CMS Proposes Rule to Strengthen Managed Care for Medicaid and CHIP enrollees

On May 26, 2015, the Centers for Medicare and Medicaid Services (CMS) proposed to modernize Medicaid and Children’s Health Insurance Program (CHIP) managed care regulations to update the programs’ rules and strengthen the delivery of quality care for beneficiaries.  This proposed rule is the major update to Medicaid and CHIP managed care regulations in more than a decade.  It would improve beneficiary communications and access, provide new program integrity tools, support state efforts to deliver higher quality care in a cost-effective way, and better align Medicaid and CHIP managed care rules and practices with other sources of health insurance coverage.  Overall, this proposed rule supports the agency’s mission of better care, smarter spending, and healthier people.

For more information, click here.

Teaching Suggestions

  • Ask students to visit the website to learn how the healthcare delivery landscape has changed and grown substantially since 2002.
  • Ask students how CMS might strengthen the quality of care provided to beneficiaries.

Discussion Questions

  1. Why is the CMS proposing new rules to strengthen managed care for Medicaid and CHIP enrollees?
  2. How does the CMS plan to modernize Medicaid and CHIP regulations?

5 Ways To Become An Informed Medicare Consumer

Each day, you make important choices about your finances, health, privacy, and more.  Medicare has 5 things you can do to help you become an informed Medicare consumer.

  1. Know your rights. As a person with Medicare, you have certain rights and protections designed to help protect you and make sure you get the health care services the law provides.
  2. Protect your identity. Identity theft happens when someone uses your personal information without your consent to commit fraud or other crimes.  Keep the following information safe:
    • Your name
    • Your Social Security Number (SSN)
    • Your Medicare Number (or your membership card if you’re in a Medicare Advantage or other Medicare health plan)
    • Your credit card and bank account numbers
  1. Help fight Medicare fraud. Medicare fraud takes money from the Medicare program each year, which means higher health care costs for you.  Learn how to report fraud.
  2. Get involved with other seniors with the Senior Medicare Patrol (SMP). The SMP educates and empowers people with Medicare to take an active role in detecting and preventing health care fraud and abuse.
  3. Make informed Medicare choices. Each year during the Fall Open Enrollment Period (October 25-December 7), review your plan to make sure it will meet your needs for the following year.  If you are not satisfied with your current plan, you can switch during the Open Enrollment Period.

For more information, click here.

Teaching Suggestions

  • Ask students to prepare a list of medical expenses that Medicare does not cover.
  • Ask students to check out the Centers for Medicare and Medicaid Services (CMS) videos for tips on preventing Medicare fraud and see how seniors are learning to stop, spot, and report fraud.

Discussion Questions

  1. Why is it vital to fight against Medicare fraud?
  2. Why is it important to review your health care plan during the Fall Enrollment Period?

Emergency Department for Routine Care?

A new study, published in March 2015 in the Annals of Emergency Medicine, shows that the annual rate of emergency department visits by young adults age 19-25 decreased by 1.4 percent in 2011.  This represents 191,000 fewer emergency department visits by young people in this age group.

For this study, currently the most extensive analysis of its kind, researchers examined more than 17 million emergency department visits between 2007 and 2011 from the Nationwide Emergency Department Sample database of the Agency for Healthcare Research and Quality’s Hospital Cost and Utilization Project.

The Affordable Care Act requires health plans that offer coverage to allow young adults to stay on their parents’ plan until age 26.  This has allowed young adults to seek care in the most appropriate setting, reserving costly emergency department use for real emergencies.

For additional information, click here.

Teaching Suggestions

  • Ask students what else can be done to reduce the high cost of healthcare.
  • What can students do to reduce their own personal healthcare costs?

Discussion Questions

  1. What are several reasons for the rising healthcare expenditures?
  2. Has the Affordable Care Act reduced the costs of healthcare?

Your 2015 Tax Return and the Health Care Law

Certain provisions of the Affordable Care Act will probably affect your federal income tax return when you file this year.  The law requires that you and each member of your family have qualifying health insurance coverage for each month of the year, qualify for an exemption from the coverage requirement, or make an individual shared responsibility payment when filing your federal income tax return.

