Question

Medicare Regulations Medicare is a federally regulated program that mandates compliance to its standards through state and federal oversight. One of the primary purposes of Medicare regulations is the protection of its recipients. Medicare Advantage is part of the Medicare Modernization Act, which was passed in 2003. Search the Internet by using the following keywords:

•Medicare regulations

•Centers for Medicare

•Medicaid services On the basis of your research, answer the following questions:

•What are the purposes of Medicare regulations other than the one mentioned above?

•How will the federal government enforce compliance in the Medicare Advantage program? Which two other Medicare regulations do you think are the most important for managed care organizations and why?

•Do you think Medicare and Medicaid programs face challenges from the perspectives of providers, the government, and consumers (recipients of Medicare or Medicaid)? Why or why not?

•What are the different services provided by the Medicare and Medicaid programs? Do you feel there is a need to have two different programs? Why or why not?

•Discuss the advantages and disadvantages of Medicare programs such as Medicare Advantage and Medicare Part D. Do you think Medicare Advantage programs ensure the survivability of Medicare? Why or why not? Additionally, respond to the questions given below after reading the following information in regard to control of managed care organizations at the state level. States have a broad range of control of managed health care organizations. The main interests of the states are to protect the interest of the consumer and regulate the structure of MCOs. •Discuss the regulatory structure used to regulate MCOs and health insurers at the state level.

•Discuss how states came to be the primary regulators of insurance.

•Evaluate the most critical components of state oversight of HMO operations.

•Review the licensing requirements for MCOs in your state and describe the specific requirements to obtain a Certificate of Authority (COA). Compare to the requirements discussed in the course textbook.

•What are the protections available to consumers under the law in your state? Compare these protections to what is discussed in the textbook. •In your opinion, are the state regulations designed for the consumers, or are they designed for the MCOs? .

Answer 1

What are the purposes of Medicare regulations other than the one mentioned above?

ANS: There are numerous regulations to ensure the safety and privacy of patients and providers. Medicare is a federal program for those 65 year-old and over and critically injured will be taken to hospital under regulation. Medicare will cover air-ambulance is the ground transporting isn’t quick enough. (Sherman, 2014).

How will the federal government enforce compliance in the Medicare Advantage program? Which two other Medicare regulations do you think are the most important for managed care organizations and why?

ANS: CMS can take action or contract action if they decide that a Medicare Plan Sponsor has done one of the following, considerably neglects to or abide by the programs and/or contract requirement, or is participating in a contract with CMS in a manner that isn’t consistent with the active and effective administration of Medicare Part C and Part D or no longer meets the appropriate conditions of the Part C and D Medicare program.

Actions that can be enforced or contract are either civil money penalties (CMP), intermediate sanctions; suspension of marketing, enrollment, payments for example, and of course terminations. (Centers For Medicare & Medicaid Services, 2013).

Do you think Medicare and Medicaid programs face challenges from the perspectives of providers, the government, and consumers (recipients of Medicare or Medicaid)? Why or why not?

ANS: Medicare and Medicaid programs are “dual eligible”, this is done to allow those who qualify to have all around medical coverage. This can cause challenges “when navigating different coverage standards” causing denials and delays for dual eligible needing DME (durable medical equipment). Also, DME suppliers become more like hall monitors. Those “dual eligible” with Medicaid prior to qualifying for Medicare, seem to encounter confusion in care due to overlapping conflicts.

“Beneficiaries, advocates, providers, and the varying state and federal agencies administering the two programs have long recognized that there are areas of friction, gaps and misalignment between the two programs”. (Burke & Prindiville, 2011).

What are the different services provided by the Medicare and Medicaid programs? Do you feel there is a need to have two different programs? Why or why not?

ANS: Medicare and Medicaid are very different programs. Medicare is a federal program for low-income, financially needy people, built by the federal government and is administered differently in each state. Medicare was designed to handle high medical costs that the elderly citizens’ faces compared to the rest of the population. Yes I feel both are equally needed and beneficial because what one doesn’t cover, the other does. .

Discuss the advantages and disadvantages of Medicare programs such as Medicare Advantage and Medicare Part D. Do you think Medicare Advantage programs ensure the survivability of Medicare? Why or why not?

ANS: Medicare Advantage Plan (Vore, 2013)

Advantages:

·         There are no healthcare questions asked.

·         Plans often have lower premiums

·         Drug coverage is included in most plans

·         Most plans support enhanced benefits as compared to original Medicare (Part A & B).

·         Possibility of lower annual out of pocket Health expenses.

Disadvantages:

·         There are contingencies on the plan that is chosen, and the area you live in and there are often restricted lists of doctors and hospitals.

·         Higher cost if chosen doctor is not in the network given

·         Government has the ability to reduce funding for Medicare Advantage plans, and cause issues with your plan.

·         Plans are all different and coverage, benefits are limited.

·         Possibility of higher annual out-of-pocket expenses as compared to original Medicare and supplemental coverage.

Medicare Part D Plan (Vore, 2013)

Advantages:

·         Saves patients money on prescription drugs

·         There are assistance programs available for low-income individuals that can’t afford the premium costs or deductible.

·         Covered up to a certain threshold, medications beyond the set amount must be paid by patient. Although, after another threshold, Medicare Part D will begin again without cost limitations.

Disadvantages:

·         Can be complex, variety of drug plans available and with the ever changing nature of the plans mean that drugs covered under one plan may not be covered by the plan again next year.

·         Part D will only pay for a particular amount of drug coverage annually. The amount varies according to plans. Once the amount of drugs purchased has reached it covered amount, period is known as donut hole, and out of pocket expenses began. It can be considered dangerous because patients could jeopardize their health if they stop taking necessary medications.

