what does the center of medicare and medicaid services do
Centers for Medicare and Medicaid Services


Medicare program. At the time, the program provided health insurance to 19 million Americans. The Social Security Administration (SSA) became responsible for the administration of Medicare and the Social and Rehabilitation Service (SRS) became responsible for the administration of Medicaid. Both agencies were organized under what was then known as the Department of Health, Education, and Welfare (HEW). In 1977, the Health Care Financing Administration (HCFA) was established under HEW. HCFA became responsible for the coordination of Medicare and Medicaid. The responsibility
2715996
Medicare dual eligible


well as the Center for Medicare and Medicaid Innovation (CMMI) in order to both strategize and monitor the type and quality of care afforded to duals. These offices focus on both monetary expenses as well as care innovation and quality for dual eligible beneficiaries. A study by the Government Accountability Office (GAO) found that the integration of Medicare and Medicaid benefits generally improves the care provided to dual-eligibles but does not lead to Medicare savings or a reduction in costly Medicare services (i.e., emergency room visits, hospital admissions,
12066102
Emergency Medical Treatment and Active Labor Act


the patient or when their condition requires transfer to a hospital better equipped to administer the treatment. EMTALA applies to "participating hospitals." The statute defines participating hospitals as those that accept payment from the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) under the Medicare program. Because there are very few hospitals that do not accept Medicare, the law applies to nearly all hospitals. The combined payments of Medicare and Medicaid, $602 billion in 2004, or roughly 44% of all medical
1278068
Center for Medicare and Medicaid Innovation


The Center for Medicare and Medicaid Innovation (CMMI; also known as the CMS Innovation Center) is an organization of the United States government under the Centers for Medicare and Medicaid Services (CMS). It was created by the Patient Protection and Affordable Care Act, the 2010 U.S. health care reform legislation. "The center is to test innovative payment and delivery system models that show important promise for maintaining or improving the quality of care in Medicare, Medicaid, and the Children's Health Insurance Program (CHIP), while slowing
5147470
Human rights in the United States


Rights. Unlike most other industrialized nations, the United States does not offer most of its citizens subsidized health care. The United States Medicaid program provides subsidized coverage to some categories of individuals and families with low incomes and resources, including children, pregnant women, and very low-income people with disabilities (higher-earning people with disabilities do not qualify for Medicaid, although they do qualify for Medicare). However, according to Medicaid's own documents, "the Medicaid program does not provide health care services, even for
21936264
All-payer rate setting


medical education and limited cost growth, but per capita Medicare hospital costs are among the country's highest. Medicare's participation in the system is authorized by the Social Security Act and is tied to a growth limit in payment per admission. The Medicare waiver created incentives to increase the volume of services. Medicare pays higher rates for hospital services in Maryland than it does under the national prospective payment systems. On January 10, 2014, the Centers for Medicare and Medicaid Services (CMS) and the State announced a new model that
4276797
Nursing home care


related services to those who are below the poverty line. Each state defines poverty and, therefore, Medicaid eligibility. Those eligible for Medicaid may be low-income parents, children, including State Children's Health Insurance Programs (SCHIPs) and maternal-child wellness and food programs. seniors, and people with disabilities. The Centers for Medicare and Medicaid Services is the component of the U.S. Department of Health and Human Services (DHHS) that oversees Medicare and Medicaid. A large portion of Medicare and Medicaid dollars is used each
2778304
Centers for Medicare and Medicaid Services


The Centers for Medicare & Medicaid Services (CMS), previously known as the Health Care Financing Administration (HCFA), is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the Children's Health Insurance Program (CHIP), and health insurance portability standards. In addition to these programs, CMS has other responsibilities, including the administrative simplification standards from the Health Insurance Portability and Accountability Act of 1996 (HIPAA
2715994
Nursing home care in the United States


to income levels and any assets involved. Medicaid is normally most available after a person has exercise every other option such as using personal funds as a form of payment. If eligible medicaid can cover any therapy, room and board or meal plans. The Centers for Medicare and Medicaid Services is the component of the U.S. Department of Health and Human Services (DHHS) that oversees Medicare and Medicaid. A large portion of Medicare and Medicaid dollars is used each year to cover nursing home care and services for the elderly and disabled.
11490535
Medicare dual eligible


certain controlled substances. Dual-eligibles typically receive their Medicare and Medicaid benefits through each program separately. For Medicare benefits, beneficiaries may opt to enroll in Medicare's traditional fee-for-service (FFS) program or in a private Medicare Advantage (MA) plan (Medicare Part C), which is administered by a Managed Care Organization (MCO), under contract with the Centers for Medicare & Medicaid Services (CMS), the agency in the Department of Health and Human Services that administers the Medicare program and oversees
12066096
Maryland hospital payment system


is tied to a growth limit in payment per admission. The Medicare waiver created incentives to increase the volume of services provided. Medicare pays higher rates for hospital services in Maryland than it does under the national prospective payment systems. On January 10, 2014, the Centers for Medicare and Medicaid Services (CMS) and the State announced a new model that will focus on overall per capita expenditures for hospital services, as well as on improvements in the quality of care and population health outcomes. For 5 years beginning in 2014,
3714805
Health care prices in the United States


2016. While on the other hand, Medicaid covered 68.4 million people as of July 2017, 74.3 million including the Children's Health Insurance Program (CHIP). Medicare and Medicaid are managed at the Federal level by the Centers for Medicare and Medicaid Services (CMS). CMS sets fee schedules for medical services through Prospective Payment Systems (PPS) for inpatient care, outpatient care, and other services. As the largest single purchaser of medical services in the U.S., Medicare's fixed pricing schedules have a significant impact on the
13865016
Hospice care in the United States


has grown. In 2007, 47.1% of agencies were for-profit, with 48.6% non-profit. The remaining 4.3% were government-owned providers. In order to receive payments for hospice patients under Medicare or Medicaid, a hospice must be certified by the Centers for Medicare and Medicaid Services, and in 2007 93.1% were. Among those that were not certified, some were in the process of seeking certification. However, some agencies do not seek certification or voluntarily relinquish it. For one example, an
8396267
Community Health Accreditation Program