Most taxpayers will simply check a box on the tax return to indicate that each member of their family had qualifying health coverage for the whole year.  Qualifying health insurance includes coverage for most, but not all, types of health care coverage plans.  If you bought coverage through the Health Insurance Marketplace, you should receive Form 1095A, Health Insurance Marketplace Statement from your Marketplace by early February.

For more information, Click Here.

Teaching Suggestions

  • Ask students to search the Internet to gather more information about the new IRS requirements and the Affordable Care Act.
  • What are provisions that might affect an individual and their families?

Discussion Questions

  1. What are the reporting requirements when you file your federal income tax return this year?
  2. How can you determine if you are eligible for an exemption?
  3. What should you do if you are expecting to receive 1095A and you don’t receive it by early February.

Health Insurance Marketplace Application Check List

When you apply for or renew your coverage in the Health Insurance Marketplace, you’ll need to provide information about you and your household, including income, and insurance coverage you currently have, and some additional information.

Use the checklist below to help you gather what you need to apply for coverage.  Open enrollment ends February 15, 2015.

  • Home and/or mailing addresses for everyone applying for coverage.
  • Social Security Numbers.
  • Document information for
  • Employer and income information for every member of your household (for example, from pay stubs or W-2 forms—Wage and Tax Statements)
  • Your best estimate of what your household income will be in 2015.
  • Policy numbers for any current health insurance plans covering members of your household.
  • A completed “Employer Coverage Tool” for every job-based plan you or someone in your household is eligible for. (You’ll need to fill out this form even for coverage you’re eligible for but don’t enroll in.)
  • Notices from current plan that include your plan ID, if you have or had bad health coverage in 2014.

For more information, go to:

Teaching Suggestions

  • Many states are expanding Medicaid to cover more people. Ask students to find out what Medicaid expansion might mean for them.
  • Why do some people qualify for an exemption from the fee based on income or other situation?

Discussion Questions

  1. Do most people who apply for health insurance through marketplace qualify for premium tax credit?
  2. What penalties are imposed on people who don’t have a coverage in 2015?
  3. Can you buy a plan outside the marketplace and still meet the health care law’s coverage requirement?

Medicaid and Children’s Health Insurance Program (CHIP)

Did you know that Medicaid and Children’s Health Insurance Program (CHIP) offer free or low cost health coverage for eligible children and other family members? Medicaid and CHIP cover:

  • Children and teens up to age 19
  • Young people up to 21 may be covered under Medicaid
  • Youth who have “aged out” of foster care can be covered under Medicaid until they reach age 26

Children may be eligible based on their family income.  Eligibility depends on your income, the number of people in your family and the rules in your state. In almost every state, children in families with income up to 200 percent of the federal poverty level ($47,700 per year for a family of four) are covered. In more than half the states, the income eligibility for children can be even higher.

Eligible children and teens can get regular check-ups, shots, doctor and dentist visits, vision care, hospital care, mental health services, needed medications and more.  All preventive services for children are available at no cost.

For more information, go to

Teaching suggestions

  • Ask students how can they find a health care provider (doctor, dentist or pharmacist) in their area who accepts Medicaid or CHIP?
  • Is there a special enrollment period for Medicaid or CHIP?
  • How can you apply for Medicaid and CHIP?

Discussion Questions

  1. Can working parents who may not have health coverage through their jobs cover their children under the CHIP program?
  2. Who can apply for Medicaid or CHIP for a child?


Discount Plans for Health Insurance?

Looking for health insurance? Make sure that’s what you’re buying, or you could find yourself on the hook for big medical bills with no way to pay them.

That’s because what sounds like affordable health insurance may be a medical discount plan instead.  Medical discount plans can help some people to save money on their health care costs, but discount plans aren’t health insurance.

Although some medical discount plans provide legitimate discounts, others take your money and offer very little in return.  The Federal Trade Commission (FTC) and its state law enforcement partners also have found that dishonest marketers selling these plans have tried to make people think they’re selling health insurance, or have lied about what their plans really offer.

If you buy a health insurance plan, it generally covers a broad range of services, and pays you or your health care provider for a portion of your medical bills. If you buy a medical discount plan, you generally are paying for a list of providers and sellers who may be willing to offer “discounts” on some of their services, products or procedures. Medical discount plans don’t pay your health care costs.

