Latest Breaking News

pat_k

(11,967 posts)

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

Mon Sep 29, 2025, 10:27 PM

Monday

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.

Edit history

Please sign in to view edit histories.

Recommendations

0 members have recommended this reply (displayed in chronological order):

53 replies

= new reply since forum marked as read

Highlight:

Schumer says he will not support 7- or 10-day stopgap to avoid shutdown [View all] BumRushDaShow Monday OP

He already knew that he was going to harm over 17 million people with health care he doesn't give a shit............ turbinetree Monday #1

I believe the funding cuts had to do with Medicaid, not Medicare, and not renewing the subsidies lostincalifornia Monday #4

Starting Jan 1st subsidies will go up around 50 to 100 percent, this will be the death of ACA which the fascists want.nt ImNotGod Monday #12

absolutely. It is the most mean, immoral, attack against the most vulnerable people in our country. lostincalifornia Monday #14

correct, and that will eventually increase healthcare costs for EVERYONE Skittles Monday #32

Medicare is going to a new managed care model in 6 states in 2026. Irish_Dem Monday #21

Aarp should be screaming about this flamingdem Monday #23

Yes, no one seems to care. Irish_Dem Monday #25

The seniors have been out there protesting flamingdem Monday #39

I hope people complain. Irish_Dem Tuesday #42

How the hell are they doing that? pat_k Monday #30

If you are living in one of the six states, they are going to do it. Irish_Dem Monday #31

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

Found more: pat_k Monday #38

Medicaid not Medicare and the way I understand it is that the cuts are so horrible Bengus81 Tuesday #46

Kudos to Sen. Schumer mcar Monday #2

I'll give him points if he holds firm Skittles Monday #34

Why that can't be, I read here on DU that Sen. Schumer and Rep. Jeffries were getting ready to cave. MarineCombatEngineer Monday #3

Not the first time.. Cha Monday #7

Nor the last. sheshe2 Monday #9

Not at this rate. Cha Monday #10

but they quoted "anonymous sources". lostincalifornia Monday #15

Oh, well then, it must be true, MarineCombatEngineer Monday #19

Keep pressuring Schumer. Justice Brandeis Monday #5

Maybe all those messages helped. ananda Monday #6

Am I missing something? He's only one person. Why can't the rest of the Dems vote their conscience? Baitball Blogger Monday #8

The House can easily pass the ridiculous C.R. because they will have the majority (which is needed for passage) BumRushDaShow Monday #11

Yep, MarineCombatEngineer Monday #13

My point is, if Shumer can't lead, why do the other senators have to listen to him? Baitball Blogger Monday #16

I understand your and others' concern about his (lack of) "leadership" skills BumRushDaShow Monday #17

Basic protocol is what gave us our weak hand. Baitball Blogger Monday #18

You need to become a CSPAN junkie to see how they operate in Congress BumRushDaShow Monday #24

The sad part is that Karma13612 Tuesday #44

CSPAN does have a YouTube channel BumRushDaShow Tuesday #48

Or... and hear me out... OldBaldy1701E Tuesday #45

What you see today BumRushDaShow Tuesday #49

There was a time when those who exploited loopholes would have been shut down by the community. OldBaldy1701E Tuesday #50

I have posted a number of times before BumRushDaShow Tuesday #52

Yes. OldBaldy1701E Yesterday #53

"the president, who was really listening to us" BWdem4life Monday #20

Hurting people in any form is exactly what psychopaths live for. ... littlemissmartypants Monday #22

Apparently he played dumb about what was going to happen. Klarkashton Monday #27

He who played dumb? littlemissmartypants Monday #33

The elections are far off. Put the fucking heat on those Klarkashton Monday #26

So, is the only "red line" ACA enhanced subsidies? pat_k Monday #28

I think Medicaid cuts were also part of that. BumRushDaShow Monday #29

Kick and Recommend! sheshe2 Monday #35

Good. Ten days is a brief headline-dimming distraction DFW Monday #36

A great way to keep up with developments in ACA tonekat Monday #40

I hope that Schumer and Jeffries hold firm. Bread and Circuses Monday #41

At the very least, Jeffries and Schumer are on the record for warning TSF no_hypocrisy Tuesday #43

He's going to have to stay strong JustAnotherGen Tuesday #47

What! When did Schumer grow a pair? lees1975 Tuesday #51