Medicaid and Medicare are health insurance programs available to those who are financially unable to obtain health insurance on their own, and for individuals with certain diseases or over the age of 65. The Centers for Medicare and Medicaid Services (CMS), as well as individual state and federal agencies, help facilitate and regulate these programs.
Medicare
Medicare is for individuals 65 or older, people with specific disabilities and anyone dealing with an end-stage kidney disease, according to Medicare.gov. Medicare has four parts. Part A covers inpatient care and expenses incurred while hospitalized as well as skilled nursing care, hospice and home health care. Part B covers general doctor visits, and Part D covers prescription medications. Part C is obtained through private companies and includes coverage contained in Part A and B.
Medicaid
Medicaid programs are administered by each state and are regulated by CMS. Individuals and families must fit a specific group set by federal and state law to be eligible for benefits. Individuals that may qualify include the disabled, pregnant, elderly and children. Your income and ability to obtain health services are also taken into consideration. You must be a U.S. citizen or legal immigrant. The health services are similar to those provided through Medicare.
Network
CMS has four divisions that implement programs on local, regional and state levels. The regulations and policies are facilitated to ensure quality health care is delivered in a timely, safe and efficient manner.
Affordable Care Act
The Patient Protection and Affordable Care Act (PPACA) signed into law in March 2010 increases the amount of outpatient drug coverage for Medicaid recipients, lowering the cost of prescription medications. It also provides for mandatory licensing verification and site visits of providers of Medicare and Medicaid programs to prevent fraud and abuse.
Conditions of Participation and Coverage
CMS has in place Conditions of Participation and Conditions for Coverage, which all health care providers must meet to participate in providing Medicare or Medicaid services. Hospitals, psychiatric institutions, hospices, nursing care centers and other health care facilities must qualify and meet minimum safety and health requirements before they are certified.
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