, non-profit subsidiary of the NLN in 1988, under the CHAP name. In 1992, CHAP was granted deeming authority for home care by the Centers for Medicare and Medicaid Services. In 1999 it received deeming authority for hospices. CHAP has the regulatory authority to survey agencies providing home health, hospice, and home medical equipment services, to determine if they meet the Medicare Conditions of Participation and CMS Quality Standards. Through "deeming authority" granted by the Centers for Medicare and Medicaid Services (CMS), in 1992
8612871
Warfarin


the dose variation between patients, mainly among Caucasian patients as these variants are rare in African American and most Asian populations. These "CYP2C9" polymorphisms do not influence time to effective INR as opposed to"VKORC1", but does shorten the time to INR 4. Despite the promise of pharmacogenomic testing in warfarin dosing, its use in clinical practice is controversial. In August 2009 the Centers for Medicare and Medicaid Services concluded that "the available evidence does not demonstrate that pharmacogenomic testing of CYP2C9 or VKORC1 alleles to predict warfarin responsiveness improves health
9495149
Medigap


and B for the preceding named services and the total amount allowed to be charged for those services by the United States Centers for Medicare and Medicaid Services (CMS). As of 2016, 34% of Medicare beneficiaries were covered by a Medigap policy. Public-option Part C Medicare Advantage health plans and private employee retiree insurance provides a similar supplemental role for almost all other Medicare beneficiaries not dual eligible for Medicaid. Medicare eligibility can start for Americans when they turn at least 64 years & 9 months old or upon retirement.
5485933
Medicare (United States)


administered prescription drugs was passed (and went into effect in 2006) as Medicare Part D. The government added hospice benefits to aid elderly people on a temporary basis in 1982, and made this permanent in 1984. Congress further expanded Medicare in 2001 to cover younger people with amyotrophic lateral sclerosis (ALS, or Lou Gehrig's disease). The Centers for Medicare and Medicaid Services (CMS), a component of the U.S. Department of Health and Human Services (HHS), administers Medicare, Medicaid, the Children's Health Insurance
13012264
Centers for Medicare and Medicaid Services


for enrolling beneficiaries into Medicare and processing premium payments remained with SSA. The CMS employs over 6,000 people, of whom about 4,000 are located at its headquarters in Woodlawn, Maryland. The remaining employees are located in the Hubert H. Humphrey Building in Washington, D.C., the 10 regional offices listed below, and in various field offices located throughout the United States. The head of the CMS is the Administrator of the Centers for Medicare & Medicaid Services. The position is appointed by the president and confirmed by the Senate. Seema Verma
2715997
Mark McClellan


brother of former White House Press Secretary Scott McClellan and the son of Texas comptroller Carole Keeton Strayhorn and attorney Barr McClellan. He was Administrator for the Centers for Medicare and Medicaid Services in the United States Department of Health and Human Services from 2004 to 2006. In this position, he was responsible for administering the Medicare and Medicaid programs, including Medicare Part D, the prescription drug benefit program engendered by the Medicare Prescription Drug, Improvement, and Modernization Act. Following the resignation of Health & Human Services Secretary Tommy Thompson in 2004
2231795
Accreditation Commission for Health Care


ACHC to accredit suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) as meeting new quality standards under Medicare Part B. In January 2009, the Centers for Medicare & Medicaid Services (CMS) announced the approval of the ACHC for continued Deeming Authority for Home Health Agencies through 2015. Initial approval of Deeming Authority of ACHC for Home Health Agencies was granted in February 2006. On November 27, 2009, ACHC was recognized by the Centers for Medicare & Medicaid Services (CMS) as a national accreditation organization for
8612962
National coverage determination


local coverage determination (LCD). As of 2015, local coverage determinations only become public on an appeal, and do not set a precedent. NCDs can be requested by external parties who identify an item or service as a potential benefit (or to prevent potential harm) to Medicare beneficiaries. External parties who may request an NCD are Medicare beneficiaries, manufacturers, providers, suppliers, medical professional associations, or health plans. NCDs can also be internally generated by the Centers for Medicare and Medicaid Services (CMS) under multiple
21633248
Disease management (health)


not incorporated into analyses." Section 721 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 authorized the Centers for Medicare and Medicaid Services (CMS) to conduct what became the "Medicare Health Support" project to examine disease management. Phase I of the project involved disease management companies (such as Aetna Health Management, CIGNA Health Support, Health Dialog Services Corp., Healthways, and McKesson Health Solutions) chosen by a competitive process in eight states and the District of Columbia. The project focused on people with
13913219
Visiting Nurse Service of New York


1993. Its IT innovations have been the subject of research VNSNY acts as a liaison between patient and government bodies such as the state and federal legislatures, as well as regulatory bodies such as the Centers for Medicare and Medicaid Services and the New York State Department of Health and the Department of Insurance. The company paid $35 million to the federal Medicaid program in order to settle a civil suit alleging it enrolled ineligible people into Medicaid plans, and is currently defending allegations it claimed Medicaid and Medicare income for care ordered by doctors
2468485
Safety net hospital


Center Program grant from the U.S. Department of Health and Human Resources and Services Administration. FQHCs that meet all the federal health center program requirements but don't receive health center grant funding are called FQHC look-alikes. These FQHCs are typically non-profit community health centers and regional clinical associations. Rural Health Centers are public, private, or non-profit health centers that provide primary care to Medicaid and Medicare populations in rural areas. RHC status is designated by the Centers for Medicare and Medicaid Services, providing enhanced reimbursements rates
5269815
Medicare dual eligible


i.e., offer home and community-based services), and accordingly state Medicaid programs vary in scope. Dual-eligibles may be categorized as full-benefit or partial-benefit. Those with full benefits may receive the entire range of Medicaid benefits; those with partial-benefits do not receive Medicaid-covered services, but Medicaid covers their Medicare premiums or cost-sharing, or both. Partial benefit dual-eligible beneficiaries have limited income and assets, but their income and assets are not low enough to qualify them for
12066094
Medicare dual eligible


