Medicare

New Committee to Consider Federal Role in Health Care

The Department of Health and Human Services and Centers for Medicare & Medicaid Services are forming a new committee to “restore patient-driven care.” The group, to be called the “Federal Healthcare Advisory Committee,” will consist of “… experts charged with delivering strategic recommendations directly to HHS Secretary Robert F. Kennedy Jr. and CMS Administrator Dr. Mehmet Oz to improve how care is financed and delivered across Medicare, Medicaid and the Children's Health Insurance Program (CHIP), and the Health Insurance Marketplace.” As described in a CMS news release, the scope of the committee’s work will encompass: Actionable policy initiatives to promote [...]

joe2025-08-21T16:38:27-04:00August 25, 2025|Centers for Medicare & Medicaid Services, health care reform, Medicaid, Medicare|

Putting Some Meat on CMS’s WISeR Bones

In June, the Centers for Medicare & Medicaid Services announced a new CMS Innovation Center model: The Wasteful and Inappropriate Service Reduction Model, or WISeR. The idea behind WISeR is for Medicare to seek to reduce waste, fraud, and abuse in the program by working through technology companies to make greater use of prior authorization and pre-payment reviews for a small group of medical items and services that the agency considers susceptible to misuse or unnecessary use. While the program is scheduled to start next January 1 and CMS has chosen a limited number of states – Arizona, New Jersey, [...]

joe2025-08-20T12:50:03-04:00August 20, 2025|Center for Medicare and Medicaid Innovation, CMMI, Medicare, Medicare reimbursement policy|

CMS Introduces First Prior Authorization Program for Traditional Medicare

Some Medicare-covered services will be subject to prior authorization in some parts of the country under a new model to be launched by the Centers for Medicare & Medicaid Services next year. To run from 2026 through 2031, the “Wasteful and Inappropriate Service Reduction Model,” or WISeR, will test a new process for determining whether enhanced technologies, including artificial intelligence, can expedite prior authorization for selected items and services that have been identified by CMS as particularly vulnerable to fraud, waste, abuse, or inappropriate use. The model will not include inpatient-only services, emergency services, and “…services that would pose a [...]

joe2025-07-01T17:06:55-04:00July 2, 2025|Centers for Medicare & Medicaid Services, CMMI, Medicare, Medicare reimbursement policy|

Federal Health Policy Update for February 20

The following is the latest health policy news from the federal government for February 14-20. Some of the language used below is taken directly from government documents. Congress The current continuing resolution funding the federal government expires on March 14 and a number of health care extenders, including preventing cuts to Medicaid disproportionate share (Medicaid DSH), an extension of telehealth flexibilities, an extension of the Acute Hospital Care at Home program, and other rural programs will expire on March 31. It is yet unclear how Congress will meet either of those deadlines. Provisions that had been included in the bipartisan [...]

joe2025-02-20T16:09:51-05:00February 20, 2025|Affordable Care Act, Centers for Medicare & Medicaid Services, hospitals, Medicaid, Medicaid disproportionate share, Medicaid DSH, Medicaid DSH allotments, Medicare, Telehealth|

Federal Health Policy Update for February 13

The following is the latest health policy news from the federal government for February 7 - 13. Some of the language used below is taken directly from government documents. Introduction With the pause in external communication that the new administration imposed on HHS three weeks ago, including announcements, advisories, regular publications, and web site updates, there has been very little public communication from or activity involving HHS in the past week. While an HHS spokesperson explained that the moratorium has been eased and agencies are now permitted to engage in some public communication, subject to review, such activity remains very [...]

Hospitals Chart 2025 Public Policy Objectives

The hospital industry has an ambitious public policy agenda for 2025 – most of it involving defending the status quo against proposed changes. Hospitals’ advocacy in 2025 will focus on: Fighting off Medicaid cuts, work requirements, reductions in the federal Medicaid matching rate, eliminating scheduled cuts in Medicaid disproportionate share (Medicaid DSH) allotments to the states, and protecting state-directed Medicaid payments and the ability of states to raise Medicaid funding through provider taxes. Preventing a transition to site-neutral payments for Medicare-covered outpatient services. Ensuring the continuation of current section 340B prescription drug discount program practices. Preserving and even extending current [...]

joe2025-02-12T11:11:23-05:00February 13, 2025|340b, hospitals, Medicaid, Medicaid disproportionate share, Medicaid DSH, Medicaid DSH allotments, Medicaid managed care, Medicaid regulations, Medicare, Medicare reimbursement policy, Telehealth|

Federal Health Policy Update for November 21

The following is the latest health policy news from the federal government for November 15-21. Some of the language used below is taken directly from government documents. The Incoming Administration President Trump has nominated Robert F. Kennedy, Jr. for Secretary of Health and Human Services and Dr. Mehmet Oz for Administrator of the Centers for Medicare & Medicaid Services (CMS). Both positions require confirmation by the Senate. Senators will start the process of confirming the President-elect’s cabinet nominees when the new Congress convenes in January. Congress Funding for the federal government will expire on December 20 and it is still [...]

joe2024-11-21T15:14:52-05:00November 21, 2024|Centers for Medicare & Medicaid Services, hospitals, Medicaid, Medicaid managed care, Medicaid regulations, Medicare, Medicare regulations, Medicare reimbursement policy, Telehealth|

MedPAC Meets

MedPAC’s commissioners held their latest public meetings on Thursday, November 7 and Friday, November 8. The subjects on the meetings’ agenda were: reforming physician fee schedule updates and improving the accuracy of payments considering the participation bonus for clinicians in advanced alternative payment models structural differences between the prescription drug plan and Medicare Advantage prescription drug plan markets assessing Medicare Advantage provider networks Medicare’s coverage limits on stays in freestanding inpatient psychiatric facilities Go here for summaries of the issues and key points and links to the presentations delivered by MedPAC staff and find a transcript of the two-day session [...]

joe2024-11-14T16:54:24-05:00November 18, 2024|Alternative payment models, hospitals, Medicare, Medicare reimbursement policy, MedPAC|

Insurers Skirting Medicare Two-Midnight Rule?

Health care payers continue to classify large numbers of Medicare admissions as “observation status,” and while the recent extension of the two-midnight rule to Medicare Advantage plans has resulted in a decline in the use of observation status classifications among those plans, Medicare Advantage plans still use the observation status classification more than three times as often as traditional Medicare. According to a new study, Medicare Advantage plans used the observation rate classification for between 14.4 percent and 16.1 percent of their claims during the first half of 2024. Traditional Medicare? With a one-month exception, from 3.7 percent to 5.2 [...]

joe2024-10-30T11:41:07-04:00October 30, 2024|hospitals, Medicare, Medicare reimbursement policy|

CMS Tinkers With ACO REACH Model

Medicare’s ACO REACH Model will undergo some changes when it heads into its 2025 performance year. To help ensure that the program controls costs and saves money, the Centers for Medicare & Medicaid Services will implement a series of changes in its voluntary Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model. According to the agency, it is: adjusting the financial methodology to improve model sustainability based on the findings in the PY [performance year] 2022 Evaluation Report; responding to feedback from interested parties on improvements to the accuracy of benchmarks; and strengthening operational flexibility and [...]

joe2024-08-13T15:57:16-04:00August 14, 2024|Accountable Care Organization, ACO, Alternative payment models, Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services, CMMI, Medicare, Medicare reimbursement policy|