“Discounts of up to 70%”–but how often will you save that much? Savings with discount plans typically are a lot less. When you consider a discount plan’s monthly premiums and enrollment fees, there may be no “discount” at all.  What’s more, if you have major health problems or an emergency, you will have to cover most, or all, of the bills if you don’t have health insurance.

For additional information go

Teaching Suggestions

  • Ask student how they should react if they are pressured to sign up quickly or miss out on a “special deal”.
  • Why is it important to check with your state insurance department, your state Attorney General, and your Better Business Bureau before signing up for such discount plans?

Discussion Questions

  1. Why medical discount plans are not health insurance plans?
  2. Do medical discount plans pay for your health care costs?

You Tube Videos: Healthcare and Taxes

In September 2014, the Internal Revenue Service announced the availability of new You Tube Videos to help taxpayers get important information about the Affordable Care Act and tax return filing.  These videos on IRS You Tube channel discuss the premium tax credit and the individual shared responsibility provision.  These provisions of the Affordable Care Act will affect tax returns beginning with the 2014 filing year.

In the premium tax credit video, the IRS Commissioner explains how it can help make purchasing health care through the Health Insurance Marketplace more affordable for people with moderate incomes.

For additional information on the tax provisions of the Affordable Care Act go to

Teaching Suggestions

You may want to use the original article to discuss

  • What are the criteria used to be exempt from the Individual Shared Responsibility provision?
  • How and where can you obtain an exemption?
  • Who is subject to the individual shared responsibility provision?
  • What you need to do if you want to be sure you have minimum essential coverage or an exemption for 2014?

Discussion Questions

  1. What will you have to do if you don’t have or don’t maintain your health insurance coverage?
  2. If you don’t have health insurance coverage or qualify for an exemption, how and when must you make an Individual Shared Responsibility payment?

Increased Oversight Needed For Growing Managed Care Expenditures

In fiscal year 2013, the Medicaid program covered about 71.7 million people at a cost of $431.1 billion, of which Centers for Medicare and Medical Services (CMS) estimated that $14.4 billion (5.8 percent) were improper  payments.  In 2014, the Government Accountability Office (GAO) examined how state and federal agencies ensure comprehensive integrity efforts, such as payment review, auditing, and investigating fraud.  To improve the efficiency and effectiveness of Medicaid program, the GAO recommends that the Administrator of CMS should:

  • update its Medicaid managed care guidance on program integrity practices,
  • provide the states with additional support in overseeing Medicaid managed care program integrity, and
  • require states to audit payments to and by managed care organizations.

For additional information and complete GAO report go to

Teaching Suggestions

  • Ask students what are typical benefits that Medicaid provides.
  • Ask students to prepare a summary report on how to prevent or reduce the Medicaid fraud.

Discussion Questions

  1. What is Medicaid and how it assists low-income individuals and families?
  2. How is Medicaid financed?
  3. Do people with Medicaid need to buy supplemental medical insurance?

What is the Health Insurance Marketplace?

Health Insurance and the Patient Protection and Affordability Care Act of 2010 created state-based health insurance marketplace (also called insurance exchange) through which individuals can purchase health insurance coverage.

Open enrollment in the Health Insurance Marketplace ends on March 31, 2014.  The next open enrollment period for 2015 coverage starts from November 15, 2014 and ends on February 15, 2015.  There are several ways to sign up for Marketplace plans, but applying online is the quickest method to  get coverage.  You can buy a marketplace plan directly from an insurance company, with the help of a broker or an agent, or using an online service.  If you can’t afford a health plan or can’t wait until coverage begins, you can get low-cost care at a Community Health Center near you.

For additional information about the Health Insurance Marketplaces go to

Discussion Questions

  1. What are several methods of getting health insurance coverage through the Health Insurance Marketplaces?
  2. Can a Marketplace refuse the coverage or charge you more because you have an illness or a medical condition?
  3. How do you choose a health insurance plan that is  right for you?

Teaching Suggestions

You may want to use the information in this blog post and the original source to discuss

  • The 5 categories of Marketplace plans: Bronze, Silver, Gold, Platinum, and Catastrophic.
  • How you may be able to get lower costs on deductibles, copayments, and coinsurance?
  • How to apply and enroll in health coverage in the Marketplace?