Signature Assignment-Medicare and Medicaid

Signature Assignment-Medicare and Medicaid

Introduction

Medicare and Medicare were signed into law in 1965 (CMS, 2020). Since their enactment, these two programs have offered healthcare insurance to millions of individuals in the United States, protecting their health and improving their health. These programs were meant to offer insurance for those who did not have any health insurance coverage, but they have evolved over the years to cover many Americans. This has ensured that Americans can access quality and affordable healthcare services whenever they need them. Our assignment writing help is at affordable prices to students of all academic levels and academic disciplines.

These two programs have transformed the healthcare delivery industry for the last fifty years. More ways have to be devised to ensure that these programs keep operating to build a stronger and more affordable healthcare system based on affordability, safety, and quality. These two programs are run by the federal government. Medicaid serves individuals from low-income families, including adults, pregnant women, the disabled, and children (CMS, 2020). There is no age limit for individuals covered in Medicaid. On the other hand, Medicare covers individuals over 65 years, provided they meet the predefined qualifications (CMS, 2020). Healthcare professionals must be aware of these two programs and how they affect the cost of healthcare. They must thus offer quality healthcare services to cover Medicaid and Medicare beneficiaries.

Quality Improvement Organizations (QIO)

A QIO is a group of clinicians, healthcare quality experts, and healthcare consumers organized to enhance the quality of healthcare offered to beneficiaries of Medicare (CMS, 2020). The QIO Program is a federal program with the aim of offering better and quality healthcare services at low costs. QIO programs aim to enhance the effectiveness, cost, and quality of healthcare services offered to individuals enrolled in Medicare. The QIO program has several core functions, including improving healthcare quality for Medicare beneficiaries and protecting Medicare Trust Fund integrity by ensuring that the services and goods paid for by Medicare are necessary, appropriate, and offered in the appropriate settings (CMS, 2020). Finally, the QIO program protects Medicare beneficiaries by promptly addressing the complaints that the consumers may have (CMS, 2020).

There are two types of QIO that support the QIO programs under the CMS. The first program is Beneficiary and Family-Centered Care (BFCC)-QIOs. BFCC-QIOs help individuals enrolled in Medicare by managing all their complaints and reviewing healthcare quality to ensure consistency during the review (CMS, 2020). BFCC-QIO also considers factors relevant to Medicare beneficiaries. In short, BFCC-QIO ensures that these consumers exercise their rights to high-quality care services. BFCC-QIO also handles cases in which Medicare beneficiaries appeal the decisions of their healthcare providers to discontinue some healthcare services or discharge them from healthcare facilities (CMS, 2020).

The second program is Quality Innovation Network (QIN)-QIOs. QIN-QIS connects healthcare providers, Medicare beneficiaries, and communities in initiatives guided by healthcare data. The data is used to enhance the safety of consumers, better coordination of post-discharge care, improve community health and enhance the quality of healthcare services (CMS, 2020). QIN-QIOs ensure the quick spread of quality healthcare services while considering local and cultural factors

Medicare and Medicaid Beneficiaries

Medicaid Eligibility

For an individual to qualify for coverage by Medicaid, they must make a written request and meet the predetermined qualification requirements. Even though Medicaid is a federal program, different states have additional options. For one to be eligible for Medicaid, one must be in one of the eligible groups. Medicaid covers individuals from low-income families, pregnant women, children, and people with disabilities who have additional security incomes (Currie & Duque, 2019).

Modified adjusted gross income (MAGI) is used to determine eligible individuals for Medicaid coverage (Medicaid.gov, n.d.). Another factor used to determine eligibility is financial aspects. However, individuals who are disabled or elderly are exempted from MAGI-based screening for Medicaid eligibility (Medicaid.gov, n.d.). When determining Medicaid financial eligibility, MAGI uses a taxable profit and tax return relationship (Medicaid.gov, n.d.). There are other non-financial factors used in determining Medicaid eligibility. The individual must be a permanent resident or have met the relevant qualifications to make them a legal resident in the United States (Medicaid.gov, n.d.). Other qualifications are pregnancy, age, and paternity. They must also be residents of the state offering Medicaid coverage (Medicaid.gov, n.d.).

Medicare Eligibility

Individuals can be eligible for hospital insurance without premiums if they are 65 years or older or if their partner has worked and paid Medicare taxes for no less than ten years (CMS, 2020). Individuals are eligible for Medicare if they are eligible or receive social security, are eligible or receive Railroad Retirement benefits, or if they or their partner worked in a Medicare-covered government job (CMS, 2020). An individual gets Medicare Part B if they are eligible for hospital insurance. Medicare Part B, however, requires monthly payments of premiums (CMS, 2020).