·         There are many common prescriptions that are excluded from Part D plans. Meaning participants who are very responsive to a certain drug may need to be prescribed a alterative that isn’t as effective. The alternative may not mix well with other medications being taken by patient. Requests by doctors may request an exception be made. This can be very time consuming.

States have a broad range of control of managed health care organizations. The main interests of the states are to protect the interest of the consumer and regulate the structure of MCOs.

Discuss the regulatory structure used to regulate MCOs and health insurers at the state level.

ANS: State regulatory structures involves “an independent agency with an elected insurance commissioner, a cabinet-level department reporting to the state governor, or an agency within a larger department responsible for banking, securities, or other financial services” (Kongstvedt, 2012a).

Discuss how states came to be the primary regulators of insurance.

ANS: It is not secret that the federal government has respected the state’s role in regulating insurance. It was in 1944, when the U.S. Congress recognized this role in the McCarran-Ferguson Act, which stated, “states that “(n)o Act of Congress shall be construed to invalidate, impair, or supersede any law enacted by any State for the purpose of regulating the business of insurance ….” (Kongstvedt P. , Essentials of Managed Health Care, 2012b).

Evaluate the most critical components of state oversight of HMO operations.

ANS: State handling of managed care mostly concentrates on two elements, “techniques and processes used by a payer”, particularly an HMO, to give or arrange the delivery of health care services to those enrolled “and the organizational structure of the payer”. (Kongstvedt P. , 2012c).

Review the licensing requirements for MCOs in your state and describe the specific requirements to obtain a Certificate of Authority (COA). Compare to the requirements discussed in the course textbook.

According to Washington State Legislature: (RCW 74.09.522, n.d.)

Medical assistance — Agreements with managed health care systems required for services to recipients of temporary assistance for needy families — Principles to be applied in purchasing managed health care — Expiration of subsections.

For the purposes of this section:

(a) "Managed health care system" means any health care organization, including health care providers, insurers, health care service contractors, health maintenance organizations, health insuring organizations, or any combination thereof, that provides directly or by contract health care services covered under this chapter and rendered by licensed providers, on a prepaid capitated basis and that meets the requirements of section 1903(m)(1)(A) of Title XIX of the federal social security act or federal demonstration waivers granted under section 1115(a) of Title XI of the federal social security act;

(b) "Nonparticipating provider" means a person, health care provider, practitioner, facility, or entity, acting within their scope of practice, that does not have a written contract to participate in a managed health care system's provider network, but provides health care services to enrollees of programs authorized under this chapter whose health care services are provided by the managed health care system.

What are the protections available to consumers under the law in your state? Compare these protections to what is discussed in the textbook.

The Consumer Protection Division enforces the Consumer Protection Act (RCW 19.86) to help keep the Washington marketplace free of unfair and deceptive practices. This is done by filing legal action, recover refunds for consumers and impose penalties to offending businesses, of course recover any fees and costs consumed during legal processes. (General, n.d.) It’s hard to compare since the textbook covers little examples when it comes to laws and regulations protecting consumers.

In your opinion, are the state regulations designed for the consumers, or are they designed for the MCOs? Use your course and text readings to support your answer.

In my opinion the state regulations benefit both consumers and MCOs. They are designed to define and protect the rights of health care consumers enrolled in managed care. Yet, solvency standards qualify HMOs to meet them. (Kongstvedt P. , Essentials of Managed Health Care, 2012d).

References:

Burke, G., & Prindiville, K. (2011). Medicare and Medicaid Alignment: Challanges and Opportunities for Serving Dual Eligibles. National Senior Citizens Law Center, 2-7.

Centers For Medicare & Medicaid Services. (2013, November 26). Retrieved from Part C and Part D Enforcement Actions: http://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/Part-C-and-Part-D-Enforcement-Actions-.html

General, W. S. (n.d.). Consumer Protection. Retrieved from WA State Office of the Attorney General: http://www.atg.wa.gov/Divisions/ConsumerProtection.aspx#Overview

Kongstvedt, P. (2012a). Essentials of Managed Health Care. Retrieved from [VitalSouce bookshelfversion]: http://digitalbookshelf.southuniversity.edu/books/9781284023169/id/ch28lev1sec8

Kongstvedt, P. (2012b). Essentials of Managed Health Care. Retrieved from [VitalSouce bookshelf version]: http://digitalbookshelf.southuniversity.edu/books/9781284023169/id/ch28lev1sec1

Kongstvedt, P. (2012c). Essentials of Managed Health Care. Retrieved from [VitalSouce bookshelf version]: http://digitalbookshelf.southuniversity.edu/books/9781284023169/id/ch28lev1sec1

Kongstvedt, P. (2012d). Essentials of Managed Health Care. Retrieved from [VitalSouce bookshelf version]: http://digitalbookshelf.southuniversity.edu/books/9781284023169/id/ch29lev1sec1

RCW 74.09.522. (n.d.). Retrieved from Washington State Legislature: http://app.leg.wa.gov/RCW/default.aspx?Cite=74.09.522

Sherman, F. (2014). Patient Transport Regulations. Retrieved from eHow: http://www.ehow.com/list_6551991_patient-transport-regulations.html

Tao Jin, B. S., Cline, R. R., & Hadsall, R. S. (2010). Pre-Medicare Elidible Individuals' Decision_Making in Medicare Part D: An Interview study . Innovations, 1(2), p. 1-10.

Vore, A. D. (2013, September 27). Medicare Advantage: Pros and Cons. Retrieved from senior 65+: https://www.senior65.com/medicare/article/medicare-advantage-pros-and-cons

What is Medicare/Medicaid? (n.d.). Retrieved from Medical News Today: http://www.medicalnewstoday.com/info/medicare-medicaid/