The Centers for Medicare and Medicaid Services (CMS) is a U.S. federal agency that helps people get health insurance and other forms of assistance with their healthcare costs. CMS runs both Medicare and Medicaid, two of the country’s largest public health insurance programs. Medicare is typically for people who are 65 or older, while Medicaid is for people with low incomes. CMS also runs the Children’s Health Insurance Program (CHIP), which helps cover children’s health insurance costs. CMS is a legitimate government agency that provides important services to millions of Americans.
Medicare and Medicaid Basics
Medicare and Medicaid are two government-sponsored health insurance programs that provide coverage to different populations in the United States. Medicare is primarily for people aged 65 and older, as well as people with certain disabilities and end-stage renal disease. Medicaid is for low-income individuals and families, pregnant women, and children. Both programs are funded through a combination of federal and state funds.
- Medicare
Medicare has four parts:
- Part A: Hospital insurance covers inpatient hospital stays, skilled nursing facility care, and hospice care.
- Part B: Medical insurance covers doctor visits, outpatient hospital care, and durable medical equipment.
- Part C: Medicare Advantage is a private health insurance plan that offers Medicare benefits and often includes additional coverage, such as dental and vision care.
- Part D: Prescription drug coverage is available to Medicare beneficiaries through private insurance plans.
- Medicaid
Medicaid is a state-administered program that provides health insurance to low-income individuals and families, pregnant women, and children. The program is jointly funded by the federal government and the states. Medicaid benefits vary from state to state, but typically include:
- Doctor visits
- Hospital stays
- Prescription drugs
- Mental health services
- Substance abuse treatment
Eligibility for Medicaid is based on income and family size. In most states, adults without dependent children must have an income below the poverty level to qualify for Medicaid. Medicaid also covers pregnant women and children whose family income is below certain limits.
Medicare and Medicaid Eligibility Comparison
| Medicare | Medicaid | |
|---|---|---|
| Age Eligibility | 65+ | Varies by state |
| Disability Eligibility | Yes | Yes |
| Income Eligibility | No | Yes |
| Family Size Eligibility | No | Yes |
| Benefits | Hospital, medical, prescription drug | Varies by state |
Government Oversight of the Centers for Medicare and Medicaid Services (CMS)
CMS Responsibilities and Structure
The Centers for Medicare and Medicaid Services (CMS) is a federal agency that oversees the Medicare and Medicaid programs, as well as other health insurance programs.
- CMS is responsible for ensuring that these programs are administered fairly and efficiently, and that beneficiaries have access to quality care.
- CMS also works to combat fraud, waste, and abuse in the healthcare system.
- The agency is headed by an Administrator who is appointed by the President and confirmed by the Senate.
Oversight of CMS
CMS is subject to oversight by several government entities, including:
- Congress: Congress has the authority to pass laws that create and modify CMS programs.
- The President: The President appoints the CMS Administrator and other top officials.
- The Office of Management and Budget (OMB): OMB reviews CMS’s budget and approves its spending plans.
- The Government Accountability Office (GAO): GAO conducts audits and investigations of CMS programs and operations.
- The Office of the Inspector General (OIG): OIG investigates allegations of fraud, waste, and abuse in CMS programs.
CMS is also subject to oversight by the courts. Individuals and organizations can file lawsuits against CMS to challenge its decisions or policies.
CMS Accountability and Transparency
CMS is committed to accountability and transparency in its operations. The agency publishes a variety of reports and data that provide information about its programs and activities
CMS also has a number of policies and procedures in place to ensure that its programs are administered fairly and efficiently. These policies and procedures include:
- Competitive bidding: CMS uses competitive bidding to purchase goods and services.
- Peer review: CMS uses peer review to evaluate the quality of care provided by healthcare providers.
- Program integrity: CMS has a number of programs in place to combat fraud, waste, and abuse.
- Beneficiary protections: CMS has a number of policies and procedures in place to protect the rights of beneficiaries.
