Low Volume Hospital:. A Prime enrollee may receive services under the Point of Service option by self-referring for non-emergency care. Refer to Section 5 , for policy on the POS option. Outpatient Deductible:. Inpatient and Outpatient Cost-Share:. Refer to Sections 2 and 3 for information on catastrophic loss protection. Effective for dates of service on or after October 14, , cost-shares are eliminated for certain preventive services for TRICARE Standard and Extra beneficiaries, as described in Section 1, paragraphs 1.
For methadone OTPs, cost-sharing is on a weekly basis e. See Chapter 7, Section 5. Note 8: For dates of service prior to October 3, , PHPs are cost-shared as inpatient services, and the same cost-sharing requirements as those for inpatient admissions for mental health treatment apply.
For dates of service prior to October 3, , these cost-sharing requirements also apply to PHP. For dates of service prior to October 3, , PHP care is cost-shared on an inpatient basis. If the bid is above the benchmark, the difference must be charged in a premium to the enrollees of the plan.
If the bid is below the benchmark, then a portion of the difference must be used to provide additional benefits to enrollees, with the Medicare trust funds receiving the remaining share. The term Medicare Advantage is used to refer to managed care plans, including HMOs, PPOs, private fee-for-service plans, special needs plans, Medicare medical savings account plans, and certain other types of plans.
Medicare enrollees can choose to enroll in a managed care program if available or to receive services on a fee-for-service basis. The two major Medicaid managed care categories are risk-based plans such as managed care organizations or MCOs, prepaid inpatient health plans, and prepaid ambulatory health plans and primary care case management PCCM arrangements.
Risk-based plans are paid a fixed fee per enrollee, which is generally paid monthly. Risk-based plans assume some or all of the financial risk for providing the services covered under the contract. PCCM providers are usually physicians, physician group practices, or entities employing or having other arrangements with such physicians, but they can also include nurse practitioners, nurse midwives, or physician assistants. These providers contract directly with the state to locate, coordinate, and monitor covered primary care and sometimes additional services.
PCCM providers are paid a per-patient case management fee and usually do not assume financial risk for the provision of services. The new benefit flexibilities for MA plans signal a similar commitment, with the hope of improving both the outcomes of patients with chronic conditions and the management of their costs. For the plan year, CMS allowed MA carriers to offer products with supplemental benefits, designed just for chronically ill enrollees, that are not necessarily health-related but have a reasonable expectation of improving or maintaining the health or overall function of the enrollees.
This action builds upon new policy that expanded the definition of health-related supplemental benefits that Medicare Advantage plans could offer to all enrollees.
CMS announced in May that in calendar year , MA carriers may count supplemental benefit spending in the numerator of the Medical Loss Ratio MLR and that eligibility for supplemental benefits goes beyond the set of specific conditions outlined in the Medicare Managed Care Manual Chapter 16b. These changes could continue the growth in supplemental benefits, as payers seek to prevent remitting portions of their revenue to CMS which occurs if 85 percent of revenue is not spent on claims and activities to improve care quality.
Additionally, the data highlight that polychronic beneficiaries with six or more conditions 17 percent of beneficiaries account for more than 50 percent of Medicare expenditures. Based on data, seniors with one chronic condition are 55 percent more likely to choose MA than those with none, and those with five or more chronic conditions are 70 percent more likely to choose MA than those with none.
The new design flexibilities for products offered for could make MA even more attractive to qualifying chronically ill patients. To qualify for benefits, patients must be diagnosed with one or more chronic conditions, have a high risk of hospitalization or adverse health outcomes, and require intensive care coordination.
In spring , CMS released data for the first time providing several insights into the emerging adoption of supplemental benefits for the chronically ill, including:. Collection and sorting through endless rows and columns of data is a daunting task for any organization, and when it comes to government regulations and documentation requirements that could change any given day, having a specialized team is essential to gathering information.
Many health systems around the nation are struggling to find the right tools or resources for obtaining this data for accurate reporting and auditing. When it comes to vendor management, there are many levels of attestation and essential document verification necessary to properly record whom you are doing business with and to maintain compliant relationships when it comes to a variety of outsourced services.
These processes, particularly when it comes to solving for current Medicare Advantage or similar requirements from the Centers for Medicare and Medicaid Services CMS are requiring a lot of time and effort for internal teams to qualify and record healthcare vendor data for auditing and reporting.
Given this level of awareness within your healthcare vendor population, educating current contractors is so important and can be a little overwhelming when you think about how many organizations you currently do business with each day. The complexities of vendor relationships cannot be understated.
There can be a lot of confusion as vendors are not necessarily completely informed of compliance requirements when it comes to Medicare Part C , the Affordable Care Act, and specific CMS requirements. CMS describes the importance of this process by using the following language:. It is critical that sponsors correctly identify those entities with which they contract that qualify as FDRs. Unless it is very clear that an entity is or is not an FDR, the determination of FDR status requires an analysis of all of the circumstances.
Sponsors should have clearly defined processes and criteria to evaluate and categorize all vendors with which they contract. With the increased demand for better data and an efficient capturing process, companies are looking to fill in the gaps with software solutions and data collection specialists.
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