Schumer says he will not support 7- or 10-day stopgap to avoid shutdown

[pat_k]

37. I poked around. It is a CMS "experiment" to root out nonexistent "waste/fraud/abuse"

It's not the states that are implementing this. It is the Centers for Medicare and Medicaid Services. They are adding some pre-authorization requirements for certain services/procedures provided under Part A and Part B (currently covered without pre-authorization).

It is not Managed Care in the same sense that Medicare Advantage is Managed Care.

So, it sounds like it will actually only affect people like me who keep their original Medicare and add a supplement because they refuse to be shoved into the rapidly deteriorating Medicare Advantage Plans.

Not surprising because Republicans hate people like me. They've fucked around with Medicare Advantage to weaken that coverage, but have been unable to touch Original Medicare. I am actually wondering if people in those six states can sue. I would like to know what authority CMS has to run this "experiment." Did the Republican Congress grant it? Or is it another case of an agency doing shit it is not allowed to do? I have more research to do.

AI Summary

CMS picked six states—Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington—for the Wasteful and Inappropriate Service Reduction (WISeR) model based on a combination of evaluability and operational criteria, including selecting within the same Medicare Administrative Contractor (MAC) jurisdictions to allow for direct comparison between test and comparison states, choosing states with sufficient claims volume for reliable impact estimates, and prioritizing states with existing administrative contractors that already had coverage policies for the targeted services.

Here's a breakdown of the selection criteria and process:

MAC Jurisdictions: The model was assigned to four MAC jurisdictions: JH, JL, JF, and J15.

Within-MAC Comparisons: CMS selected states within the same MAC jurisdictions so they could compare the test states to other states within that same MAC.

Adequate Claims Volume: States were chosen for their sufficient volume of claims, which allows for precise estimates of the model's impact.

Existing Coverage Policies: CMS prioritized states where the administrative contractors already had coverage policies for the services targeted by the model.

Geographic Diversity: The selected states represent diverse geographic areas.

Highest Historical Claim Paid Amounts: States meeting the evaluation criteria were also selected based on the highest historical claim paid amounts.