Health Plan & Provider Report Index Summary

MAINE

– State-subsidized Dirigo health plan, tax assessments revised to fund, 715

MALPRACTICE

– Treatment authorization denied, ERISA preempts stroke patient's state law claims against plan (N.J. Super. Ct. App. Div.), 293

MANAGED CARE

– HMOs

See HEALTH MAINTENANCE ORGANIZATIONS (HMOs)

– MA

See MEDICARE ADVANTAGE (MA)

– Timely nonemergency, Cal. rules issued, 188

MANDATED BENEFITS

– Autism

– – Coverage required under new Colo. law, 679
– – Tex., bill passed requiring coverage, 716; new law, 744

– Brain injuries, new Or. law requires treatment coverage, 746
– Children's health care, hearing aids covered under N.J. law, 43
– Employer health coverage, large job losses would result, study, 132
– Health insurance coverage, federal requirements

See generally HEALTH CARE REFORM, FEDERAL

– Included in House Democrats' legislative framework, 697

MARKET TRENDS

– High-deductible plans, 17 percent with private insurance in 2007, report, 297
– LSCs

See LIMITED SERVICE CLINICS (LSCs)

– Medical tourism

See MEDICAL TOURISM

– PPOs, value-based benefit designs improve outcomes, study, 196
– Small group carriers, largest increased median market share in 2008, GAO study, 391

MARKETING

– Deceptive

See DECEPTIVE PRACTICES

– Long-term care insurance, model marketing disclosures

See LEGISLATION, FEDERAL, S 1177

– Medicare Advantage

– – Fair market value sales agent compensation rates also set for Part D, 7; rule may discourage independent agent assistance, 64
– – Guidance, CMS revises, 609
– – Strict guidelines needed to protect beneficiaries, advocacy groups say, 737
– – WellCare, CMS orders suspension, 211

– Prescription drugs

– – Data mining

See PRESCRIPTION DATA MINING

– – Discount cards, company settles deceptive practices charges (Pa. Commw. Ct.), 192
– – Part D, CMS revises guidance, 609

MARYLAND

– Antitrust, proposed self-insured employer joint contracting with physician-hospital organization allowed, FTC advisory opinion, 456
– Electronic health records, provider incentives bill passed, 502; new law, 625
– Health insurance, lawmakers pass bill to tighten individual market regulation, 463; new law, 625
– Telemedicine, Price Frederick hospital links to Wilmington, Del., tertiary care facility, 682

MASSACHUSETTS

– Health reform law

– – Catholic hospital affiliation, agency approves subsidized plan affording family planning services, 315
– – Initial success, affordability gains eroded, study, 651
– – Insurance coverage mandate, tax penalties schedule for noncompliance issued, 294
– – Over 97 percent of residents insured, report, 15
– – Reliance on private plans hinders spending control, report, 350
– – Single-payer advocates criticize potential use as model, report, 222
– – Spending distribution unchanged, BCBS report, 437
– – Subsidized care, $794 million in 2008, report, 417

– Hospitals

– – Gifts, network implements rules restricting drug and device company ties, 439
– – Medical errors, rule adopted barring providers from billing for care, 592
– – Overtime, network pays millions to settle failure to pay claims (D. Mass.), 535

– Provider reimbursement

– – Cost of health care, officials probe link between increase and insurer payments to providers, 43
– – Panel recommends end to fee-for-service method, 594

MEDICAID

See also specific states
– Coding

See generally CODING

– Drug rebates

See DISCOUNTS

– Economic stimulus package

– – Baucus (D-Mont) plan includes funding increase, 94
– – House package includes funding boost, 61
– – Increased funding, House measures

See LEGISLATION, FEDERAL, HR 1, HR 598, S 1

– FY2010 budget, billions in cuts proposed over 10 years, 249; final proposal would cut program spending by $309 billion to fund health reform, 557; President defends program spending reductions in address to AMA, meeting, 692; Obama proposes $313 more program cuts, 694
– Information technology, “meaningful use” payment incentives

See INFORMATION NETWORKS AND TECHNOLOGY

MEDICAID MANAGED CARE

– Capitated, not all states report encounter data to national database, IG report, 672
– Drug rebates

See DISCOUNTS

– Savings for states likely, report, 616

MEDICAL DEVICES

– Hearing aids, N.J. law mandates coverage for children, 43
– Hospital gainsharing, industry concerns expressed in letter to CMS, 212
– Industry gifts for health care providers

