Medicare & Medicaid

Last updated by Bill Manning on 1/18/98

About This Page

The federal and state governments are the largest payors of health care services in the United States. The largest federal programs are Medicare and Medicaid. It has often been said that Medicare is the second largest segment of the federal budget, second only to Social Security payments. It alone accounted for more than 3% of the GDP, insured more than 37 million individuals in 1990, and cost the federal government more than $109 billion in FY 1990. Medicaid, federal-state health care coverage for the poor, is one of the single fastest growing budget areas for states, with federal-state combined outlays in FY 1992 of $118 billion, a 25% increase over FY 1991.
Federal payment policies often determine how and what health care services are provided. Senator Durenburger, in a speech on a bill to restructure Medicare payment to physicians, articulates the role that Medicare and Medicaid payment policies play in influencing health care:

"The basic principle which underlies the Federal role in health care is that we can change the way we provide services in this country by changing the way we pay for these services."

135 CONG. REC. S14424 (daily ed. Oct. 31, 1989) (statements concerning S. 1809, the RBRVS legislation). Compare Senator Durenburger's remarks about the U.S. Congress and health legislation in a law review health care symposium:

"[T]hings are moving on their own - under their own energy. We try to do some fine tuning and maybe influence direction, but sometimes we are just along for the ride." Senator David Durenburger, Health Care Financing: The Challenge for the Future, 20 LOY. CHI. L.J. 705, 708 (1989).

The resources on this page are intended for both the uninitiated and the expert on Medicare and Medicaid reimbursement policy. Of course, it can be no substitute (nor is it intended as such) for digging into the statutes, regulations and provider manuals. Please feel free to contribute material here by e-mailing me at wmanning@netreach.net

What's

Medicare Part B Services (Other than Physician Services); Federal Register, January 7, 1998 (Volume 63, Number 4), Page 687-690.

Medicare

General

Overview of Medicare: Written by the folks at the Health Care Financing Administration (HCFA).
Medicare: Millions Can Be Saved by Screening Claims for Overused Services, GAO Report, HEHS-96-49.
Medicare: Private-Sector and Federal Efforts to Assess Health Care Quality, GAO Testimony, T-HEHS-96-215.

Provider Information

Medicare 1995 Handbook. Part A and Part B Instructions from HCFA.
Medicare Part B Reference Manual. From Xact Medicare Services -- committed to providing quality service to Medicare beneficiaries and health care professionals in Pennsylvania, New Jersey, Delaware and the District of Columbia Metropolitan Area. (Requires Netscape ENVOY plug-in - link from Xact).
Provider/Supplier Enrollment Information. Provided by HCFA.

Reimbursement

Interin Final Rule: Medicare Program; Application of Inherent Reasonableness to All
Medicare Part B Services (Other than Physician Services); Federal Register, January 7, 1998 (Volume 63, Number 4), Page 687-690.
Interagency Agreement Between FDA & HCFA: Categorization of Investigational Devices for Coverage Under Medicare From the FDA's site.
Medicare: Early Resolution of Overcharges for Therapy in Nursing Homes is Unlikely. GAO/HEHS-96-145. 13 pp. plus 1 appendix (4 pp.) August 16, 1996.
Assuring Nursing Home Quality: The History and Impact of Federal Standards in OBRA-87 (December 1996), Catherine Hawes, The Commonwealth Fund. Documents the difficulties encountered in enforcing state and federal nursing home standards before the enactment of OBRA-87 and suggests that a withdrawal or weakening of the new federal-state regulatory system could undermine the quality of nursing home care.
Medicare: Home Health Cost Growth and Administration's Proposal for Prospective Payment, GAO Testimony, T-HEHS-97-92.
Medicare: Inherent Program Risks and Management Challenges Require Continued Federal Attention, GAO Testimony, T-HEHS-97-89, March 4, 1997.
Medicare Post-Acute Care: Home Health and Skilled Nursing Facility Cost Growth and Proposals for Prospective Payment, GAO Testimony, T-HEHS-97-90, March 4, 1997.
Skilled Nursing Facilities: Approval Process for Certain Services May Result in Higher Medicare Costs, GAO Report, HEHS-97-18.
Medicare: Enrollment Growth and Payment Practices for Kidney Dialysis Services, GAO Report, HEHS-96-33.
Medicare: Excessive Payments for Medical Supplies Continue Despite Improvements, GAO Testimony, T-HEHS-96-5.
Medicare: Federal Efforts to Enhance Patient Quality of Care, GAO Report, HEHS-96-20.
Medicare: Home Health Utilization Expands While Program Controls Deteriorate GAO Report, HEHS-96-16.

