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State Operations and Technical Assistance (SOTA) initiative was created to work through policy and operational changes required in Medicaid by the Affordable Care Act. In July 2015, CMS announced an enhancement to this initiative called SOTA 2.0 (PDF 212.83 KB).

The goal of SOTA 2.0 is to provide a smoother and more efficient experience for states when working across CMS on Medicaid-related issues. By creating a team that will organize itself around a state and can be accountable to them, we believe that the new SOTA 2.0 structure will provide states a more seamless experience for states as they work with CMS.

Further reading –

https://www.medicaid.gov/state-resource-center/state-operations-and-technical-assistance/index.html

Medicaid State Technical Assistance Teams – The staff in the Center for Medicaid and CHIP Services (CMCS) provides technical assistance to states on an ongoing basis on all Medicaid and CHIP topics. However, for several specific programs, CMCS has also contracted with outside entities to provide technical assistance to states on behalf of the Center.

Further reading –

https://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/medicaid-state-technical-assistance.html

Medicare, Medicaid, and SCHIP Extension Act of 2007 – A law that extended and expanded provisions of the Social Security Act relating to Medicare, Medicaid, and the State Children’s Health Insurance Program (SCHIP). Of particular note, Section 111 of the Act addresses Medicare secondary payer issues. This section establishes the mandatory reporting to the Centers for Medicare and Medicaid Services (CMS) of all monetary compensation provided to an individual eligible for Medicare resulting from a workers compensation, general liability, or automobile no-fault claim.

Further reading –

https://www.congress.gov/110/plaws/publ173/PLAW-110publ173.pdf

The Minimum Monthly Maintenance Needs Allowance (MMMNA) is the minimum income your spouse is entitled to have each month. If his or her income falls below the MMMNA, you can transfer a portion of your income to your spouse without penalty.

Further reading –

https://www.familyassets.com/medicaid-planning/resources/monthly-needs

Medicare-Medicaid Coordination Office – The Federal Coordinated Health Care Office (Medicare-Medicaid Coordination Office) serves people who are dually enrolled in both Medicare and Medicaid, also known as dual eligible individuals or Medicare-Medicaid enrollees. Our goal is to make sure Medicare-Medicaid enrollees have full access to seamless, high quality health care and to make the system as cost-effective as possible.

The Medicare-Medicaid Coordination Office works with the Medicaid and Medicare programs, across federal agencies, states, and stakeholders to align and coordinate benefits between the two programs effectively and efficiently.

Further reading –

https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/

The Medicare Recovery Audit Contractor (RAC) program was established by the Centers for Medicare & Medicaid Services (CMS) through the Medicare Modernization Act of 2003. In 2005, pilot programs were initiated in California, New York, and Florida. The goal of the program was to develop an efficient model to ensure correct payments to providers and suppliers submitting claims for reimbursement under Medicare Parts A and B.

These audits, consisting of a post-payment review of supporting documentation as well as data analysis, resulted in the identification of more than $900 million in overpayments and $38 million in underpayments made to Medicare providers during the three-year demonstration period. Based on the success of the RAC pilot program, the Tax Relief and Health Care Act of 2006 made permanent the Medicare RAC program.

Medicaid RACs
In 2010, the passage of the Affordable Care Act (ACA) expanded the RAC program to include Medicaid. Section 6411 of the ACA specifically required states to

Contract with RACs to identify overpayments and underpayments of Medicaid claims, and to recoup overpayments;
Establish a process for entities to appeal adverse determinations made by RACs; and
Coordinate recovery efforts with other government agencies performing audits, including federal and state law enforcement agencies such as the FBI, HHS, and the state Medicaid Fraud Control Unit.

Further reading –

http://www.medicaid-rac.com/medicaid-rac-mic-comparison/

Medicaid Integrity Contractor – The MICs are private companies that conduct audit-related activities under contract to the Medicaid Integrity Group (MIG), the component within CMS that is charged by the U.S. Department of Health & Human Services with carrying out the MIP.

There are three primary MICs:

1) the Review MICs, which analyze Medicaid claims data to determine whether provider fraud, waste, or abuse has occurred or may have occurred;

2) the Audit MICs, which audit provider claims and identify overpayments; and

3) the Education MICs, which provide education to providers and others on payment integrity and quality-of-care issues.

Further reading –

https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Provider-Audits/Downloads/MIP-Contractors-Presentation.pdf

The Mental Health Parity Act (MHPA) is legislation signed into United States law on September 26, 1996 that requires annual or lifetime dollar limits on mental health benefits to be no lower than any such dollar limits for medical and surgical benefits offered by a group health plan or health insurance issuer offering coverage in connection with a group health plan.[1] Prior to MHPA and similar legislation, insurers were not required to cover mental health care and so access to treatment was limited, underscoring the importance of the act.

The MHPA was largely superseded by the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA), which the 110th United States Congress passed as rider legislation on the Troubled Asset Relief Program (TARP), signed into law by President George W. Bush in October 2008.[2] Notably, the 2010 Patient Protection and Affordable Care Act extended the reach of MHPAEA provisions to many health insurance plans outside its previous scope.[3]

Further reading –

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

The Medicaid Eligibility Quality Control (MEQC) program at § 431.810 through § 431.822 implements section 1903(u) of the Social Security Act (the Act) and requires states to report to the Secretary the ratio of states’ erroneous excess payments for medical assistance under the state plan to total expenditures for medical assistance. Section 1903(u) of the Act sets a 3 percent threshold for eligibility-related improper payments in any fiscal year (FY) and generally requires the Secretary to withhold payments to states with respect to the amount of improper payments that exceed the threshold. The Act requires states to provide information, as specified by the Secretary, to determine whether they have exceeded this threshold.

Further reading –

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/PERM/downloads/PERM_Elig_MEQC_update_2010.pdf

The Medicare Payment Advisory Commission (MedPAC) is an independent congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program. The Commission’s statutory mandate is quite broad: In addition to advising the Congress on payments to private health plans participating in Medicare and providers in Medicare’s traditional fee-for-service program, MedPAC is also tasked with analyzing access to care, quality of care, and other issues affecting Medicare.

The Commission’s 17 members bring diverse expertise in the financing and delivery of health care services. Commissioners are appointed to three-year terms (subject to renewal) by the Comptroller General and serve part time. Appointments are staggered; the terms of five or six Commissioners expire each year. For more information on the commissioner appointment process, please click here. The Commission is supported by an executive director and a staff of analysts who typically have backgrounds in economics, health policy, public health, or medicine.

MedPAC meets publicly to discuss policy issues and formulate its recommendations to the Congress. In the course of these meetings, Commissioners consider the results of staff research, presentations by policy experts, and comments from interested parties. (Meeting transcripts are available on this website.) Commission members and staff also seek input on Medicare issues through frequent meetings with individuals interested in the program, including staff from congressional committees and the Centers for Medicare & Medicaid Services (CMS), health care researchers, health care providers, and beneficiary advocates.

Two reports—issued in March and June each year—are the primary outlet for Commission recommendations. In addition to these reports and others on subjects requested by the Congress, MedPAC advises the Congress through other avenues, including comments on reports and proposed regulations issued by the Secretary of the Department of Health and Human Services, testimony, and briefings for congressional staff.

Further reading –

http://www.medpac.gov/