demonstration that is intended to further integrate the programs' services. CMS expects that the demonstration will decrease incentives for cost shifting and increase care coordination, resulting in improved care for beneficiaries and savings to Medicare and Medicaid. CMS projects that approximately 61 to 75 percent of savings will come from reductions in costly Medicare-covered services. Historically, one of the major challenges for the dually-eligible has been care coordination between Medicare and Medicaid. These two systems of care do not "talk to each other" systematically, so one
12066099
Telepsychiatry


federal requirements of efficiency, economy and quality of care. Since 1999, Medicare and Medicaid reimbursement for all kinds of telehealth services have expanded, requirements of providers have been reduced, and grants have been given to support telehealth program adoption. For 2014, the Center for Medicare (CMS) services does cover telemedicine services, including telepsychiatry in many areas. Telepsychiatry includes a variety of sub-specialties based on different contexts of service delivery. Psychiatric treatment of patients who are at home or in another private setting is called home-
18699940
Supplier-induced demand


a Center of Medicare and Medicaid Services Innovation Center (CMMI). This new Center fosters health care transformation by finding new ways to pay for and deliver care that improves quality and health while lowering costs. These innovative models of payment and care service delivery include care for Medicare, Medicaid and CHIP beneficiaries using an open, transparent, and competitive process. Other provisions of PPACA include the establishment of additional methods designed to move the current system from volume (fee for service) to value (outcomes based payment), such as
273392
Seema Verma


on Medicaid reform. She contributed to the report "A New Medicaid: A Flexible, Innovative and Accountable Future." Verma has also presented to the Medicaid Task Force of the Committee on Energy and Commerce and provided testimony before the U.S. House Energy Subcommittee on Health. On November 29, 2016, President-elect Donald Trump nominated Verma to serve as administrator of the Centers for Medicare and Medicaid Services, the Health Department agency that oversees Medicare, Medicaid, and the insurance markets. On March 13, 2017, the United
2800075
Contemporary Native American issues in the United States


care services provided at IHS facilities. A key distinction between IHS health services and insurance concerns the policy framework and logic of budgeting that underpins them. This produces a fundamentally different dynamic than that which drives programs such as Medicare or Medicaid, or especially private managed care plans. The IHS does what it can with the resources it is provided by Congress but is not obligated to provide the services required to meet the broader health needs of Native Americans in the pursuit of measurable outcomes. In 2008, Oregon initiated Medicaid to 10,000 of
18407750
Minimum Data Set


/Vocational Nurses, Therapists, Social Services, Activities and Dietary staff employed by the nursing home. MDS information is transmitted electronically by nursing homes to the MDS database in their respective states. MDS information from the state databases is captured into the national MDS database at Centers for Medicare and Medicaid Services (CMS). Sections of MDS (Minimum Data Set): The MDS is updated by the Centers for Medicare and Medicaid Services. Specific coding regulations in completing the MDS can be found in the Resident Assessment Instrument User’s Guide
17895243
Medical school


include rotations in clinical settings where students learn patient care firsthand. Today, clinical education is spread across all four years with the final year containing the most clinical rotation time. The Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) has published mandatory rules, obliging on all inpatient and outpatient teaching settings, laying down the guidelines for what medical students in the United States may do, if they have not completed a clerkship or sub-internship. These rules apply to
11092518
Electronic visit verification


the US Patent and Trademark website. In 1999, Thomas Hoyer, the senior and Chief Policy Maker for Post-Acute Regulations for the Center for Medicare and Medicaid Services (CMS, formerly HCFA) invited Michelle Boasten, RN to the Baltimore CMS offices to demonstrate EVV. At that meeting, he congratulated the invention and predicted that it would take two decades to see EVV legislation requiring EVV to be mandated as a practice within every Medicare and Medicaid agency providing publicly funded home visits to Medicare and Medicaid beneficiaries. Mr. Hoyer's
12301592
Marilyn Tavenner


Marilyn Barbour Tavenner (born May 31, 1951) is the former Administrator of the Centers for Medicare and Medicaid Services, an agency of the United States Department of Health and Human Services. She became Acting Administrator following the resignation of Dr. Donald M. Berwick in December 2011, after serving as the agency's Principal Deputy Administrator. Prior to her original appointment to the Centers for Medicare and Medicaid Services, she served as Secretary of Health and Human Resources in the Cabinet of Virginia Governor Tim Kaine from 2006 to 2010. From 1981
17597441
Medicare (United States)


is becoming more common because whereas the eligibility age for Medicare has remained at 65 per the 1965 legislation, the so-called Full Retirement Age for Social Security has been increased to 66 and will go even higher over time. Therefore, many people delay collecting Social Security but join Medicare at 65 and have to pay their Part B premium directly. Part C plans may or may not charge premiums (almost all do), depending on the plans' designs as approved by the Centers for Medicare and Medicaid Services. Part D
13012323
Matt Bevin


communications director said, "Matt has been consistent on the issue of Medicaid expansion from day one. What he has called for is repeal of Obama's Medicaid expansion by applying to [the Centers for Medicare and Medicaid Services] for 1115 waivers (as other states have successfully done) in order to better customize a solution to address the healthcare needs of the commonwealth." Bevin said he "strongly disagreed" with the Supreme Court's decision in "Obergefell v. Hodges" legalizing same-sex marriage, continuing "When the
7809300
Emergency medicine


(whereas hospitals are subject to penalties regardless of who brings the suit). Additionally, the Center for Medicare and Medicaid Services (CMS) can discontinue provider status under Medicare for physicians that do not comply with EMTALA. Liability also extends to on-call physicians that fail to respond to an ED request to come to the hospital to provide service. While the goals of EMTALA are laudable, commentators have noted that it appears to have created a substantial unfunded burden on the resources of hospitals and emergency physicians. As a result
8182921
Medicaid


. Eligibility is determined largely by income. The main criterion for Medicaid eligibility is limited income and financial resources, a criterion which plays no role in determining Medicare coverage. Medicaid covers a wider range of health care services than Medicare. Some people are eligible for both Medicaid and Medicare and are known as Medicare dual eligible or medi-medi's. In 2001, about 6.5 million Americans were enrolled in both Medicare and Medicaid. In 2013, approximately 9 million people qualified for Medicare and Medicaid. There are two general types of
11132679
Pete Stark