Managed care

Complying With The Physician Incentive Plan Regulation
Resources from the American Association of Health Plans (AAHP) & elsewhere.
- Federal Rules: Physician Incentive Plans in Medicare/Medicaid Health Plans.
- Notice on Physician Incentive Regulation Compliance Dates.
- Physician Incentive Plan Regulation -- Clarification AAHP Disclosure Forms and Instructions
- Self Extracting zip file, for the Physician Incentive Plan Regulation Material. All three files are in WordPerfect 6.1 format and are contained in this zipped program and are from American Association of Health Plans (AAHP).
- Implementation of Physician Incentive Plan Regulation Memo, from AAHP
- AAHP Summary Chart Instructions, from AAHP.
- AAHP Physician Incentive Plan Worksheet, from AAHP.
Final Rule: Medicare Appeals of Individual Claims, Federal Register, Volume 62 (5-12-97). For the file in .pdf format, click here.
Medicare HMOs: Rapid Enrollment Growth Concentrated in Selected States, GAO Letter Report, 01/18/96 (GAO/HEHS-96-63).
Medicare Managed Care: Growing Enrollment Adds Urgency to Fixing HMO Payment Problem, GAO Report, HEHS-96-21.

Medicaid

Overview of Medicaid Written by the folks at HCFA.
HCFA's State Medicaid Manual (Dec. 1995 rev.).
Listing of state Medicaid directors
HCFA Medicaid Contacts by Program
The Medicaid-Medicare Relationship
Evaluation of the Oregon Medicaid Proposal, OTA Report (May 1992).
Government Policy and the Cost and Quality of Nursing Homes The Rand Corporation: May 1996.
List of States with Approved 1115 Waivers
List of States with Approved 1915(b) Waivers
Arizona Medicaid: Competition Among Managed Care Plans Lowers Program Costs, GAO Report, HEHS-96-2.
Long-Term Care: Some States Apply Criminal Background Checks to Home Care Workers, GAO Report, PEMD-96-5.
Medicaid Long-Term Care: State Use of Assessment Instruments in Care Planning, GAO Report, PEMD-96-4.
Medicaid Managed Care: Serving the Disabled Challenges State Programs, GAO Report, HEHS-96-136.
Medicaid: Oversight of Institutions for the Mentally Retarded Should Be Strengthened, GAO Report, HEHS-96-131.
Medicaid Section 1115 Waivers: Flexible Approach to Approving Demonstrations Could Increase Federal Costs, GAO Report, HEHS-96-44.
Medicaid: Spending Pressures Spur States Toward Program Restructuring, GAO Testimony, T-HEHS-96-75.
Medicaid: States' Efforts to Educate and Enroll Beneficiaries in Managed Care GAO Report, HEHS-96-184.
Negotiating the New Health System: A Nationwide Study of Medicaid Managed Care Contracts, A searchable index of the GWU Medical Center's findings on Medicaid managed care contracting process. Volume I - The Overview of Negotiating the New Health System: A Nationwide Study of Medicaid Managed Care Contracts is currently available.
Survey of State Managed Medicaid Programs, from the St. Louis office of Milliman & Robertson -- Consultants and Actuaries. (This is a 67k WP6.1 file).
Measuring Health Plan Quality for Medicaid (March 1996).
Prescription Drugs and Medicaid: Automated Review Systems Can Help Promote Safety, Save Money., GAO/AIMD-96-72. June 11, 1996.
Medicaid: Waiver Program for Developmentally Disabled Is Promising but Poses Some Risks, GAO/HEHS-96-120, July 22.

Recently In the News

Welfare HMO effort denounced by official, By Karl Stark, Philadelphia Inquirer, 1-09-98.
HCFA publishes final rule for home health surety bonds. The Healthcare News Server, 1/05/98.

Related Resources

State Reform agendas, from American Public Welfare Ass'n. For information on a particular state�s social service agency, or its welfare or Medicaid reform initiatives, click on a state on a map provided.
IGNet
HHS OIG Special Fraud Alerts
(Search) ICD-9 Codes
State Legislative Profiles, MGMA representatives and state legislative information.
September 1996 Managed Care in Medicaid and Medicare, Overview from HCFA.
State Agency & Medicare/Medicaid Resources Query.
Glossary of Terms for long term care.
Medicaid and Managed Resource Center, Center for Health Care Strategies: an excellent site with links to papers, people and organizations dealing with Medicaid and managed care.

Explore These Relevant Links

HCFA
GPO Access search the Federal Register, U.S. Code, Congressional bills and other government pubs.
State Statutes by Topic
Modern Healthcare Magazine
EMTALA.COM An excellent resource on EMTALA issues.
Operation Restore Trust

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Last updated by Bill Manning on 1/18/98

Visitors Since 1/06/97