Provider enrollment is the first line of defense in program integrity. When applying for enrollment, providers are required to furnish information that State Medicaid agencies (SMAs) can use to prevent fraudulent providers from enrolling. In 2011 CMS adopted regulations under the Affordable Care Act that require providers (other than individual practitioners or groups of practitioners) wanting to enroll in Medicaid or the Children’s Health Insurance Program (CHIP) to disclose additional information about individuals and entities that have an ownership interest in 5 percent or more of the provider.
Full Answer
What do you need to know about Medicare enrollment?
Top 5 things you need to know about Medicare Enrollment. 1. People are eligible for Medicare for different reasons. Some are eligible when they turn 65. People under 65 are eligible if they have received Social Security Disability Insurance (SSDI) or certain Railroad Retirement Board (RRB) disability benefits for at least 24 months.
Why is it important to know how people qualify for Medicare?
It’s important to know the different ways that people qualify for Medicare so you can help current and former employees and their dependents anticipate their eligibility for Medicare so they can make timely and appropriate decisions about their enrollment. 2.
What is the initial enrollment period for Medicare?
Initial Enrollment Period – a 7-month period when someone is first eligible for Medicare. For those eligible due to age, this period begins 3 months before they turn 65, includes the month they turn 65, and ends 3 months after they turn 65.
Can I defer Medicare enrollment without penalty?
There is an exception made for those who are working (or whose spouse is working) and have coverage sponsored by a company with 20 or employees. Such people can defer Medicare enrollment without penalty.
What is Medicare disclosure?
Creditable Coverage Disclosure to CMS Entities that provide prescription drug coverage to Medicare Part D eligible individuals must disclose to CMS whether the coverage is "creditable prescription drug coverage". This disclosure is required whether the entity's coverage is primary or secondary to Medicare.
What must all Medicare Advantage sponsors have in place in order to meet CMS compliance guidelines?
Medicare Advantage Plans Must Follow CMS Guidelines In the United States, according to federal law, Part C providers must provide their beneficiaries with all services and supplies that Original Medicare Parts A and B cover. They must also provide any additional benefits proclaimed in their Part C policy.
Can disclose information to Medicare CMS without consent?
If a Medicare provider or supplier is a covered entity, it is subject to the Privacy Rule which implements provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and generally cannot disclose protected health information on Medicare beneficiaries or other patients without the permission ...
What entities are required to provide a disclosure of creditable coverage status to CMS?
A disclosure is required whether the entity's coverage is primary or secondary to Medicare. Health plans and other entities that must comply with these provisions are listed in 42 CFR §423.56(b) and are also referenced on the creditable coverage homepage at http://www.cms.hhs.gov/creditablecoverage.
What are the negatives of a Medicare Advantage plan?
Medicare Advantage can become expensive if you're sick, due to uncovered copays. Additionally, a plan may offer only a limited network of doctors, which can interfere with a patient's choice. It's not easy to change to another plan. If you decide to switch to a Medigap policy, there often are lifetime penalties.
Does Medicare require a compliance program?
Compliance Program Requirement The Centers for Medicare & Medicaid Services (CMS) requires Sponsors to implement and maintain an effective compliance program for its Medicare Parts C and D plans.
Which is the right of individuals to keep their information from being disclosed to others?
The Privacy Act of 1974 (5 U.S.C. § 552a) protects personal information held by the federal government by preventing unauthorized disclosures of such information. Individuals also have the right to review such information, request corrections, and be informed of any disclosures.
Is CMS a covered entity under HIPAA?
CMS' Original Medicare (fee-for-service) health plan, which includes Medicare Part A (Hospital Insurance) and Part B (Medical Insurance), is a HIPAA covered entity.
What is a patient required to do in order for a request to restrict the use or disclosure of their PHI to their health plan to be granted?
A covered entity is required to agree to an individual's request to restrict the disclosure of their PHI to a health plan when both of the following conditions are met: (1) the disclosure is for payment or health care operations and is not otherwise required by law; and (2) the PHI pertains solely to a health care item ...
What is the annual creditable coverage disclosure notice?
You'll get this notice each year if you have drug coverage from an employer/union or other group health plan. This notice will let you know whether or not your drug coverage is “creditable.”
Who can file CMS disclosure?
The first disclosure requirement is to provide a written disclosure notice to all Medicare eligible individuals annually who are covered under its prescription drug plan, prior to October 15th each year and at various times as stated in the regulations, including to a Medicare eligible individual when he/she joins the ...
What is the difference between credible and non creditable coverage?
A group health plan's prescription drug coverage is considered creditable if its actuarial value equals or exceeds the actuarial value of standard Medicare Part D prescription drug coverage. Prescription drug coverage that does not meet this standard is called “non-creditable.”
Disclosure of Affiliations For Medicare, Medicaid and Chip
- The most anticipated (or dreaded) provision of the Final Rule requires any provider or supplier initially enrolling in or revalidating its enrollment in the Medicare, Medicaid or CHIP programs to identify any affiliations that it (or any owning or managing individuals or organizations of the provider or supplier) has with (or within the previous fi...
Expansion of CMS’s Denial and Revocation Authorities Under The Medicare Program
- The Final Rule also expands the ability of CMS to deny or revoke the enrollment of a provider or supplier seeking to enroll in or currently enrolled in the Medicare program. The provisions under this expanded authority include denying or revoking the enrollment of a provider or supplier that: 1. Fails to fully and completely provide a list of affiliates and disclosable events upon request b…
Extension of Medicare’s Reenrollment Bar; Institution of Reapplication Bar
What Next?
- As you contemplate your next moves in relation to this new Final Rule, consider the following: 1. The Final Rule seeks comments from the provider and supplier community in various places. To the extent you are interested in submitting comments those are due on or before November 4, 2019. Given the lack of comments submitted in connection with the March 2016 proposed rule, t…