As part of an ongoing investigation into the May 2023 data breach of Progress Software’s MOVEit Transfer software on the corporate network of Maximus Federal Services, Inc.| www.cms.gov
United States| www.cms.gov
Consumers| www.cms.gov
Surprise billing & protecting consumers As of January 1, 2022, consumers have new billing protections when getting emergency care, non-emergency care from out-of-network providers at| www.cms.gov
Background| www.cms.gov
New Drug Law Enhances Part D Prescription Drug Benefit and Keeps Part D Premiums Stable for 2024| www.cms.gov
Agency Will Begin Auditing All Eligible Medicare Advantage Contracts Each Payment Year and Add Resources to Expedite Completion of 2018 to 2024 Audits| www.cms.gov
This page is an overview of the Health Plan General Information page.| www.cms.gov
Wasteful and Inappropriate Service Reduction (WISeR) Model webpage| www.cms.gov
Rural Health Clinics Center| www.cms.gov
129 Million People Could Be Denied Affordable Coverage Without Health Reform IntroductionAccording to a new analysis by the Department of Health and Human Services, 50 to 129 million (19 to 50 percent of) non-elderly Americans have some type of pre-existing health condition. Up to one in five non-elderly Americans with a pre-existing condition – 25 million individuals – is uninsured.| www.cms.gov
Critical Access Hospitals| www.cms.gov
Final rule modernizes the health care system and reduces patient and provider burden by streamlining the prior authorization process| www.cms.gov
Crushing Fraud, Waste, & Abuse| www.cms.gov
Building on the CMS Interoperability and Patient Access final rule (CMS-9115-F), this proposed rule would place new requirements on Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service programs, and Qualified Health Plans (QHP) issuers on the Federally-facilitated Exchanges (FFEs) to improve the electronic exchange of health care data, and streamline processes related to prior authorization.| www.cms.gov
Calendar Year 2026 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Proposed Rule (CMS-1834-P)| www.cms.gov
Proposed policies would increase value-based care, strengthen primary care, and expand access to behavioral and oral health care| www.cms.gov
On July 10, 2024, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that announces and solicits public comments on proposed policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, effective on or after January 1, 2025.| www.cms.gov
Hospital price transparency lays the foundation for a patient-driven health care system by making hospital standard charges’ data available to the public and supports President Biden’s Executive Order on Promoting Competition. On July 13, 2023, the Centers for Medicare & Medicaid Services (CMS) proposed changes to the hospital price transparency regulations.| www.cms.gov
Note: The information included in this Fact Sheet is based on the 2024 Star Ratings published on the Medicare Plan Finder on October 13, 2023. For details on the Medicare Advantage (MA) and Part D Star Ratings, please refer to the 2024 Part C & D Star Ratings Technical Notes available at http://go.cms.gov/partcanddstarratings. Introduction| www.cms.gov
Hospital price transparency helps Americans know the cost of a hospital item or service before receiving it. Starting January 1, 2021, each hospital operating in the United States will be required to provide clear, accessible pricing information online about the items and services they provide in two ways:| www.cms.gov
Unnecessary, Duplicate Enrollment Wasting $14 Billion AnnuallyThe Centers for Medicare & Medicaid Services (CMS) continue to crush fraud, waste, and abuse in America’s healthcare programs by stopping duplicative enrollment in government health programs, with the potential to save taxpayers approximately $14 billion annually.| www.cms.gov
Today, the Centers for Medicare & Medicaid Services (CMS) released the Final Calendar Year (CY) 2026 Part D Redesign Program Instructions (the Final CY 2026 Program Instructions) concurrently with the Announcement of CY 2026 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies (the CY 2026 Rate Announcement).| www.cms.gov
The Department of Health and Human Services and Centers for Medicare & Medicaid Services (“CMS”) are rescinding July 2022 guidance from CMS with the subject “Reinforcement of EMTALA Obligations specific to Patients who are Pregnant or are Experiencing Pregnancy Loss” (QSO-22-22-Hospitals) and (| www.cms.gov
The Centers for Medicare & Medicaid Services (CMS) Center for Consumer Information and Insurance Oversight (CCIIO) is committed to increasing transparency in the Health Insurance Exchanges. While health plan information including benefits, copayments, premiums, and geographic coverage is publicly available on Healthcare.gov, CMS also publishes downloadable public use files (PUFs) so that researchers and other stakeholders can more easily access Exchange data.| www.cms.gov