CMS Performance Measurement
CMS uses a variety of performance measures to assess the quality of its programs and services. These measures include:
- Healthcare quality: CMS measures the quality of care provided by healthcare providers.
- Access to care: CMS measures the number of people who have access to affordable health insurance.
- Cost of care: CMS measures the cost of healthcare services.
- Program efficiency: CMS measures the efficiency of its programs and services.
CMS uses these performance measures to identify areas where it can improve its programs and services.
Table: CMS Oversight Entities
| Entity | Role |
|---|---|
| Congress | Passes laws that create and modify CMS programs |
| The President | Appoints the CMS Administrator and other top officials |
| The Office of Management and Budget (OMB) | Reviews CMS’s budget and approves its spending plans |
| The Government Accountability Office (GAO) | Conducts audits and investigations of CMS programs and operations |
| The Office of the Inspector General (OIG) | Investigates allegations of fraud, waste, and abuse in CMS programs |
History and Evolution of the CMS
The Centers for Medicare and Medicaid Services (CMS) is a government agency that administers Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). It was created in 2010 when the Centers for Medicare & Medicaid Services and the Health Care Financing Administration were merged.
The agency’s mission is to ensure that all Americans have access to affordable, quality health care.
- The CMS is responsible for:
- Setting and enforcing standards for health care providers.
- Paying for health care services provided to Medicare, Medicaid, and CHIP beneficiaries.
- Conducting research and demonstration projects to improve the quality of health care.
- Providing information and assistance to beneficiaries and health care providers.
The CMS is headed by an Administrator who is appointed by the President and confirmed by the Senate.
The CMS is divided into four operating centers:
- The Center for Medicare
- The Center for Medicaid and CHIP
- The Center for Consumer Information and Insurance Oversight
- The Center for Program Integrity
| Center | Responsibilities |
|---|---|
| Center for Medicare | Administers the Medicare program, which provides health insurance to people aged 65 and older, people with disabilities, and people with end-stage renal disease. |
| Center for Medicaid and CHIP | Administers the Medicaid program, which provides health insurance to low-income families and individuals, and the CHIP program, which provides health insurance to children from low-income families. |
| Center for Consumer Information and Insurance Oversight | Oversees the implementation of the Affordable Care Act, which expanded access to health insurance for millions of Americans. |
| Center for Program Integrity | Investigates and prosecutes fraud, waste, and abuse in the Medicare, Medicaid, and CHIP programs. |
CMS Fraud Investigation
To maintain the stability of the federal health insurance programs, the Centers for Medicare & Medicaid Services (CMS) takes reports of fraud, waste, and abuse very seriously. CMS has developed the Medicare Integrity Program (MIP) to help combat fraud, waste, and abuse, safeguard taxpayer dollars, and ensure beneficiary protection. MIP is the overarching name for a comprehensive program designed to promote the integrity of the Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) programs. MIP includes a wide range of activities to detect and prevent fraud, waste, and abuse.
Reporting Fraud
You can report suspected fraud, waste, or abuse to CMS by calling 1-800-MEDICARE (1-800-633-4227). You can also report suspected fraud, waste, or abuse online at the CMS website.
How to Avoid Fraud
- Beware of people who call, email, or visit your home and claim to be from Medicare.
- Never give your Medicare number or other personal information to anyone you don’t know.
- Don’t sign up for Medicare Advantage or Part D plans unless you’re sure they’re legitimate.
- Keep your Medicare card and other personal information safe.
- Report any suspected fraud, waste, or abuse to CMS.
CMS Fraud Investigations
CMS conducts fraud investigations in a variety of ways. These include:
- Reviewing claims data to identify potential fraud.
- Conducting audits of providers.
- Receiving and investigating complaints from beneficiaries and other sources.
- Working with law enforcement agencies to investigate and prosecute fraud.
CMS Fraud Investigation Results
| Year | Number of Fraud Cases Investigated | Amount of Fraud Recovered |
|---|---|---|
| 2018 | 2,800 | $1.2 billion |
| 2019 | 3,000 | $1.4 billion |
| 2020 | 3,200 | $1.6 billion |