, Section 1395nn (42 U.S.C. 1395nn, "Limitation on certain physician referrals"). The Omnibus Budget Reconciliation Act of 1993 contained what is known as "Stark II" amendments to the original law. "Stark II" extended the "Stark I" provisions to Medicaid patients and to DHS other than clinical laboratory services. The Centers for Medicare and Medicaid Services has issued rules in the Federal Register to implement Stark Law, including a 2001 "Phase I" final rule, a 2004 "Phase II" interim final rule
18133518
Stark Law


. The Omnibus Budget Reconciliation Act of 1993 contained what is known as "Stark II" amendments to the original law. "Stark II" extended the "Stark I" provisions to Medicaid patients and to DHS other than clinical laboratory services. The Centers for Medicare and Medicaid Services has issued rules in the Federal Register to implement Stark Law, including a 2001 "Phase I" final rule, a 2004 "Phase II" interim final rule, and a 2007 "Phase III" final rule. Penalties for violations of Stark
19375167
Medicaid Drug Rebate Program


to be eligible for Medicaid coverage a rebate agreement must be signed with Centers for Medicare and Medicaid Services (CMS). Section 606 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA) amended Section 1927(a)(1) allowing states to have the option of different rebate effective dates. This section states that agreements to the rebate program that have been entered on or after November 29, 1999 may go into effect that day, and states option, any date after up to the first day of the quarter
15330796
Medigap


that is considered "creditable coverage" (i.e. that it meets four criteria defined by the Centers for Medicare and Medicaid Services); a Medigap policy with prescription drug coverage bought before mid-1992 may pay out as much as or more than a Medicare Part D plan. Medigap policies sold in Massachusetts, Minnesota, and Wisconsin with prescription coverage may also pay out as much as or more than Part D. Thus, individuals who qualify for the Qualified Medicare Beneficiary (QMB) program generally also do not need, and should not pay for
5485946
Public health emergency (United States)


319 of the Public Health Service Act. Under section 1135 of the Social Security Act, this declaration permits the state government to request waivers of certain Medicare, Medicaid and CHIP requirements from the Centers for Medicare and Medicaid Services (CMS) Regional Office. Examples include allowing Medicare health plan beneficiaries to go out of network, allowing critical access hospitals to take more than the statutorily mandated limit of 25 patients, and not counting the expected longer lengths of stay for evacuated patients against the 96-hour average. In the swine flu outbreak,
14902418
Medicare (United States)


% (17,057) were able to find a match. In comparison, match rates were 80.3% of osteopathic graduates, 53.9% of US citizen international medical school graduates, and 50.5% of non-US citizen international medical schools graduates. In 1977, the Health Care Financing Administration (HCFA) was established as a federal agency responsible for the administration of Medicare and Medicaid. This would be renamed to Centers for Medicare and Medicaid Services (CMS) in 2001. By 1983, the diagnosis-related group (DRG)
13012382
Oncology Care Model


which pays doctors and hospitals according to the number of procedures they do, toward value-based care, which pays based on what helps patients get better." This idea was advanced by the Affordable Care Act (ACA), which was signed into law on March 23, 2010. , OCM is being utilized by 190 healthcare provider groups, which include over 3,000 physicians in the United States. Along with Centers for Medicare and Medicaid Services, the payment system is accepted by 16 other health care coverage programs in the US
21045966
Manatt, Phelps & Phillips


policymakers and agencies, foundations, associations, and technology companies. In January 2016, the group added Chiquita Brooks-LaSure as a managing director. She is a former deputy center director and deputy director for policy and regulation at the Centers for Consumer Information and Insurance Oversight, Centers for Medicare and Medicaid Services. Other notable professionals include Deborah Bachrach, former director of New York State Medicaid and Deputy Commissioner of Health; Cindy Mann, former Deputy Administrator and Director of the U.S. Center for Medicaid and CHIP Services; Joel Ario,
20728576
Oncology Care Model


is not eliminating FFS altogether. Other criticisms include the lack of flexibility in allowing primary care physicians to conduct care as they see fit, the arbitrary nature of the time period or episode, the cumbersome burden of the reporting standards and how it penalizes practices for outcomes out of their control. The Affordable Care Act mandated the creation of the Center for Medicare and Medicaid Innovation (CMMI) as part of the Centers for Medicare and Medicaid Services (CMS). It was created to test new "payment and delivery system models"
21045968
Jerrold Hercenberg


. He also served in the Health Care Financing Administration in the Office of the CFO where he contributed many ideas toward savings to the Government and received several awards from the Administrator and Secretary of HHS. Eventually, he became a Senior Advisor to the Administrator of the Centers for Medicare and Medicaid Services (formerly HCFA). While serving as the Chief Regulator for managed care plans, he authored the Medicare regulations that created Medicare and Medicaid risk contracts for managed care plans in the early 1980s. He then left the government to become
2284088
Home medical equipment


is the advent of internet retailers who have lower operating costs so they often sell equipment for lower prices than local "brick and mortar", but lack the ability to offer in-home setup, equipment training and customer service. In all cases, however, there are strict rules and laws governing HME / DMEPOS suppliers that participate in Medicare and Medicaid programs. In addition to rules outlined the National Supplier Clearinghouse, of division of CMS (centers for Medicare and Medicaid), all Medicare DME suppliers must obtain and maintain accreditation
528191
Deemed status