State Specific Rating Variations The Market Rules and Rate Review Final Rule (45 CFR Part 147) provides that each state will have age rating ratios of 3:1 using a federally established age curve, tobacco rating ratios of no more than 1.5:1 and per member rating unless a state requests ratios less than the standard, is a community rating state with uniform family tiers, or allows for averaging of enrollee premiums in the small group market.| www.cms.gov
On June 30, 2025, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that proposes updates to Medicare payment policies and rates for home health agencies (HHAs) under the Home Health (HH) Prospective Payment System (PPS) Proposed Rule for calendar year (CY) 2026. CMS is publishing this proposed rule consistent with the legal requirements to update Medicare payment policies for HHAs annually. This fact sheet discusses the major provisions of the proposed rule.| www.cms.gov
Effective January 1, 2024, MFTs and MHCs can bill Medicare independently for their services furnished for the diagnosis and treatment of mental illnesses. Medicare Part B pays MFTs and MHCs for these services at 75% of what a clinical psychologist is paid under the Medicare Physician Fee Schedule.| www.cms.gov
To ensure op| www.cms.gov
The Affordable Care Act requires health insurance companies to disclose how much they spend on health care and how much they spend on administrative costs, such as salaries and marketing. If an insurance company spends less than 80% (85% in the large group market) of premium on medical care and efforts to improve the quality of care, they must refund the portion of premium that exceeded this limit. This rule is commonly known as the 80/20 rule or the Medical Loss Ratio (MLR) rule.| www.cms.gov
No Surprises Act - OverviewTitle I (No Surprises Act) and Title II (Transparency) of Division BB of the Consolidated Appropriations Act, 2021 (CAA), establish new protections for consumers related to surprise billing and transparency in health care. The legislation contains new requirements for group health plans, health insurance issuers in the group and individual markets, providers, facilities, and air ambulance providers.| www.cms.gov
When’s the Medicare Open Enrollment Period? Every year, Medicare’s open enrollment period is October 15 - December 7. What’s the Medicare Open Enrollment Period? Medicare health and drug plans can make changes each year—things like cost, coverage, and what providers and pharmacies are in their networks. October 15 to December 7 is when all people with Medicare can change their Medicare health plans and prescription drug coverage for the following year to better meet their needs.| www.cms.gov
ANNUAL ELECTION PERIOD | www.cms.gov
On January 30, 2023, the Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury (collectively, the Departments) released proposed rules with comment period entitled “Coverage of Certain Preventive Services Under the Affordable Care Act.” These proposed rules would amend regulations regarding coverage of certain preventive services under the Affordable Care Act (ACA), which, consistent with guidelines supported by the Health Resources and...| www.cms.gov
Under President Biden, over 45 million people have coverage thanks to the Affordable Care Act and key actions taken under the Administration to strengthen the law| www.cms.gov
Summary: The Centers for Medicare & Medicaid Services (CMS) seeks public input to identify challenges and improve compliance and enforcement processes related to the transparent reporting of complete, accurate, and meaningful pricing data by hospitals. CMS seeks responses to the “Questions for Public Comment” section of this Request for Information (RFI). CMS may use the responses collected to inform the development and implementation of future policies and processes, among other purposes.| www.cms.gov
The Centers for Medicare & Medicaid Services (CMS) is committed to being a responsible steward of public funds and to promoting the sustainability of its programs for future generations. While CMS’ improper payments reporting programs are designed to protect the integrity of CMS programs, it is important to keep in mind that not all improper payments represent fraud or abuse. Improper payments are payments that do not meet CMS program requirements.| www.cms.gov
The Health Insurance Exchanges 2019 Open Enrollment Report summarizes health plan selections made on the individual Exchanges during the 2019 Open Enrollment Period (2019 OEP) for the 39 states that use the HealthCare.gov eligibility and enrollment platform, as well as for the 12 State-Based Exchanges (SBEs) that use their own eligibility and enrollment platforms.| www.cms.gov
