Health Care Delivery and Financing: Centers for Medicare and Medicaid Services

The Centers for Medicare and Medicaid Services, or CMS, is critical in administering the Medicare and Medicaid programs that provide millions of Americans with basic health insurance. The World of Medicare, an online program, raises two significant challenges. First is the incredibly intricate Parts A and B payment system of Medicare, which consists of Part B for medical insurance and Part A for hospital insurance. Part A covers inpatient hospital care. In contrast, Part B extends coverage to outpatient care, physician, and preventive services (Klees et al., 2020). Conversely, Medicare beneficiaries can obtain their Medicare benefits from private insurance providers under the Medicare Advantage Plan, increasing the flexibility of the traditional Medicare system (Klees et al., 2020).

Notably, the impact of these issues on my future practice as an advanced practice nurse (APN) is substantial. First, understanding the complex coverage under Medicare Parts A and B is essential for providing accurate billing and advising patients on their healthcare options. Since Medicare often serves as a primary payer, knowing the limitations and coverage gaps of Parts A and B will help me guide patients through treatment choices and manage expectations, particularly for services not covered by Medicare (El-Nahal, 2020). Additionally, with the growing enrollment in Medicare Advantage Plans, I will need to navigate the network restrictions and understand the supplementary benefits these plans offer. This knowledge is critical for providing holistic care and ensuring that patients receive the appropriate services while staying within the guidelines of their insurance plan (Klees et al., 2020).

Additionally, as noted by Bhati et al. (2023), CMS continues to face significant obstacles, such as equitable access to care, especially in underserved areas, affordability in the health insurance marketplace, and cost controls while ensuring high-quality care versus the rising healthcare demands. Further, organizations like the National Academy of Medicine, the Kaiser Family Foundation, and the American Public Health Association are key players in facilitating policy evaluation and development. Subsequently, as noted by Sriram and Vikash (2023), interest groups have an equally important influence, as they promote rulemaking that will eventually affect healthcare providers and patients.

References

Bhati, D., Deogade, M. S., & Kanyal, D. (2023). Improving Patient Outcomes through effective Hospital Administration: A comprehensive review. Cureus, 15(10). https://doi.org/10.7759/cureus.47731

El-Nahal, W. (2020). An Overview of Medicare for Clinicians. Journal of General Internal Medicine, 35(12), 3702–3706. https://doi.org/10.1007/s11606-019-05327-6

Klees, B., Ii, E., & Curtis, C. (2020). BRIEF SUMMARIES Of MEDICARE & MEDICAID Title XVIII and Title XIX of The Social Security Act as of November 13, 2020 Prepared by. https://www.cms.gov/files/document/brief-summaries-medicare-medicaid-november-13-2020.pdf

Sriram, V., & Vikash Ranjan Keshri. (2023). Interest Groups and Health Facility Regulation – Future Directions for Health Policy and Systems Research; Comment on “What Lies Behind Successful Regulation? A Qualitative Evaluation of Pilot Implementation of Kenya’s Health Facility Inspection Reforms.” International Journal of Health Policy and Management, 23(1). https://doi.org/10.34172/ijhpm.2023.7826

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The focus of this Discussion Board is to gain a better understanding of the Centers for Medicare and Medicaid Services (CMS). This knowledge will be of value to you either as an advanced practice nurse or as a leader who can share this knowledge with others.

Discussion Board Items:

1. Identify two key issues you learned from the online program, The World of Medicare. (See Attached)
2. Explain the impact of the two issues you identified in #1 on your future practice as an advanced practice nurse.
3. Describe two challenges that CMS faces in managing the health insurance marketplace.
4. List and describe three organizations that support policy evaluating activity.
5. Describe the role of interest groups in the rulemaking process. Be specific in this response.

Reminder: Complete the CMS module, the World of Medicare, and post to assignment.

Health Care Delivery and Financing: Centers for Medicare and Medicaid Services

Readings:

• Read Chapter 8, 9 and Appendices 1, 2, and 3 from your textbook: Meacham, M. R. (2021). Longest’s Health policymaking in the United States (7th ed.).
• Centers for Medicare and Medicaid Services (CMS) Brief Summaries of Medicare and Medicaid:
  • https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareProgramRatesStats/SummaryMedicareMedicaid
  • https://www.cms.gov/files/document/brief-summaries-medicare-medicaid-november-13-2020.pdf
• InfusionCenters (2020). Medicare & Medicaid 101 video: https://www.youtube.com/watch?v=KIh29MJOXhc