Other Free Encyclopedias » Medicine Encyclopedia » Aging Healthy - Part 2 » Federal Agencies on Aging - Social Security Administration, Centers For Medicare And Medicaid Services, National Institute On Aging, Employment And Training Administration - Administration on Aging

Federal Agencies on Aging - Centers For Medicare And Medicaid Services

nursing social health care cmms individuals

The Centers for Medicare and Medicaid Services (CMMS), formerly the Health Care Financing Administration (HCFA), is located in the Department of Health and Human Services and administers Medicare, Medicaid, and the State Children's Health Program. The name was changed in 2001. Medicare and Medicaid were enacted in 1965, and were originally administered by the SSA. HCFA was created as a separate agency within the Department of Health and Human Services in 1977. When Medicare was enacted, it was directed exclusively to people age sixty-five and above; today it serves 33 million older individuals, 4 million disabled individuals, and 162,000 individuals with end-stage renal disease. Medicaid is a federal-state grant program in which the states receive federal reimbursements for expenditures they make on behalf of low-income individuals eligible for Medicaid coverage. Medicaid serves low-income individuals of all ages. However, it is especially important for older people who have long-term chronic illnesses and live in nursing homes or other institutional settings (Coughlin, Ku, and Holahan). Through Medicare and Medicaid, CMMS insures some 75 million Americans.

Medicare beneficiaries may receive their benefits through the traditional fee-for-service system or through a managed care organization, such as a health maintenance organization. In the former case, CMMS contracts with insurance companies, known as "fiscal intermediaries," that actually process claims from beneficiaries, hospitals, doctors, and other health care providers. Providers receive 80 percent of the fee established by the intermediary, following rules established by CMMS, with the beneficiary responsible for the remaining 20 percent. Prior to 1992, these reimbursements were based on a standard of "reasonable and customary charges;" since that date, reimbursements are based on a fee schedule established by HCFA that reduces reimbursements for surgeries and other selected procedures while increasing them for basic office visits (Moon).

In the case of managed care organizations, CMMS contracts with the managed care organization and provides a fixed amount per beneficiary to that organization, which manages all health care services available to the enrollee. The amounts vary widely around the country, using a complex formula based on 95 percent of the costs per beneficiary under the traditional fee-for-service model (Koff and Park). Other financing and delivery models CMMS is experimenting with include the social health maintenance organization, which includes social as well as health services, and the Program for All-Inclusive Care of the Elderly (PACE), which provides adult day care services for older persons who would otherwise need to be living in nursing homes or other institutional settings.

In purchasing health care services for beneficiaries of these programs, CMMS assures that the programs are being properly run by contractors and states; establishes policies for paying health care providers; conducts research on various aspects of health care management, delivery, treatment, and financing; and assesses and assures the quality of health care being provided through the programs. Of particular concern in recent years have been efforts to rein in fraud and abuse within the Medicare and Medicaid programs, and efforts to assure quality of care.

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