Medicare Compliance & Reimbursement

M+C reg has good news and bad.

A health plan's cost for terminating a Medi-care+Choice contract mid year just got steeper.

The Centers for Medicare & Medicaid Services has jacked up the civil monetary penalty for such terminations to either $250 per enrolled Medicare member or $100,000, whichever is greater. The cap used to be only $25,000.

The provision is one of many in CMS' Aug. 22 managed care final rule, which implements a number of provisions of the Benefits Improvement and Protection Act of 2000.

On the plus side for plans, the rule forbids CMS from implementing major new regulatory requirements on M+COs more than once a year (except when the agency is compelled to do so by statute).

Other provisions in the grab-bag rule address: handling local coverage policies in plans covering multiple geographic areas, M+C appeals, end-stage renal disease payments and issues connected with skilled nursing facility residents.

To see the rule, go to www.access.gpo.gov/su_docs/fedreg/a030822c.html.

Lesson Learned: M+COs should pay close attention to how CMS' new policies affect enrollees who reside in skilled nursing facilities - a frequent trouble spot highlighted in HHS Office of Inspector General audits.