Category: MAOTD (Medicaid Acronym of the Day)

The Office of the Actuary conducts and directs the actuarial program for CMS and directs the development of and methodologies for macroeconomic analysis of health care financing issues.
Performs actuarial, economic and demographic studies to estimate CMS program expenditures under current law and under proposed modifications to current law.

Provides program estimates for use in the President’s budget and for reports required by Congress.
Studies questions concerned with financing present and future health programs, evaluates operations of the Federal Hospital Insurance Trust Fund and Supplementary Medical Insurance Trust Fund and performs microanalyses for the purpose of assessing the impact of various health care financing factors upon the costs of Federal programs.
Estimates the financial effects of proposals to create national health insurance systems or other national or incremental health insurance reform.
Develops and conducts studies to estimate and project national and area health expenditures.
Develops, maintains, and updates provider market basket input price indexes and the Medicare Economic Index.
Analyzes data on physicians’ costs and charges to develop payment indices and monitors expansion of service and inflation of costs in the health care sector.
Performs actuarial reviews and audits of employee benefit expenses charged to Medicare by fiscal intermediaries and carriers.
Publishes cost projections and economic analyses, and provides actuarial, technical advice and consultation to CMS components, governmental components, Congress, and outside organizations.

Further reading 

https://www.cms.gov/About-CMS/Agency-Information/CMSLeadership/Office_OACT.html

Medicaid Statistical Information System – The 25 MSIS statistical tables contain national state-by-state data. These tables contain high-level aggregated statistics relating to Medicaid eligibility and claims data.

Further reading 

https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenInfo/index.html

 

The Medicaid Analytic eXtract (MAX) data is a set of person-level data files on Medicaid eligibility, service utilization, and payments. The MAX data are created to support research and policy analysis. The MAX data are extracted from the Medicaid Statistical Information System (MSIS). The MAX development process combines MSIS initial claims, interim claims, voids, and adjustments for a given service into final action events.

Further reading 

https://www.cms.gov/research-statistics-data-and-systems/computer-data-and-systems/medicaiddatasourcesgeninfo/maxgeneralinformation.html

 

Department of Health and Human Services – HHS administers more than 100 programs across its operating divisions. HHS programs protect the health of all Americans and provide essential human services, especially for those who are least able to help themselves.

Further reading 

https://www.hhs.gov/

 

Health Plan Employer Data and Information Set –

HEDIS is a tool used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an “apples-to-apples” basis. Health plans also use HEDIS results themselves to see where they need to focus their improvement efforts.

HEDIS measures address a broad range of important health issues. Among them are the following:
Asthma Medication Use
Persistence of Beta-Blocker Treatment after a Heart Attack
Controlling High Blood Pressure
Comprehensive Diabetes Care
Breast Cancer Screening
Antidepressant Medication Management
Childhood and Adolescent Immunization Status
Childhood and Adult Weight/BMI Assessment

Further reading 

http://www.ncqa.org/hedis-quality-measurement/what-is-hedis

 

The Freedom of Information Act (FOIA) is a law that gives you the right to access information from the federal government. It is often described as the law that keeps citizens in the know about their government.

Further reading 

https://www.foia.gov/

 

The Federal Employees Health Benefits (FEHB) Program is a system of “managed competition” through which employee health benefits are provided to civilian government employees and annuitants of the United States government. The government contributes 72% of the weighted average premium of all plans, not to exceed 75% of the premium for any one plan (calculated separately for individual and family coverage).[1]

The FEHB program allows some insurance companies, employee associations, and labor unions to market health insurance plans to governmental employees. The program is administered by the United States Office of Personnel Management (OPM).

Further reading 

https://en.wikipedia.org/wiki/Federal_Employees_Health_Benefits_Program

 

The Federal Acquisition Regulation (FAR) is the principal set of rules in the Federal Acquisition Regulations System.[1] The FAR System governs the “acquisition process” by which executive agencies of the United States federal government acquire (i.e., purchase or lease) goods and services by contract with appropriated funds.[1][2][3] The process consists of three phases:[4] Need recognition and acquisition planning; Contract formation; and Contract administration.