See generally GIFTS

MEDICAL ERRORS

– Hospitals

– – Colo. Medicaid, executive order signed to deny payments for avoidable mistakes, In Brief, 417
– – Mass., rule adopted barring providers from billing for care, 592

– Medicare, 3 CMS national coverage decisions deny payment for some surgical mistakes, 98
– Pa. senate to vote on bill to deny payment, 416

MEDICAL RECORDS

– HIPAA rules

See HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

– Personal electronic

See ELECTRONIC HEALTH RECORDS

– Privacy

See generally PRIVACY AND CONFIDENTIALITY

MEDICAL TECHNOLOGY

– ICD-10 coding conversion

See generally CODING

MEDICAL TOURISM

– BNA audio conference, In Brief, 187
– Growth industry, possible risks and legal issues discussed, Special Reports, 354

MEDICALLY NECESSARY SERVICES

– Anthem BCBS, class action alleges regular payment denial (Cal. Super. Ct.), 292; treatment approved in coverage reversal, 314
– Autism, Cal. group seeks changes to policy allowing plans to deny treatment, 265; state regulatory clarifies coverage requirements, 316
– Fraud, guilty plea entered by recruiter of healthy patients for unnecessary surgeries (Cal. Super. Ct.), 264
– Idaho, lawmakers pass bill creating external review system for denied claims, 384
– Neurofeedback therapy, plan administrator properly denied coverage (5th Cir.), 216
– Out-of-network care, denial proper where Medicare beneficiary did not prove surgery was superior to procedure plan covered (9th Cir.), 261

MEDICARE

– Bariatric surgery, covered for some obese diabetics, 181
– Chronic illness disease management pilot, limited impact of interventions, report, 33; AMA study confirms, 178
– Coding

See generally CODING

– Comparative effectiveness research, experts promote use, conference, 97
– Compliance, CMS recommends voluntary self-reporting of suspected issues, 581
– Delivery system reform

– – CMS requires increased resources and greater flexibility, hearing, 493
– – Payment structure lacks incentives, MedPAC report, 702

– Drug coverage

See MEDICARE DRUG COVERAGE

– Eligibility, most American support expansion, survey, 214
– Exhaustion of remedies, federal law preempts cancer patient's fraud and breach of contract claims against Humana (S.D. Fla.), 288
– FY2010 budget, billions in cuts proposed over 10 years, 249; final proposal would cut program spending by $309 billion to fund health reform, 557; President defends program spending reductions in address to AMA, meeting, 692; Obama proposes $313 more program cuts, 694
– Funding increase, Baucus (D-Mont) economic stimulus plan includes, 94
– Health care reform, program key to legislative efforts, Leavitt says, 66
– Hospital gainsharing, medical device makers express concerns in letter to CMS, 212
– HRAs, payment errors source, conference, 306
– Information technology, “meaningful use” payment incentives

See INFORMATION NETWORKS AND TECHNOLOGY

– MA

See MEDICARE ADVANTAGE (MA)

– Medical errors, 3 CMS national coverage decisions deny payment for some surgical mistakes, 98
– Out-of-network care, denial proper where beneficiary did not prove medical necessity or superiority of surgery plan covered (9th Cir.), 261
– Physicians

See generally PHYSICIANS; SPECIALISTS

– Private-sector insurer payments, CMS and Treasury Dep't officials consider timing changes, GAO report, 282
– Provider incentives, Accountable Care Promotion Act bill introduced to create voluntary shared savings program, 740
– Secondary Payer Act

– – BCBS, statute not violated by reimbursement for non-network dialysis at lower rates (N.D. Ga.), 261
– – Hospital reimbursement, federal program had superior claim and first right before facility's claim to policy covering patient hit by uninsured motorist (N.D. Ind.), 100
– – Plan reporting requirements, implementation deadline extended, 614
– – Sanctions imposed on individual who did not receive benefits and therefore lacked standing to bring qui tam suits (U.S., rev sought), 70

– SNFs, most Part A payments improper, IG report, 674
– Virtual colonoscopy, bipartisan House members urge coverage, 340
– Wrongful death, federal program has right to reimbursement from family's insurance settlement for medical costs of deceased beneficiary (8th Cir.), 156

MEDICARE ADVANTAGE (MA)

– Ed. Note: The name of this program was changed from Medicare+Choice to Medicare Advantage under the Medicare Prescription Drug, Improvement, and Modernization Act.
– Bidding

