J.Sena-HCA320-A8..docx - 1 Medicaid and Medicare Programs...

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1 Medicaid and Medicare Programs Jennifer Sena Aspen University HCA320- Healthcare Policy and Economics Professor Stacy Severin MSN, Ed August 30, 2021
2 Medicaid and Medicare Programs According to An Overview of Medicare (2019), Medicare is a health insurance program created by the federal government in 1965 and is open to individuals older than 65 years of age, regardless of their economic status, medical records, or health situation. The federal government further extended the program in 1972 to include disabled individuals below the age of 65. Today, Medicare represents a crucial role in implementing wellness and financial protection for 60 million seniors and young individuals with disabilities. The program helps compensate for many health care assistances, including hospitalizations, doctor visits, prescription drugs, preventive services, specialized nursing facilities, home care, and hospice care. According to the Centers for Medicare and Medicaid Services (2018), Medicaid is a system of state programs administered by the state government that support comprehensive national guidelines placed by federal laws, regulations, and policies. Health care coverage for low-income families, pregnant women, and children; however, eligibility varies from state to state. Medicaid is the largest payer for mental health services, long-term care services, and childbirth services in the United States. Quality Improvement Organizations According to the Centers for Medicare and Medicaid Services (2020), the Quality Improvement Organization (QIO) program is one of the most extensive federal programs dedicated to improving the quality of health for Medicare beneficiaries. It is an integral part of the US Department of Health and Human Services (HHS) national strategy for quality services to provide better care and service. Under the law, the mission of the QIO program is to improve the effectiveness, efficiency, economy, and quality of services provided to health insurance beneficiaries. Based on this legal fee and CMS planning experience, CMS determined that the primary functions of the QIO program are providing health at a lower cost, improving the quality
3 of care for beneficiaries, and ensuring that Medicare only pays for services and goods that are reasonable and necessary. Centers for Medicare and Medicaid Services (2020) states that the Quality Improvement Organization (QIO) is a group of health quality experts, physicians, and consumers to improve the quality of care provided to Medicare patients. Under the guidance of the Medical Insurance and Medicaid Service Center, there are two types of QIO operations to support the QIO program: the Beneficiary and Family Center Care (BFCC), which helps medical insurance beneficiaries utilize high-quality healthcare. They manage all beneficiary complaints and care quality reviews to ensure the consistency of the review process, taking into account local factors that are important to beneficiaries and their families. They also deal with cases where the beneficiary wishes to ask a healthcare provider to be discharged or stop other services. In addition, they are

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