A federal agency within the United States Department of Health and Human Services (HHS) responsible for administering the nation’s major healthcare programs. CMS oversees Medicare, which provides healthcare coverage for individuals aged 65 and older, as well as certain younger people with disabilities, and Medicaid, which offers coverage to low-income individuals and families.
A federal health insurance program primarily for people aged 65 and older, regardless of income, and for younger people with disabilities or End-Stage Renal Disease (ESRD). Medicare is divided into several parts, including Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage plans), and Part D (prescription drug coverage).
A joint federal and state program that provides health coverage to eligible low-income individuals, including children, pregnant women, elderly adults, and people with disabilities. While Medicaid is jointly funded by the federal and state governments, each state has its own specific guidelines and benefits.
Refers to the range of medical services covered by insurance plans, including doctor visits, hospital stays, prescription medications, preventive care, and more. CMS plays a pivotal role in setting standards for healthcare coverage and ensuring that Medicare and Medicaid beneficiaries have access to necessary healthcare services.
The process through which healthcare providers receive payment for services rendered to Medicare and Medicaid beneficiaries. CMS establishes reimbursement rates for different services and procedures, often based on factors such as geographic location, provider specialty, and Medicare/Medicaid guidelines.
Efforts led by CMS to enhance the quality and efficiency of healthcare services provided to Medicare and Medicaid beneficiaries. This may include promoting preventive care, reducing hospital readmissions, implementing electronic health records, and incentivizing value-based care models that prioritize outcomes over volume of services.
Payment structures designed to incentivize healthcare providers to deliver high-quality care while controlling costs. Examples include accountable care organizations (ACOs), bundled payments, and pay-for-performance programs, which tie reimbursement to quality metrics and patient outcomes rather than the volume of services provided.
CMS works to combat fraud, waste, and abuse in the Medicare and Medicaid programs through various initiatives, including auditing, data analytics, provider education, and enforcement actions. This helps safeguard taxpayer dollars and ensures that beneficiaries receive appropriate and legitimate healthcare services.
CMS develops and implements regulations, policies, and guidelines related to Medicare and Medicaid, covering areas such as coverage determinations, payment methodologies, beneficiary eligibility criteria, and program integrity. These regulations help govern the operation of the healthcare programs and ensure compliance with federal laws.
CMS provides information and resources to help Medicare and Medicaid beneficiaries make informed decisions about their healthcare coverage and navigate the complexities of the healthcare system. This includes educational materials, online tools, helplines, and outreach campaigns aimed at promoting health literacy and empowering consumers to advocate for their healthcare needs.