Deemed status is a hospital accreditation for hospitals in the United States. For any organization to receive funding from Centers for Medicare and Medicaid Services (CMS), that organization must meet either the "Conditions for Coverage" or the "Conditions of Participation". These are a set of minimal standards which must be met before CMS will ever issue any reimbursement for Medicare and Medicaid Services. Two kinds of organizations can review a health care provider to check for compliance with these conditions - either a state level agency acting on behalf of
3543156
Medicare (United States)


standardized (though it is highly regulated by the Centers for Medicare and Medicaid Services). Plans choose which drugs they wish to cover (but must cover at least two drugs in 148 different categories and cover all or "substantially all" drugs in the following protected classes of drugs: anti-cancer; anti-psychotic; anti-convulsant, anti-depressants, immuno-suppressant, and HIV and AIDS drugs). The plans can also specify with CMS approval at what level (or tier) they wish to cover
13012315
Community health centers in the United States


revenues. In the same time period, grants for the uninsured decreased from 51% to 21%. In 2008, Medicaid payments had grown to account for 37% of all CHC revenues. In 1989, Congress created the Federally Qualified Health Center (FQHC) program, which established a preferential payment policy for health centers by requiring “cost-based” reimbursement for both Medicaid and Medicare. The policy designated FQHC services as a mandatory Medicaid service that all states must cover and reimburse on a cost-related basis, using
15424457
WellCare


Centers for Medicare and Medicaid Services (CMS) awarded WellCare a 4 out of 5 star rating for Plan Year 2018 Medicare plans for quality and care. In January 2018, WellCare announced the company will use the care management platform of VirtualHealth for population health management in 20 states. In January 2018, "Fortune" magazine named WellCare as one of World's Most Admired Companies. Since late 2012, WellCare has acquired many smaller Medicare & Medicaid supplement providers that has significantly expanded the company's national coverage areas: • November,
21040221
Intermediate Care Facilities for Individuals with Mental Retardation


DD individuals be ICF/MR certified. The Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) has issued regulations regarding seclusion and restraint. These regulations are called "Conditions of Participation (CoPs)." CoPs serve as the basis of survey activities for the purpose of determining whether a facility qualifies for a provider agreement under Medicare or Medicaid. There is a set of CoPs for each type of provider or supplier subject to certification. Providers must meet the applicable CoPs
150479
Medicare Sustainable Growth Rate


The Medicare Sustainable Growth Rate (SGR) was a method used by the Centers for Medicare and Medicaid Services (CMS) in the United States to control spending by Medicare on physician services. President Barack Obama signed a bill into law on April 16, 2015, the Medicare Access and CHIP Reauthorization Act of 2015, which ended use of the SGR. The measure went into effect in July 2015. Enacted by the Balanced Budget Act of 1997 to amend Section 1848(f) of the Social Security Act, the SGR replaced the "
14274566
Long-term care


traditional home health services and is payor of adult day care services. Currently, the US Centers for Medicaid and Medicare also have a user-directed option of services previously part of grey market industry. In the US, Medicaid is a government program that will pay for certain health services and nursing home care for older people (once their assets are depleted). In most states, Medicaid also pays for some long-term care services at home and in the community. Eligibility and covered services vary from state to state.
1110696
Health care quality


and expectations of quality. This complex situation creates a challenge because most often the measures of quality are not comparable across organizations and there are issues of transferability and merging across systems. Consequently, while measuring health care quality for these reasons, high quality longitudinal provides a substantive framework from which health services researchers can work. The Centers for Medicare and Medicaid Services (CMS) designs quality evaluations, collects quality, and manages funding for the central government Medicare and Medicaid programs. In 2001, CMS started multiple quality initiatives including, but
18408238
Ambulatory Payment Classification


APCs or Ambulatory Payment Classifications are the United States government's method of paying for facility outpatient services for the Medicare (United States) program. A part of the Federal Balanced Budget Act of 1997 made the Centers for Medicare and Medicaid Services create a new Medicare "Outpatient Prospective Payment System" (OPPS) for hospital outpatient services -analogous to the Medicare prospective payment system for hospital inpatients known as Diagnosis-related group or DRGs. This OPPS, was implemented on August 1, 2000. APCs are an outpatient prospective payment system applicable
16902744
Health information technology


HIT and provide technical assistance through various regional centers. The other $17 billion in incentives comes from Medicare and Medicaid funding for those who adopt HIT before 2015. Healthcare providers who implement electronic records can receive up to $44,000 over four years in Medicare funding and $63,750 over six years in Medicaid funding. The sooner that healthcare providers adopt the system, the more funding they receive. Those who do not adopt electronic health record systems before 2015 do not receive any federal funding. While electronic health records have potentially many advantages
13507405
Nursing home care in the United States


, audiologist).Conversion of group homes or community residences into intermediate care facilities was of great concern due to its "overly medical" nature and requirements not meeting the community needs of the population group. In the U.S. Centers for Medicare and Medicaid Services ensures that every Medicare and Medicaid beneficiary receives health care, both within health care settings such as nursing homes, and among health care settings during care transitions. The states in the US have health departments also responsible for oversight of the facilities and regulation. Home and community services are new developments
11490502
Financial gerontology


the subject. While a substantial part of long-term care financing is seen in individually-purchased long-term care insurance, a substantial proportion of older Americans believe they will pay for their long-term care, either services or nursing home residence, from Medicare. While Medicare's primary function is health insurance, under some circumstances it does pay for some long-term services. Further, Medicaid does pay for nursing home services under some circumstances. Both of these "under some circumstances" make the financial planning for
17719795
Azar v. Allina Health Services


Azar v. Allina Health Services, 587 U.S. ___ (2019) was a United States Supreme Court case in which the Court held the Department of Health and Human Services' new policy to retroactively reduce Medicare payments must be vacated due to the Department's failure to uphold its notice-and-comment obligations. In 2014, the Centers for Medicare and Medicaid Services (CMS) announced on its website the "Medicare fractions" for hospitals for the year 2012. As part of the posting, CMS declared that, when
19048761
Medicare Fraud Strike Force


The Medicare Fraud Strike Force is a multi-agency team of United States federal, state, and local investigators who combat Medicare fraud through data analysis and increased community policing. Launched in 2007, the Strike Force is coordinated by the United States Department of Justice and the Department of Health and Human Services. It combines the data-analysis capabilities of the Centers for Medicare and Medicaid Services, the investigative resources of the FBI, and the prosecutorial resources of the Department of Justice and the U.S. Attorneys' Offices. The Strike Force
14463927
Medicaid


services. Medicaid serves as the nation's primary source of health insurance coverage for low-income populations. States are not required to participate. Those that do must comply with federal Medicaid laws under which each participating state administers its own Medicaid program, establishes eligibility standards, determines the scope and types of services it will cover, and sets the rate of payment. Benefits vary from state to state, and because someone qualifies for Medicaid in one state, it does not mean they will qualify in another. The federal Centers for
11132655
Long-term care