– – Budget, MedPAC debates pros and cons of competitive process included in proposal, 255
– – Enrollment, competitive bids might reduce, MedPAC report, 739
– – Former CMS chief predicts competitive program, meeting, 373
– – Payments based on average submitted, industry leaders object to White House proposal, 250; OMB director defends, forum and hearing, 306; MedPAC deems long-term impact of lower pay hard to predict, 309
– – Preparation, draft 2010 call letter for plans released, 31; withdrawn, 95; oversight focus in revision, 253
– – Spending, CBO estimates competitive process would reduce by $159 billion, 609

– CMS subregulatory guidance, compliance risks defined and discussed, BNA Analysis, 77
– Coding

See generally CODING

– Comparative cost adjustment, possible congressional focus issue, reports, 285
– Compliance, CMS recommends voluntary self-reporting of suspected issues, 581
– Consumer satisfaction, CMS seeks to raise quality ratings, forum, 151
– Coverage denial, Kaiser dismissed as improper defendant but leave to amend granted to sue HHS (S.D. Cal.), 676
– Enforcement

– – CMS actions updated, In Brief, 674
– – Revised rules, CMS to propose, 584

– Exhaustion of remedies, federal law preempts cancer patient's fraud and breach of contract claims against Humana (S.D. Fla.), 288
– Fraud and abuse, 2 charged in 5-state billing scheme for bogus treatments (S.D. Fla.), 590
– Hospitalization, shorter less costly stays than Medicare patients, study, 67
– International economic crisis, compliance programs critical, BNA Analysis, 470
– Marketing

See MARKETING

– Out-of-pocket expenses, less protection than Medigap, studies, 339
– Outlook 2009, among top health issues to be addressed, Special Reports, 18
– Plan types, 3-limit requirement to avoid 2010 duplication, CMS call letter, 368; more definitive, Kaiser brief, 563; CMS telephone campaign to drop duplicative plans, 607
– Rates

See PREMIUMS AND RATES

– Reimbursement

– – Alternative payment system, MedPAC says Congress should focus first on program goals, 431
– – CMS estimates 0.5 percent increase in 2010, 208; physician pay may be considered in rate calculations, BCBSA says, 337; 0.81 percent is actual rate, 403
– – Cuts will result in fewer plans and options, MedPAC says, 65
– – Fee-for-service providers

– – – MA plans to be paid $11.4 billion more in 2009, report, 528
– – – Payments may be less, Sebelius says, hearing, 429
– – – Private MA plans should receive same pay, briefing, 615
– – – Wellcare to withdraw from private market in 2010, 571

– – Funding cuts likely, summit, 211
– – Payment policy changes, House leaders and Baucus (D-Mont) support proposal, 282
– – Private-sector insurer payments, CMS and Treasury Dep't officials consider timing changes, GAO report, 282

– Reporting requirements

– – CMS posts, 209
– – Private plan monitoring will improve, forum, 117

– Special needs plans, survival problematic, teleconference, 179

MEDICARE+CHOICE

– Ed. Note: The name of this program was changed from Medicare+Choice to Medicare Advantage under the Medicare Prescription Drug, Improvement, and Modernization Act.

MEDICARE DRUG COVERAGE

– Ed. Note: Entries at this heading refer to Medicare Part D unless otherwise indicated.
– Access, no improvement for many beneficiaries, study, 284
– Bid preparation

– – Draft 2010 call letter for plans released, 31; withdrawn, 95; oversight focus in revision, 253
– – Errors, no refunds for overcharged enrollees, 487

– Brand and generic access increased, report, 45
– Choices, numerous options impede ability to select low-cost plan, study, 739
– E-prescriptions, community pharmacists want federal incentives, 489
– Enforcement

– – CMS actions updated, In Brief, 674
– – New regulations proposed, 584

– Gap

– – Affected seniors cut prescriptions 14 percent, study, 152
– – Closing, AARP campaign fact sheet, 616
– – Cost cuts, drug industry pledges, 731
– – 7 percent total of 2006 beneficiaries, report, 283

– Government-negotiated prices, former CMS chief says benefits are threatened, summit, 178
– Low-income persons, health reform would help most, briefing, 615
– Marketing guidance, CMS revises, 609
– Outpatients, spending up in first program year, brief, 433
– Oversight challenges loom, IG report, 34
– Payment policy changes, House leaders and Baucus (D-Mont) support proposal, 282
– Plan marketing, fair market value sales agent compensation rates set, 7; rule may discourage independent agent assistance, 64
– Premiums

See PREMIUMS AND RATES

– Private-sector insurer payments, CMS and Treasury Dep't officials consider timing changes, GAO report, 282
– Protected classes, comments sought on proposed CMS rule requiring coverage, 61; managers' group opposes expansion, 371
– Reporting requirements, CMS posts, 209
– Stand-alone plans, over 40 percent of beneficiaries purchased, study, 284

