In the United States, Medicaid is a government program that provides health insurance for adults and children with limited income and resources. The program is partially funded and primarily managed by state governments, which also have wide latitude in determining eligibility and benefits, but the federal government sets baseline standards for state Medicaid programs and provides a significant portion of their funding.
Medicare is a federal health insurance program in the United States for people age 65 or older and younger people with disabilities, including those with end stage renal disease and amyotrophic lateral sclerosis. It was begun in 1965 under the Social Security Administration and is now administered by the Centers for Medicare and Medicaid Services (CMS).
The Centers for Medicare & Medicaid Services (CMS) 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), quality standards in long-term care facilities through its survey and certification process, clinical laboratory quality standards under the Clinical Laboratory Improvement Amendments, and oversight of HealthCare.gov. CMS was previously known as the Health Care Financing Administration (HCFA) until 2001.
The Medicare Prescription Drug, Improvement, and Modernization Act, also called the Medicare Modernization Act or MMA, is a federal law of the United States, enacted in 2003. It produced the largest overhaul of Medicare in the public health program's 38-year history.
A subcontractor is a person or business which undertakes to perform part or all of the obligations of another's contract, and a subcontract is a contract which assigns part of an existing contract to a subcontractor.
Dual-eligible beneficiaries refers to those qualifying for both Medicare and Medicaid benefits. In the United States, approximately 9.2 million people are eligible for "dual" status. Dual-eligibles make up 14% of Medicaid enrollment, yet they are responsible for approximately 36% of Medicaid expenditures. Similarly, duals total 20% of Medicare enrollment, and spend 31% of Medicare dollars. Dual-eligibles are often in poorer health and require more care compared with other Medicare and Medicaid beneficiaries.
Medicare Part D, also called the Medicare prescription drug benefit, is an optional United States federal-government program to help Medicare beneficiaries pay for self-administered prescription drugs. Part D was enacted as part of the Medicare Modernization Act of 2003 and went into effect on January 1, 2006. Under the program, drug benefits are provided by private insurance plans that receive premiums from both enrollees and the government. Part D plans typically pay most of the cost for prescriptions filled by their enrollees. However, plans are later reimbursed for much of this cost through rebates paid by manufacturers and pharmacies.
Tricare is a health care program of the United States Department of Defense Military Health System. Tricare provides civilian health benefits for U.S Armed Forces military personnel, military retirees, and their dependents, including some members of the Reserve Component. Tricare is the civilian care component of the Military Health System, although historically it also included health care delivered in military medical treatment facilities.
In the healthcare industry, pay for performance (P4P), also known as "value-based purchasing", is a payment model that offers financial incentives to physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures. Clinical outcomes, such as longer survival, are difficult to measure, so pay for performance systems usually evaluate process quality and efficiency, such as measuring blood pressure, lowering blood pressure, or counseling patients to stop smoking. This model also penalizes health care providers for poor outcomes, medical errors, or increased costs. Integrated delivery systems where insurers and providers share in the cost are intended to help align incentives for value-based care.
A rural health clinic (RHC) is a clinic located in a rural, medically under-served area in the United States that has a separate reimbursement structure from the standard medical office under the Medicare and Medicaid programs. RHCs were established by the Rural Health Clinic Services Act of 1977, . The RHC program increases access to health care in rural areas by
- creating special reimbursement mechanisms that allow clinicians to practice in rural, under-served areas
- increasing utilization of physician assistants (PA) and nurse practitioners (NP)
The Medicare Quality Cancer Care Demonstration Act of 2009 in the United States is a federal program designed to improve the quality of cancer care for elderly individuals covered by Medicare, with a particular focus on approximately 45% of cancer patients who are beneficiaries of the Medicare program.
Bundled payment is the reimbursement of health care providers "on the basis of expected costs for clinically-defined episodes of care." It has been described as "a middle ground" between fee-for-service reimbursement and capitation, given that risk is shared between payer and provider. Bundled payments have been proposed in the health care reform debate in the United States as a strategy for reducing health care costs, especially during the Obama administration (2009–2016). Commercial payers have shown interest in bundled payments in order to reduce costs. In 2012, it was estimated that approximately one-third of the United States healthcare reimbursement used bundled methodology.
An accountable care organization (ACO) is a healthcare organization that ties provider reimbursements to quality metrics and reductions in the cost of care. ACOs in the United States are formed from a group of coordinated health-care practitioners. They use alternative payment models, normally, capitation. The organization is accountable to patients and third-party payers for the quality, appropriateness and efficiency of the health care provided. According to the Centers for Medicare and Medicaid Services, an ACO is "an organization of health care practitioners that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it".
Connolly, LLC is a private, global-recovery audit firm with more than 1,200 employees, and two divisions Global Retail and Healthcare. The company is headquartered in Wilton, Connecticut.
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 Portability and Accountability Act of 1996.
Recovery auditing is the systematic process of reviewing disbursement transactions and the related supporting data to identify and recover various forms of over payments and under-deductions to suppliers. In other words, it is the recovery of lost money.
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), (H.R. 2, Pub. L. 114–10 (text)(PDF)) commonly called the Permanent Doc Fix, is a United States statute. Revising the Balanced Budget Act of 1997, the Bipartisan Act was the largest scale change to the American health care system following the Affordable Care Act in 2010.
Seema Verma is a General Manager and Executive Vice President at Oracle Corporation. She is the former administrator of the Centers for Medicare & Medicaid Services in the Donald Trump administration. During her tenure, she was involved in efforts to repeal the Affordable Care Act, as well as reduce Medicaid benefits and increase restrictions on Medicaid. She was embroiled in ethics and legal controversies related to her use of taxpayer money while in office.
The Oncology Care Model (OCM) is an episode-based payment system developed by the Center for Medicare and Medicaid Innovation. The multipayer model is designed for discrete instances of care, especially those involving chemotherapy, which triggers the six-month episode. The program combines fee-for-service (FFS) payments for established services, monthly payments for additional care under a structured guideline, and performance-based payments weighed against quality metrics and benchmarks.
Maine Community Health Options v. United States, 590 U.S. ___ (2020), was a United States Supreme Court case involving the expired Risk Corridors program of the Patient Protection and Affordable Care Act (ACA), through which the Department of Health and Human Services (DHHS) mitigated losses of unprofitable healthcare plans through the profits of the profitable plans during the first three years of the program. Congress had passed legislation as riders in appropriations bills, which prevented the government from making payments to the unprofitable plans. Several of the insurers went bankrupt from the lack of payment, and multiple insurers sued the government to recover their funds on the basis the risk corridor was a commitment to be paid. The Federal Circuit Appeals Court rejected those claims, concluding that the subsequent appropriation riders absolved the government of its responsibility to pay. In the 8–1 decision that consolidated three of the subsequent appeals, the Supreme Court ruled that Congress's riders did not cancel the government's obligation under the ACA to pay the full amount to the unprofitable plans, and that the insurers had properly sought relief through a Tucker Act action in the Court of Federal Claims.