An individual can also be eligible for Medicare if they never worked, but they may pay a premium for the hospital insurance. The person must be a citizen of the United States aged over sixty-five years, and the person or their spouse did not pay Medicare taxes for no less than ten years (). These persons will file for an enrollment application, and they must purchase both Medicare Part A and Part B. Individuals under sixty-five years are also eligible for coverage under Medicare. These individuals must have received the Social Security Disability Insurance (SSDI) for two years, have an end-stage renal disease (ESRD), or have Lou Gehrig’s disease (CMS, 2020). An individual is eligible for Medicare Part C if they are enrolled in Part A and Part B. Medicare Part C is available in their area, and they do not have ESRD (CMS, 2020). For an individual to be eligible for Medicare Part D, they must be enrolled in Part A only or both Part A and Part (). They must, however, not be enrolled in Medicare Part C (CMS, 2020)

Modifications to Cover Vulnerable Populations

There are disparities in access to healthcare services in the United States, with the vulnerable populations immensely affected. It is thus critical that the Federal and state governments expand Medicare and Medicaid coverage for vulnerable populations. One such modification would be to reduce the age limit for beneficiaries of Medicare to fifty-five years. By expanding coverage to individuals aged fifty-five years, the cost of healthcare services will be reduced. This would force private insurance companies to reduce their premiums. By putting cost limits on premiums and reducing deductions for Medicare and Medicaid consumers, more individuals will enroll in these programs.

There should be modifications to cover all Americans and not put any conditions for coverage in these two programs. By removing the conditions for enrollment, minority groups such as the uninsured, ethnic minorities, and individuals of low socioeconomic status will access healthcare services through coverage by these two programs. The government should provide universal healthcare coverage for all individuals. This will ensure that Americans receive healthcare services without struggling financially (Wagstaff & Neelsen, 2020). This will ensure that vulnerable populations will access healthcare services with no struggles.

Medicare should also expand to accommodate the LGBTQ community. There is a lot of discrimination in accessing healthcare services for the LGBTQ community (Hafeez et al., 2017). This discrimination makes it hard for them to access quality healthcare services. The government should also include individuals earning below 138% of the federal property level. Ethnic minorities such as African Americans and Latinos will benefit from this modification. Many ethnic minorities have financial difficulties in the United States (Hero et al., 2017).

Impact of ACA on Medicare and Medicaid Beneficiaries

The Affordable Care Act (ACA)  was implemented to expand access to healthcare insurance. Since its implementation, approximately 20 million adults who were not insured have gained coverage under ACA (Kominski et al., 2017). Many individuals have been enrolled in the Children’s Health Insurance Program and Medicaid since the enactment of ACA. There has been increased enrollment in many states. Many individuals who were initially eligible for Medicaid enrolled after the enactment of ACA due to the ease in the application process (Kominski et al., 2017). The ACA has led to many young individuals aged between nineteen to twenty-five years signing up for ACA. This is mainly because of the ACA provision that allows young adults to be in their parents’ insurance plans up to 26 (Kominski et al., 2017).

ACA has led to reduced costs of insurance. ACA has lowered Medicare reimbursements to hospitals, nursing homes, hospices, and other healthcare facilities. ACA offered new sources of insurance for the uninsured and reduced Medicare payments to hospitals offering care to uninsured and low-income patients (McIntyre & Song, 2019). In addition to this, ACA reformed the reimbursements to Medicare Advantage plans which required a set portion to be spent on medical benefits with bonus payments for high-quality plans. These provisions have reduced the cost of healthcare services, with healthcare professionals offering quality healthcare services. ACA has reduced the cost of prescription drugs  (McIntyre & Song, 2019). It also covers preventive healthcare services such as regular screenings with low deductibles and co-pays (McIntyre & Song, 2019). Individuals can now access high-quality healthcare services at low costs

ACA has, however, increased the cost of insurance premiums. ACA barred insurance companies from covering individuals with preexisting conditions such as cancer (McIntyre & Song, 2019). This has forced insurance companies to offer their consumers a wide range of benefits and cover individuals with preexisting conditions. This has increased the cost of premiums for individuals who already have health insurance. The second negative outcome of ACA is that new tax laws were implemented to help pay for ACA. There are tax laws on pharmaceutical and medical device sales. It also led to the increase of tax on individuals with high incomes. In addition to this, ACA funding comes from Medicare payments savings (McIntyre & Song, 2019). This means that wealthy individuals are paying more to help subsidize insurance for individuals of low income.

Role of Healthcare Leaders

The primary role of healthcare leaders in advocating for cost-effective healthcare is through policy advocacy. Individuals who are of low socioeconomic status are the ones negatively impacted most by healthcare policies. Hence, they are the ones who can benefit the most from healthcare policies that can address these inequalities (Williams et al., 2018). The best healthcare policies can address the social determinants of healthcare (SODH). SODH is associated with social injustices, healthcare inequalities, poor health, and increased mortality rates (Williams et al., 2018). Healthcare leaders should thus take a primary role in advocating for policies. They should advocate for policies that shape the well-being of vulnerable populations. These policies should address the costs of healthcare and how they affect the disparities in access to healthcare services.