Departments of Labor, Health and Human Services, Treasury announce move to strengthen healthcare price transparencyTrump administration issues request for information, guidance to expand access to real prices The departments of Labor, Health and Human Services, and the Treasury took action today to advance President Trump’s directive to ensure Americans have clear, accurate, and actionable information about healthcare prices.| www.cms.gov
The Centers for Medicare & Medicaid Services (CMS) is committed to being a responsible steward of public funds and to promoting the sustainability of its programs for future generations. While CMS’ improper payments reporting programs are designed to protect the integrity of CMS programs, not all improper payments are fraud or abuse. It is important to understand that improper payments are payments that do not meet CMS program requirements.| www.cms.gov
Thanks to President Biden’s new law to lower prescription drug costs, the final rule will also improve access to affordable prescription drug coverage for an estimated 300,000 low-income individuals| www.cms.gov
The Centers for Medicare & Medicaid Services (CMS) today announced that the average total monthly premium for Medicare Part D coverage is projected to be approximately $55.50 in 2024. This expected amount is a decrease of 1.8% from $56.49 in 2023.| www.cms.gov
Today, under President Trump’s leadership, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would improve the electronic exchange of health care data among payers, providers, and patients, and streamline processes related to prior authorization to reduce burden on providers and patients. By both increasing data flow, and reducing burden, this proposed rule would give providers more time to focus on their patients, and provide better quality care.| www.cms.gov
National Health Accounts by service type and funding source| www.cms.gov
The Transparency in Coverage final rule released today by the Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury (the Departments) delivers on President Trump’s executive order on Improving Price and Quality Transparency in American Healthcare to Put Patients First.[1] This final rule is a historic step toward putting health care| www.cms.gov
On September 5, 2023, the Centers for Medicare & Medicaid Services (CMS) announced a new voluntary, state total cost of care (TCOC) model: the States Advancing All-Payer Health Equity Approaches and Development Model (“States Advancing AHEAD” or “AHEAD” Model). CMS’s goal in the AHEAD Model is to collaborate with states to curb health care cost growth, improve population health, and promote healthier living.| www.cms.gov
Today, the Centers for Medicare & Medicaid Services (CMS) announced that average premiums, benefits, and plan choices for Medicare Advantage and the Medicare Part D prescription drug program will remain stable in 2024.| www.cms.gov
Medicare has selected 15 more drugs to negotiate directly with participating drug companies. Building on the success of the first round of negotiations, the aim is to lower prices for some more of the costliest prescription drugs.| www.cms.gov
Updated Medicare Advantage and Part D policies ensure the overall Medicare program remains strong and stable for the 65 million beneficiaries today and future generations to come, payments to private insurance companies are accurate, and taxpayer dollars are well spent| www.cms.gov
On November 8, 2024, the Centers for Medicare & Medicaid Services (CMS) released the 2025 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs, and the 2025 Medicare Part D income-related monthly adjustment amounts. Medicare Part B Premium and DeductibleMedicare Part B covers physicians’ services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered by Medicare ...| www.cms.gov
Medicare Drug Price Negotiation| www.cms.gov
Hospitals| www.cms.gov
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MAC & specialty contractor websitesMACs:CGS First Coast National Government Services Noridian Novitas Palmetto GBA| www.cms.gov
In largest-ever investment in the program, CMS is awarding $80 million to support Navigators in ensuring health coverage access to underserved populations| www.cms.gov
Annual Reports of the Boards of Trustees of the Medicare Trust Funds| www.cms.gov
Background| www.cms.gov
Learn how providers, facilities, plans and issuers can comply with surprise billing protections and resolve out-of-network payment disputes| www.cms.gov
In August 2022, President Biden signed the Inflation Reduction Act of 2022 (P.L. 117-169) into law. The law makes improvements to Medicare by expanding benefits, lowering drug costs, and improving the sustainability of the Medicare program for generations to come. The law provides meaningful financial relief for millions of people with Medicare by improving access to affordable treatments and strengthening Medicare, both now and in the long run.| www.cms.gov
