ACA Risk Adjustment - Overview, Context, and Challenges | Volume 4, Issue 3 of the Medicare and Medicaid Research Review includes three articles describing the Department of Health and Human Services (HHS) developed risk adjustment methodology under the Affordable Care Act (ACA). The ACA provides for a program of risk adjustment in the individual and small group markets using the HHS risk adjustment methodology, so as to compensate health insurance plans for differences in enrollee health mix so plan premiums reflect differences in scope of coverage and other plan factors, but not differences in health status. The methodology includes a risk adjustment model and a risk transfer formula. The article, Affordable Care Act Risk Adjustment - Overview, Context, and Challenges, describes the key program goal and issues in the HHS developed risk adjustment methodology and identifies key choices in how it responds to these issues, while The HHS-HCC Risk Adjustment Model for Individual and Small Group Markets under the Affordable Care Act, estimates differences in health risks taking into account the new population and scope of coverage. Risk Transfer Formula for Individual and Small Group Markets under the Affordable Care Act, describes how the transfer formula calculates balanced transfers intended to account for health risk differences while preserving permissible premium differences. | | 577 | 9/9/2014 8:33:49 AM | 9/9/2014 8:33:49 AM | Publications | Medicaid-Expansion, Medicare Advantage, Health Insurance Marketplace | Physician Services, Hospital, Inpatient, Outpatient, Part D | National | Quality, Claims, Covered Services, Eligibility, Enrollment, Expenditures, Payments | http://www.cms.gov/mmrr/Articles/A2014/MMRR2014_004_03_a02.html | No | Active |
Access to Care Issues Among Qualified Medicare Benes (QMB) | This report contains two studies to assess access to care for Qualified Medicare Beneficiaries (i.e., QMB enrollees). The first study entails qualitative interviews with beneficiaries to better understand access to care among QMB enrollees and whether QMB enrollees are inappropriately balance billed (charged the cost-sharing on Medicare-covered services). The second study investigated whether there is an association between state policies on reimbursement to providers for Medicare cost-sharing and QMB health service utilization.
| | 13 | 12/6/2017 2:47:13 PM | 12/6/2017 2:47:13 PM | Reports | Medicare-Medicaid Dual Beneficiaries, Medicaid, Medicare | Physician Services | | Research, Access to Care, Payments, Persons Served | https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/QMB.html | No | Active |
Accounting for Unobservable Exposure Time Bias Wh... | Accounting for Unobservable Exposure Time Bias When Using Medicare Prescription Drug Data
Unobservable exposure time is common among Medicare Part D beneficiaries, and they are often in worse health. To retain patients with unobservable exposure time, we recommend stratifying patients on receipt of post-acute facility-based care, calculating and using observable days as a covariate and, when appropriate, using the discharge date from contiguous post-acute facility care for beginning the exposure assessment period. | | 9 | 11/20/2013 8:23:17 AM | 11/20/2013 8:23:17 AM | Publications | Medicare | Acute Care Hospital, Hospital, Inpatient, Part D, Pharmacy, Skilled Nursing (SNF), Nursing Home, Psychiatric Facility, Long Term Care (LTC) | National | Prescription Drugs | http://www.cms.gov/mmrr/Articles/A2013/MMRR2013_003_04_a01.html | No | Active |
Actuarial Studies | The Office of the Actuary in the Centers for Medicare and Medicaid Services (CMS) from time to time conducts studies on various aspects of the Medicare and Medicaid programs. The available studies include the following-
Medicare Financial Status, Budget Impact, and Sustainability-Which Concept is Which, Actuarial Report on the Financial Outlook for Medicaid, Estimated Impact of Health Care Reform Proposals, Analysis of volume-and-intensity response to a price change for physicians services, Analysis of expenses in the last year of life. | | 10254 | 10/3/2018 1:28:07 PM | 10/3/2018 1:28:07 PM | Reports, Statistics | Medicaid | Long Term Care (LTC) | National | Trends, Budget, Enrollment, Expenditures, Payments | http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/ | No | Active |
Acute Inpatient PPS Final Rule Data Files | Below are the data files and impact file for the FY 2015 final Rule. The tables for the FY 2015 final rule are located on a separate list. | | 1752 | 6/12/2018 2:37:24 PM | 6/12/2018 2:37:24 PM | Publicly Available Data File - for download | Medicare | Acute Care Hospital, Hospital, Inpatient, Providers | County, National, Regional, State | Prospective Payment System (PPS), Diagnosis Related Grouping (DRG) | https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html | No | Active |
Acute Inpatient PPS Final Rule Data Files - 2011 | Below are the data files and impact file for the FY 2011 Final Rule. The tables for the FY 2011 final rule are located on a separate list. | | 813 | 6/12/2018 2:39:01 PM | 6/12/2018 2:39:01 PM | Publicly Available Data File - for download | Medicare | Acute Care Hospital, Hospital, Inpatient, Providers | County, National, Regional, State | Prospective Payment System (PPS) | http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2011-IPPS-Final-Rule-Home-Page-Items/CMS1237932.html | No | Inactive |
Acute Inpatient PPS Final Rule Data Files - 2012 | Below are the data files and impact file for the FY 2012 Final Rule. The tables for the FY 2012 final rule are located on a separate list. | | 133 | 6/12/2018 2:39:13 PM | 6/12/2018 2:39:13 PM | Publicly Available Data File - for download | Medicare | Acute Care Hospital, Hospital, Inpatient, Providers | County, National, Regional, State | Prospective Payment System (PPS) | http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2012-IPPS-Final-Rule-Home-Page-Items/CMS1250507.html | No | Inactive |
Acute Inpatient PPS Final Rule Data Files - 2014 | Below are the data files and impact file for the FY 2014 Final Rule. The tables for the FY 2014 final rule are located on a separate list. | | 609 | 6/12/2018 2:38:43 PM | 6/12/2018 2:38:43 PM | Publicly Available Data File - for download | Medicare | Acute Care Hospital, Hospital, Inpatient, Providers | County, National, Regional, State | Readmissions, Prospective Payment System (PPS), Diagnosis Related Grouping (DRG) | http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2014-IPPS-Final-Rule-Home-Page-Items/FY-2014-IPPS-Final-Rule-CMS-1599-F-Data-Files.html | No | Inactive |
Acute IPPS - Direct Graduate Medical Education (DGME) | Section 1886(h) of the Act, establish a methodology for determining payments to hospitals for the costs of approved graduate medical education (GME) programs. | | 6553 | 1/6/2016 9:56:40 AM | 1/6/2016 9:56:40 AM | Statistics | Medicare | | National | Payments, Prospective Payment System (PPS), Survey | http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/dgme.html | No | Active |
Acute IPPS - Disproportionate Share Hospital - DSH | There are two methods for a hospital to qualify for the Medicare DSH adjustment. The primary method is for a hospital to qualify based on a statutory formula that results in the DSH patient percentage. The DSH patient percentage is equal to the sum of the percentage of Medicare inpatient days attributable to patients eligible for both Medicare Part A and Supplemental Security Income (SSI), and the percentage of total inpatient days attributable to patients eligible for Medicaid by not Medicare Part A. | | 29591 | 1/6/2016 9:09:09 AM | 1/6/2016 9:09:09 AM | Statistics | Medicare, Medicare Advantage | Hospital, Inpatient, Part A, Providers, Part C, Disproportionate Share Hospitals (DSH) | National, Regional | Research, Claims, Eligibility, Enrollment, Payments, Prospective Payment System (PPS) | http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/dsh.html | No | Active |