At the healthcare organization level, healthcare leaders should advocate for their patients to the upper management. By advocating for patients, the healthcare organization can reduce the cost of healthcare services to ensure that vulnerable populations can access healthcare services at affordable costs.

Conclusion

Medicare and Medicaid programs were implemented to ensure that Americans received insurance coverage. Medicare covers individuals from low socioeconomic families, children, and pregnant women, while Medicaid covers individuals aged over 65 years and who have ESRD. Different states also have additional options for Medicare and Medicaid. The CMS has QIO, which aims to enhance healthcare quality for Medicare beneficiaries. QIO also handles complaints from patients, which are used in continuous review processes. Even though Medicare and Medicaid have helped in insurance coverage, certain modifications can be made to help cover vulnerable populations. Such modifications include reducing the age limit to 55 years for Medicaid. They should also implement provisions to stop the discrimination of the LBGTQ community. ACA has been beneficial to Medicaid and Medicare beneficiaries since its enactment. This act has improved insurance coverage and increased access to healthcare and preventive services for patients. However, it has its disadvantages, such as increased taxation and higher premium rates. Healthcare leaders must advocate for the cost of healthcare for vulnerable populations through policy advocacy.

References

CMS. (2020, January 13). History. Centers for Medicare & Medicaid Services | CMS. https://www.cms.gov/About-CMS/Agency-Information/History

CMS. (2020, February 11). Quality improvement organizations. Centers for Medicare & Medicaid Services | CMS. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityImprovementOrgs

CMS. (2020, July 8). Original Medicare (Part A and B) eligibility and enrollment. Centers for Medicare & Medicaid Services | CMS. https://www.cms.gov/Medicare/Eligibility-and-Enrollment/OrigMedicarePartABEligEnrol

Currie, J., & Duque, V. (2019). Medicaid: What does it do, and can we do it better? The ANNALS of the American Academy of Political and Social Science, 686(1), 148-179. https://doi.org/10.1177/0002716219874772

Hafeez, H., Zeshan, M., Tahir, M. A., Jahan, N., & Naveed, S. (2017). Health care disparities among lesbian, gay, bisexual, and transgender youth: A literature review. Cureus. https://doi.org/10.7759/cureus.1184

Hero, J. O., Zaslavsky, A. M., & Blendon, R. J. (2017). The United States leads other nations in differences by income in perceptions of health and health care. Health Affairs, 36(6), 1032-1040. https://doi.org/10.1377/hlthaff.2017.0006

Kominski, G. F., Nonzee, N. J., & Sorensen, A. (2017). The Affordable Care Act’s impacts on access to insurance and health care for low-income populations. Annual Review of Public Health, 38(1), 489-505. https://doi.org/10.1146/annurev-publhealth-031816-044555

McIntyre, A., & Song, Z. (2019). The US Affordable Care Act: Reflections and directions at the close of a decade. PLOS Medicine, 16(2), e1002752. https://doi.org/10.1371/journal.pmed.1002752

Medicaid.gov. (n.d.). Eligibility. Medicaid.gov: the official U.S. government site for Medicare | Medicaid. https://www.medicaid.gov/medicaid/eligibility/index.html

Wagstaff, A., & Neelsen, S. (2020). A comprehensive assessment of universal health coverage in 111 countries: A retrospective observational study. The Lancet Global Health, 8(1), e39-e49. https://doi.org/10.1016/s2214-109x(19)30463-2

Williams, S., Phillips, J., & Koyama, K. (2018). Nurse advocacy: Adopting a health in all policies approach. OJIN: The Online Journal of Issues in Nursing, 23(3). https://doi.org/10.3912/ojin.vol23no03man01

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Assignment:

Signature Assignment: Medicare and Medicaid

Consider how people qualify to receive Medicare and/or Medicaid and write a paper that addresses the bullets below. There should be four (4) sections in your paper, one for each bullet below. Separate each section in your paper with a clear, brief heading that allows your professor to know which bullet you are addressing in that section of your paper. Start your paper with an introduction and include a “Conclusion” section that summarizes all topics. This paper should consist of at least 1750 words and no more than 2,000.

This week, reflect upon the Medicare and Medicaid programs to address the following:

Describe the Quality Improvement Organization (QIO) and explain how the QIO improves policies and healthcare for Medicare beneficiaries.
Briefly define the qualifications for Medicare and Medicaid benefits. How can qualifications be modified to serve more people who are considered a vulnerable population?
Discuss the impact (including at least two positive and two negative aspects) that the ACA has had on benefits and coverage for Medicare and Medicaid recipients.
Describe your role(s) as a healthcare leader as it applies to the practice of advocating for cost-effective care for vulnerable populations.

Assignment Expectations

Length: 1750-2000 words in length

Structure: Include a title page and reference page in APA format. These do not count towards the minimal word amount for this assignment. Your essay must include an introduction and a conclusion.

References: Use the appropriate APA style in-text citations and references for all resources utilized to answer the questions. A minimum of two (2) scholarly sources are required for this assignment.