Marketplace enrollment climbs nearly 5 million higher than previous year| www.cms.gov
For Medicare hospitals and Critical Access Hospitals (CAH): Learn about EMTALA and find CMS interpretive guidelines.| www.cms.gov
The Centers for Medicare & Medicaid Services (CMS) is committed to protecting consumers from bad actors and ensuring the program integrity of the Federally-facilitated Marketplace (FFM). That’s why CMS is taking additional action to address increases in unauthorized changes in consumers’ enrollments by agents and brokers. Starting on July 19, 2024, CMS will block an agent or broker from making changes to a consumer’s FFM enrollment unless the agent is already associated with the consume...| www.cms.gov
CMS remains committed to protecting consumers in the Marketplaces to ensure they are enrolled in the plan of their choosing and to terminate brokers who defraud consumers.| www.cms.gov
Broader Medicare coverage is now available for Biogen and Eisai’s Leqembi (the brand name for lecanemab) following the Food and Drug Administration’s (FDA) move to grant traditional approval to the drug that treats individuals with Alzheimer’s disease. The Centers for Medicare & Medicaid Services had previously announced this would be the case and released more details on coverage today.| www.cms.gov
The Centers for Medicare & Medicaid Services (CMS) affirms its commitment to advancing interoperability and improving prior authorization processes with the publication of the CMS Interoperability and Prior Authorization final rule (CMS-0057-F).| www.cms.gov
The Centers for Medicare & Medicaid Services (CMS) reports that 21.3 million consumers have signed up for 2024 individual market health insurance coverage through the Marketplaces since the start of the 2024 Marketplace Open Enrollment Period (OEP) on November 1.| www.cms.gov
The 2024 Open Enrollment Period (OEP) for the Health Insurance Marketplaces ran between November 1, 2023 and January 16, 2024 for the 32 states that used HealthCare.gov (HC.gov).| www.cms.gov
On November 2, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that announces finalized policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, effective on or after January 1, 2024.| www.cms.gov
Independent Dispute Resolution ReportsThe No Surprises Act (NSA) and its implementing regulations establish a Federal Independent Dispute Resolution (IDR) process that out-of-network (OON) providers, facilities, and providers of air ambulance services, and group health plans, health insurance issuers in the group and individual markets, and Federal Employees Health Benefits (FEHB) Program carriers (collectively, the disputing parties) may use to determine the OON rate for qualified IDR items ...| www.cms.gov
Quick summary of NHE Facts| www.cms.gov
Defining key terms:Accountable Care: A person-centered care team takes responsibility for improving quality of care, care coordination and health outcomes for a defined group of individuals, to reduce care fragmentation and avoid unnecessary costs for individuals and the health system.| www.cms.gov
Medicare Shared Savings Program (Shared Savings Program) ACOs are groups of doctors, hospitals, and other health care providers who collaborate to give coordinated high-quality care to people with Medicare, focusing on delivering the right care at the right time, while avoiding unnecessary services and medical errors. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, the ACO may be eligible to share in the savings it achieves for the Medic...| www.cms.gov
CY 2024 Hospital Outpatient Prospective Payment System (OPPS) Policy Changes: Hospital Price Transparency (CMS-1786-FC)| www.cms.gov
The Inflation Reduction Act provides meaningful financial relief for millions of people with Medicare by improving access to affordab| www.cms.gov
The Affordable Care Act requires non-grandfathered health insurance coverage in the individual and small group markets to cover essential health benefits (EHB), which include items and services in at least the following ten benefit categories: (1) ambulatory patient services; (2) emergency services; (3) hospitalization; (4) maternity and newborn care; (5) mental health and substance use disorder services including behavioral health treatment; (6) prescription drugs; (7) rehabilitative and hab...| www.cms.gov
The Center for Consumer Information & Insurance OversightDirect Enrollment/Enhanced Direct Enrollment Resources for the Federally-facilitated ExchangeWelcomeThis page provides information about Direct Enrollment (DE) and Enhanced Direct Enrollment (EDE), and provides additional guidance and resources for web-brokers and issuers using or interested in these enrollment pathways.| www.cms.gov