MEDIGAP

– Ambiguous policy provision, plan must pay hospital's standard rate rather than lower Medicare charges reimbursement (Wis.), 590
– Consumer satisfaction, 88 percent of policyholders pleased, study, 701
– Deceptive practices, BCBS of Mich. plan warned, 16
– ESRD, new Fla. coverage law, 711
– Genetic Information Nondiscrimination Act, CMS to use Natl. Ass'n of Ins. Comm'n model for regulations, 486
– Out-of-pocket expenses, MA affords less protection, studies, 339
– Policy sales increasing, study, 750

MENTAL HEALTH

– Dependents

– – Disabled, medical and denial plan acted arbitrarily to deny 23-year-old son's enrollment (N.D. Ill.), 387
– – Eating disorders, Horizon BCBS of N.J. settlement of coverage claims approved (D.N.J.), 494
– – Out-of-network care, claim over denial of residential treatment for eating disorder barred (S.D.N.Y.), 347

– Employer health plan options and requirements explored, ABA meeting, 587
– Parity

– – Act, business groups seek agency clarification, 644; industry representatives cite enforcement concerns, 671
– – Federal agencies seek public comment on regulations, 488
– – Outlook 2009, among top health issues to be addressed, Special Reports, 18

MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES

– Dependents, medical and dental plan acted arbitrarily to deny disabled 23-year-old son's enrollment (N.D. Ill.), 387

MERGERS AND ACQUISITIONS

– Antitrust

– – CVS/Caremark, FTC probe sought, 561
– – FTC to focus on hospital quality improvement potential, meeting, 177
– – Justice Dep't review, hospital association urges, letter and report, 585
– – Long-term care pharmacy's claims against merged insurance companies dismissed for insufficient evidence (N.D. Ill.), 89; Omnicare to appeal, 89

– BCBS

– – Highmark and Independence, Pa. plans halt effort, 103
– – Transferring funds to subsidiary, suit alleging state law violation dismissed (Mich. Cir. Ct.), 72

– PBM, Express Scripts/WellPoint agreement, 441; community pharmacists file objections with FTC, 536
– Preferred Care Partners/Humana, claims over alleged breach of confidentiality agreement proceed (S.D. Fla.), 495
– Sales, binding arbitration hearing set in suit over sale of 3 hospitals (Colo. Dist. Ct.), 73; 2 sales disallowed for violation of state nonprofit law but third proceeds, 712

MICHIGAN

– BCBS

– – Individual health insurance market rates, lawmakers adjourn without action, 16; insurer to cut jobs and seek increases to offset losses, 106; commissioner sets hearing, 681
– – Medigap policies, insurer warned about deceptive business practices, 16
– – Mergers and acquisitions, suit alleging state law violation for transferring funds to subsidiary dismissed (Mich. Cir. Ct.), 72
– – Omega Hosp., trial over plan reimbursement proceeds (E.D. La.), 376

– Emergency services, no ERISA fiduciary duty breach claim for GM participants over BCBS coverage denials (E.D. Mich.), 413
– Health insurance, ERISA does not preempt state rules barring discretionary clauses in policies (6th Cir.), 343
– No-fault automobile insurer bound by 2-year limitations period in ERISA plan contract (E.D. Mich.), 158

MINNESOTA

– Antitrust, legislative exemption of health care cooperatives activities will reduce competition and increase costs, FTC letter, 384
– Hospitals

– – Allina pays $1.1 million to settle patients' usury claims (Minn. Dist. Ct.), 460
– – Net income, many lost money on operations, report, 596

– Medical debt, state attorney general sues Allina Health Sys. over interest rate charges that violated state usury laws (Minn. Dist. Ct.), 128

MISREPRESENTATION

– Aetna underpricing to gain market share, class securities action dismissed (E.D. Pa.), 742
– Insurance eligibility, former plan participant's claims proceed (S.D.N.Y.), 376
– Out-of-network care, ERISA no bar to negligent misrepresentation claim over physician statement that knee treatment would be covered by plan (S.D. Ohio), 675
– Standing, spouse cannot sue insurer over terms of policy covering late wife (Cal. Ct. App.), 500

MISSOURI

– BCBS, ERISA preempts physician's state law prompt payment claims (S.D. Fla.), 158
– HMOs, state regulation violated by charging copayment and percentage fee for same single service (W.D. Mo.), 706