The FAR System regulates the activities of government personnel in carrying out that process. The FAR System is codified at Title 48, Chapter 1 of the Code of Federal Regulations. These requirements can be found in the Code of Federal Regulations at 48 C.F.R. 31.

While nearly all federal government executive agencies are required to comply with the FAR, some executive agencies are exempt (e.g., the Federal Aviation Administration[5][6] and the U.S. Mint[7][8]). In those cases, the agency promulgates its own specific procurement rules.[9][10] The remainder of the FAR System consists mostly of sets of regulations issued by executive agencies of the federal government of the United States to supplement the FAR.[1]

The purpose of the FAR is to provide “uniform policies and procedures for acquisition.”[11] Among its guiding principles is to have an acquisition system that satisfies customer’s needs in terms of cost, quality, and timeliness; minimize administrative operating costs; conduct business with integrity, fairness, and openness; and fulfill other public policy objectives.[12]

Further reading 

https://en.wikipedia.org/wiki/Federal_Acquisition_Regulation

 

Consumer Price Index for Prescription Drugs and Medical Supplies –

The prescription drugs index is comprised of drugs one may purchase by prescription at a retail, mail order or Internet pharmacy. However, prescription drugs that are primarily consumed and paid for as part of hospital visits are not included in this sample.

Item sampling: This index employs a streamlined sampling method. At each of the pharmacies selected, the BLS field staff selects a specific item for each of the assigned number of items to be priced. To do this, the field staff obtains a list of the last 20 prescriptions dispensed. This “last 20 list” serves as a proxy for all the prescription drugs dispensed at that pharmacy, and a price is obtained for each prescription on the list. The price includes both patient and insurance payments to the pharmacy, and the sum of all 20 prices makes up total spending (by the consumer at this pharmacy). Thus, each price represents an observed share of total spending, and the probability of any one prescription being selected is proportional to its share in total spending. The more frequently a certain drug shows up in the “last 20 list” and the more expensive it is, the more likely it is to be selected for the index. This item selection procedure is done for every outlet when it is initiated for pricing.

SPECIAL PRICING PROCEDURES FOR PRESCRIPTION DRUGS
Drugs losing patent protection: When a brand-name drug in the sample loses its patent protection, generic versions of the drug receive a one-time chance to replace the original, brand-name drug even if the pharmacy continues to sell the brand name drug. Six months after a drug in the sample loses patent protection, CPI field staff selects among all drugs (including the original) that the Food and Drug Administration deems to be therapeutically-equivalent. Delaying the reselection for six months allows emerging generic drugs an opportunity to gain market share. The chance of drug selection is proportional to the number of prescriptions sold for each version of the drug over the previous 3 months. If a generic is selected, the CPI treats any price difference between the original drug and its selected substitute as a price change, and reflects this change in the index in the month when the procedure was performed.

When prescription drugs become available over-the-counter (OTC), the CPI continues to price them in the prescription drug index until they rotate out under normal rotation procedures. They are not transferred to the non-prescription drugs index. The observations remain in the prescription drug sample, and any price change is reflected in the prescription drug index. Similarly, if any over-the-counter drugs were to change so they required prescriptions, they would remain in the non-prescription drugs and medical supplies index until the next rotation and any resulting price change would occur in that index.

Further reading 

https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/Downloads/CMS1191206dl.pdf

 

The Bureau of Labor Statistics (BLS) was originally established under the Department of the Interior as the Bureau of Labor under the Bureau of Labor Act (23 Stat. 60) of June 27, 1884. After several reorganizations and transfers, the agency was renamed the Bureau of Labor Statistics and transferred to the Department of Labor in 1913.

Further reading 

https://www.federalregister.gov/agencies/labor-statistics-bureau