Most often, eligibility is based on income and personal resources. Individuals eligible for Medicaid are eligible for community services, such as home health, but governments have not adequately funded this option for elders who wish to remain in their homes after extended illness aging in place, and Medicaid's expenses are primarily concentrated on nursing home care operated by the hospital-nursing industry in the US. Generally, Medicare does not pay for long-term care. Medicare pays only for medically necessary skilled nursing facility or home health care. However
1110697
Lori Swanson


the Centers for Medicare and Medicaid Services to investigate a large insurer that sold Medicare policies after receiving complaints about shoddy payment practices. In 2016, Swanson required Minnesota hospitals to refund rape survivors who were improperly charged for sexual assault exams. In 2017, after the Minnesota Legislature authorized for-profit HMOs do business in Minnesota, Swanson sounded the alarm about the need to protect the nonprofit assets held by Minnesota HMOs from being acquired by for-profit companies. After Swanson pushed for legislation to regulate such nonprofit conversions, the legislature enacted
16889423
Medicare (United States)


Part B benefits. The sponsor of a Part C plan could be an integrated health delivery system or spin-out, a union, a religious organization, an insurance company or other type of organization. Public Part C Medicare Advantage and other Part C health plans are required to offer coverage that meets or exceeds the standards set by Original Medicare but they do not have to cover every benefit in the same way (the plan must be actuarially equivalent to Original Medicare benefits). After approval by the Centers for Medicare and Medicaid
13012302
Medicare dual eligible


beneficiaries. Medicare is the primary payer for most services, but Medicaid covers benefits not offered by Medicare. Medicare coverage for dual-eligibles includes hospitalizations, physician services, prescription drugs, skilled nursing facility care, home health visits, and hospice care. Under Medicaid, states are required to cover certain items and services for dual-eligibles, including long-term nursing facility services and home health services. Although states are required to cover certain populations and services, they have the option to expand coverage beyond these mandatory levels (
12066093
EMBRACE Healthcare Reform Plan


through a menu of plans developed by the Board that is similar to the Medigap Plans A to N now offered through the Centers for Medicare & Medicaid Services. Although each insurance carrier does not have to offer all the plans listed on the menu, the plans that are offered by the insurance carrier must cover all the services stipulated by the Board. This assures that consumers (whether state governments, unions, employers or individuals) can compare the price of the plans and can be confident of the scope of their coverage. In
11883705
Hospital readmission


or operation during the index admission. Though the medical and health services literature has a variety of definitions of readmissions, the Centers for Medicare and Medicaid Services (CMS) has created a stricter set of criteria. CMS defines a hospital readmission as "an admission to an acute care hospital within 30 days of discharge from the same or another acute care hospital." It uses an "all-cause" definition, meaning that the cause of the readmission does not need to be related to the cause of the initial hospitalization.
370012
Better Medicare Alliance


The Better Medicare Alliance (BMA) is an American 501(c)(4) non-profit advocacy coalition that supports sustaining and improving Medicare Advantage, a private health insurance option available to Medicare beneficiaries. The BMA was one of the most prominent voices in the rate-setting process for MedIcare Advantage in 2015. The Centers for Medicare and Medicaid Services (CMS) proposed a 2016 average baseline rate decrease of .95% in February 2015. The BMA opposed this reduction with a campaign that included digital and print ads. The BMA was particularly concerned
12117885
Utah’s HCBS ID/RC Waiver


a large public demand for a more family-directed system of accessing services. Self-Administered services have allowed families to hire individuals they know to provide community care for loved ones. Much of the administration of services to qualifying recipients is done through contractual partnerships beginning at Medicaid's top agencies. Contractual arrangements continue down through those entities working directly with service recipients. The Utah Department of Health, Division of Health Care Financing (Utah's Medicaid administering agency) contracts with the Center for Medicare and Medicaid Services (the federal government
15086688
Federally Qualified Health Center


Omnibus Budget Reconciliation Act of 1990. FQHCs provide Medicare beneficiaries with preventive primary health services such as immunizations, visual acuity and hearing screenings, and prenatal and post-partum care. However, eyeglasses, hearing aids, and preventive dental services are not covered under the FQHC preventive primary services. A FQHC Prospective Payment System (PPS) was scheduled to be implemented in 2014. The Patient Protection and Affordable Care Act (ACA) mandates that the Centers for Medicare and Medicaid Services (CMS) collect and analyze health services data prior
16466279
Psychiatric advance directive


to prepare advance directives and—with certain caveats—that clinicians are obliged to follow these directives. Finally, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) requires behavioral health facilities to ask patients if they have PADs. The Centers for Medicare and Medicaid Services announced that patients have the right to formulate advance directives and to have hospital staff and practitioners who provide coercive interventions in the hospital comply with these directives. Hospitals out of compliance risk loss of Medicare and Medicaid revenue. Proponents of these directives believe thy of
13270263
American Kidney Fund


misunderstood the guidelines. In a statement on its website, the Kidney Fund called the article "factually incorrect and unfair," and said that they have never turned away a patient who was financially qualified to receive a grant, and that 40% of dialysis providers with patients receiving help don’t contribute anything to the Kidney Fund. The U.S. Centers for Medicare and Medicaid Services (CMS) charged that dialysis providers steered patients to private insurance companies, which cost patients more, rather than to Medicaid and Medicare, which cost patients
16766089
Medicaid


States and are administered by the U.S. Centers for Medicare & Medicaid Services in Baltimore, Maryland. Beginning in the 1980s, many states received waivers from the federal government to create Medicaid managed care programs. Under managed care, Medicaid recipients are enrolled in a private health plan, which receives a fixed monthly premium from the state. The health plan is then responsible for providing for all or most of the recipient's healthcare needs. Today, all but a few states use managed care to provide coverage to a significant proportion of Medicaid
11132651
Medicare Advantage


program except for grandfathered beneficiaries. The out-of-balance Employer Group plan program was cut back beginning in 2017. On an absolute basis, in 2017 Medicare spent 1% less on Medicare Advantage and other Part C beneficiaries per person than they did per person on Medicare beneficiaries under FFS Medicare. In 2016 the difference in parity on an absolute basis was 4% less per person on Part C. As a result of these 2009/2010 changes and other administrative choices by Centers for Medicare and Medicaid Services CMS, per-person expenditures
13682746
Beatrice, Nebraska


institution's name was changed to the current Beatrice State Developmental Center. A 2006 investigation by the federal Centers for Medicare and Medicaid Services revealed a number of severe deficiencies at the Center; after two years of appeals, the Center lost its Medicaid certification in 2009. As of 2011, the Center served about 175 clients. The majority had been diagnosed with "severe" or "profound" retardation; nearly all suffered from two or more other disabling conditions. Beatrice is located at (40.268449, -96.743192). According to the
3049249
Lung cancer screening


Services Task Force (USPSTF) and the Centers for Medicare and Medicaid Services (CMS) concur and endorse low-dose, computerized tomographic screening for individuals at high-risk of lung cancer. Research has found that regular early screening with two other clinically available tests – sputum cytology and chest radiograph (CXR) — does not have an overall benefit. There is evidence suggesting that regular screening of high-risk smokers and former smokers may reduce the mortality in this particular group of people. More research is necessary to determine the
1961524
Zone Program Integrity Contractor


The Zone Program Integrity Contractor (ZPIC) is an entity established in the United States by the Centers for Medicare & Medicaid Services (CMS) to combat fraud, waste and abuse in the Medicare program. As a result of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which established seven zones throughout the United States for the purpose of processing Medicare claims, CMS created ZPICs to more effectively protect the Medicare program. ZPICs replaced Program Safeguard Contractors (PSC), which had been established by the Health Insurance
4328382
Association of American Physicians and Surgeons


make mistakes". It opposed the Social Security Act of 1965 which established Medicare and Medicaid and encouraged member physicians to boycott Medicare and Medicaid. The organization requires its members to sign a "declaration of independence" pledging that they will not work with Medicare, Medicaid, or even private insurance companies. AAPS opposes mandated evidence-based medicine and practice guidelines, opposes abortion and over-the-counter access to emergency contraception and opposes electronic medical records. The AAPS opposes gun control and does not recognize handgun violence as a public
14188644
Patient Protection and Affordable Care Act


that did "not" expand Medicaid had a 14.1% uninsured rate, among adults aged 18 to 64. Following the Supreme Court ruling in 2012, which held that states would not lose Medicaid funding if they didn't expand Medicaid under the ACA, several states rejected expanded Medicaid coverage. Over half of the national uninsured population lived in those states. In a report to Congress, the Centers for Medicare and Medicaid Services (CMS) estimated that the cost of expansion was $6,366 per person for 2015, about 49 percent
9602011
Centers for Medicare and Medicaid Services


), quality standards in long-term care facilities (more commonly referred to as nursing homes) through its survey and certification process, clinical laboratory quality standards under the Clinical Laboratory Improvement Amendments, and oversight of HealthCare.gov. President Lyndon B. Johnson signed the Social Security Amendments on July 30, 1965, establishing both Medicare and Medicaid. Arthur E. Hess, a deputy commissioner of the Social Security Administration, was named as first director of the Bureau of Health Insurance in 1965, placing him as the first executive in charge of the
2715995
Physician Payments Sunshine Act


The Physician Payments Sunshine Act is a 2010 United States healthcare law to increase transparency of financial relationships between health care providers and pharmaceutical manufacturers. The Sunshine Act requires manufacturers of drugs, medical devices, biological and medical supplies covered by the three federal health care programs Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) to collect and track all financial relationships with physicians and teaching hospitals and to report these data to the Centers for Medicare and Medicaid Services (CMS). The goal of the law is to increase
5310738
Medicare Part D coverage gap


-pocket costs and a moderate increase in medication utilization among Medicare beneficiaries, although there was no evidence of improvement in emergency department use, hospitalizations, or preference-based health utility for those eligible for Part D. The dollar limits increase yearly. The following table shows the Medicare benefit breakdown (including the doughnut hole) for 2019. The costs shown in the table above represent the 2019 defined standard Medicare Part D prescription drug plan parameters released by the Centers for Medicare and Medicaid Services (CMS) in April 2017. Individual Medicare
20554896
Medicare Physician Group Practice (PGP) Demonstration


Year 2 added measures related to congestive heart failure and coronary artery disease, and Year 3 added preventive care measures related to hypertension and cancer screening. Source: Medicare Physician Group Practice Demonstration: Physicians Groups Continue to Improve Quality and Generate Savings Under Medicare Physician Pay-for-Performance Demonstration, Centers for Medicare & Medicaid Services, Department of Health & Human Services, July 2011. In the first year of participation, PGPs invested $1.7 million on average. Some additional funding was provided by CMS to offset the high start-
158541
Scott Gottlieb


the National Coalition for Cancer Survivorship. He has also worked as a senior policy advisor to the Administrator at the Centers for Medicare & Medicaid Services, where he worked on implementation of the Medicare Prescription Drug, Improvement, and Modernization Act and the Medicare Part D drug benefit, and helped advance the agency's coverage policies related to new medical technology. He has served as an advisor to Cancer Commons. Before first joining the FDA, and in between each of his three tours of government service, Gottlieb was a resident fellow at
12925834
Bundled payment


included in both the Patient Protection and Affordable Care Act and the Affordable Health Care for America Act. The former bill establishes a national Medicare pilot program starting in 2013 with possible expansion in 2016, which is consistent with the Obama proposal. The latter bill requires "a plan to reform Medicare payments for post-acute services, including bundled payments." 450 healthcare organizations participated in the Bundled Payments for Care Improvement (BPCI) initiative held by the Centers for Medicare & Medicaid Services. The program tested the ability of bundling payments
17577047
Metropolitan Area Commuter System


more outlying destinations. Only the Gray Line does not connect to the Transit Center or overlap with other routes, requiring a transfer from either University of Alaska Fairbanks (UAF) or Fred Meyer East to connect to other routes. No service is provided on Sundays and holidays. Some routes also lack service on Saturdays. Reduced fare rides are offered to youth (ages 6 to 18), individuals with Medicare or Medicaid cards, active duty military servicemembers and their dependents, and those with qualifying disabilities. Free fare rides are offered
6439844
Riverview Psychiatric Center


mental health patients. The federal Centers for Medicare and Medicaid Services announced on October 2, 2013, that Riverview's Medicare Provider Agreement would be terminated, ending the roughly $20 million in federal funds the Center receives a year, due to numerous problems at the Center. These include contentions that the facility is overcrowded, inadequately staffed, and has used improper methods to control patients, including the use of Tasers. DHHS Commissioner Mary Mayhew stated that the State would appeal the decision, and that if it stood, the Center
12587468
Clinical Laboratory Improvement Amendments


descriptions listed for scores of 1 and 3. Criteria for categorization: Centers for Medicare and Medicaid Services (CMS) has the primary responsibility for the operation of the CLIA Program. Within CMS, the program is implemented by the Center for Medicaid and State Operations, Survey and Certification Group, and the Division of Laboratory Services. The CLIA Program is funded by user fees collected from approximately 200,000 laboratories, most located in the United States. Under CLIA, tests and test systems that meet risk, error, and complexity requirements are
21233022
Medicaid


low-asset people who fall into one of these eligibility categories "pay for some or all of their medical bills." While Congress and the Centers for Medicare and Medicaid Services (CMS) set out the general rules under which Medicaid operates, each state runs its own program. Under certain circumstances, an applicant may be denied coverage. As a result, the eligibility rules differ significantly from state to state, although all states must follow the same basic framework. As of 2013, Medicaid is a program intended for those
11132685
Arizona Health Care Cost Containment System


The Arizona Health Care Cost Containment System (AHCCCS) is the name of the Medicaid program in the state of Arizona. As with all Medicaid programs, it is a joint program between the state and the Centers for Medicare and Medicaid Services (CMS). It became the final such state Medicaid program to implemented under Title XIX (as all other states had previously created their own programs) when it began in October 1982 as a section 1115 demonstration project. The program acronym AHCCCS is frequently pronounced like the word "access.
6201778
Patient navigators


and training, the Centers for Medicare and Medicaid Services (CMS) require that all navigator and non-navigator individuals or entities seeking to facilitate public enrollment in plans disclose information that may result in a conflict of interest to exchanges and consumers. This information includes: If a navigator or non-navigator does have a conflict of interest while serving in their respective roles, they are to provide a plan for mitigating these conflicts. Failure to submit a mitigation plan will result in the inability to serve as a navigator and promote ACA
6077938
Oregon Health Authority


member Oregon Health Policy Board. The Health Authority director is Patrick Allen. Its first director was Bruce Goldberg, M.D., former director of the Oregon Department of Human Services. The mission of the Oregon Health Authority is helping people and communities achieve optimum physical, mental and social well-being through partnerships, prevention and access to quality, affordable health care. OHA is responsible for the state's Medicaid program, which is operated under a Medicaid Demonstration waiver from the U.S. Centers for Medicare and Medicaid Services (CMS), known
4804568
Accreditation Association for Ambulatory Health Care


The Accreditation Association for Ambulatory Health Care (AAAHC), founded in 1979, is an American organization which accredits ambulatory health care organizations, including ambulatory surgery centers, office-based surgery centers, endoscopy centers, and college student health centers, as well as health plans, such as health maintenance organizations and preferred provider organizations. AAAHC has been granted "deemed status" to certify ambulatory surgery centers for Medicare by the Centers for Medicare and Medicaid Services. In 2009, the AAAHC added the Medical home to the types of organizations
8163381
Developmental-Behavioral Screening and Surveillance


is guaranteed under the Individuals with Disabilities Education Act (IDEA) beginning at birth. Because almost all children receive health care, primary care providers (e.g., nurses, family medicine physicians, and pediatricians) are charged by their various professional societies, by the Centers for Medicare and Medicaid Services, the Centers for Disease Control, and by IDEA to search for difficulties and make needed referrals. So what are the methods used to detect children with difficulties and how effective are they? Screening tools are brief measures designed to sort those
20532930
Federally Qualified Health Center


of the Department of Health and Human Services (HHS) to meet the requirements for receiving a grant based on the Health Resources and Services Administration recommendations. Also, FQHC Look-Alikes receive cost-based reimbursement for their Medicaid services, but do not receive malpractice coverage under FTCA or a cash grant. Look-Alikes also qualify as health professional shortage areas (HPSA) automatically. FQHC benefit under Medicare became effective October 1, 1991, when Section 1861(aa) of the Social Security Act was amended by Section 4161 of the
16466278
Accountable care organization


Medicare Shared Savings Program (PPACA Section 3201) on March 31, 2011. These guidelines stipulate the necessary steps that physician, hospital and other health care provider groups must complete to become an ACO. Section 3022 of the Patient Protection and Affordable Care Act (ACA) authorized the Center for Medicare and Medicaid Services (CMS) to create the Medicare Shared Savings program (MSSP), which allowed for the establishment of ACO contracts with Medicare by January 2012. ACA intended for the MSSP to promote "accountability for a patient population
1109355
Recovery Audit Contractor


directed the DHHS to conduct a three-year demonstration program to detect and correct improper payments in the Medicare FFS program. DHHS, through its Centers for Medicare and Medicaid Services (CMS) branch, began the program in 2005, using Recovery Audit Contractors to perform the actual work of reviewing, auditing, and identifying improper Medicare payments. At the inception of the program, it focused on Medicare payments in the states of California, New York, and Florida. The program eventually expanded to Massachusetts and South Carolina before ending in
16755116