HCA 320 Module 8 Assignment Medicare and Medicaid

HCA 320 Module 8 Assignment Medicare and Medicaid

HCA 320 Module 8 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 2000.

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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.

M8 Assignment UMBO – 2, 3, 4

M8 Assignment PLG – BSHCA – 2, 4, 5 RN-BSN – 1, 2, 5

M8 Assignment CLO – 1, 2, 3, 4, 5, 6, 7, 8

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Instructions & SpecificationsSubmissionsRubric

Start by reading and following these instructions:

Study the required chapter(s) of the textbook and any additional recommended resources. Some answers may require you to do additional research on the Internet or in other reference sources. Choose your sources carefully.

Consider the discussion and the any insights you gained from it.

Review the assignment rubric and the specifications below to ensure that your response aligns with all assignment expectations.

Create your assignment submission and be sure to cite your sources, use APA style as required, and check your spelling.

The following specifications are required for this assignment:

Length: 1750-2000 words; answers must thoroughly address the questions in a clear, concise manner

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.

Format: Save your assignment as a Microsoft Word document (.doc or .docx).

Filename: Name your saved file according to your first initial, last name, and the module number (for example, “RHall Module 1.docx”)

HCA 320 Module 8 Assignment Medicare and Medicaid Sample

The Medicare and Medicaid programs support the American healthcare sector, giving critical services to different populations. Medicare, an insurance program for healthcare, provides coverage for people 65 or older, those under 65 with disabilities, and individuals dealing with conditions like End-Stage Renal Disease or ALS (LaPelusa & Bohlen, 2023). It comprises four sections: Part D is the drug coverage; Part B is the Medicare insurance; Part C is the Medicare Advantage Plans; and Part A is the hospital insurance. Conversely, Medicaid is a collaborative effort between the federal and state governments that provides vital assistance to people with poor incomes or limited resources. It offers a variety of treatments that Medicare does not cover (LaPelusa & Bohlen, 2023). Medicaid beneficiaries receive benefits above and beyond standard therapy, including full dental, vision, and hearing coverage and necessary services like personal and nursing home care. Medicaid eligibility varies by state according to domicile, citizenship in the United States, or legal immigration status. Expansion initiatives in many states have widened the scope under Medicaid to offer crucial healthcare services to more people.

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The relationship between Medicare and Medicaid results in a particular group of beneficiaries known as “dual eligibles.” Understanding their coverage through Original Medicare or a Medicare Advantage Plan reveals the extensive support these individuals receive, including prescription drugs and extra services (Aggarwal et al., 2022). Exploring the roles of Quality Improvement Organizations, benefits qualifications, the impact of the Affordable Care Act, and the responsibilities of healthcare leaders will provide a better understanding of Medicare and Medicaid programs. These systems serve as safety nets for specific demographics and adapt to meet evolving healthcare needs.

Quality Improvement Organizations (QIO) Improving Healthcare for Medicare Beneficiaries

The Quality Improvement Organization (QIO) program is an integral part of the National Quality Strategy (NQS) of the U.S. Department of Health and Human Services (HHS), which aims to make Medicare recipients’ healthcare better. QIOs are federally mandated non-profit organizations contractually bound to the Centers for Medicare and Medicaid Services (CMS) (CMS.gov, 2023). This section unravels the layers of the QIO program, explaining its functions and exploring how it dynamically evolves to meet the changing landscape of healthcare.

The QIO program must carry out three essential functions: enhancing the quality of care, preserving the Medicare Trust Fund’s integrity, and safeguarding beneficiaries. It achieves this by confirming that Medicare covers services that are justified, essential, and delivered in suitable settings (CMS.gov, 2023). In doing so, the QIO program plays a crucial role in upholding the program’s financial sustainability. Two entities Within the QIO program work harmoniously: Beneficiary and Family Centered Care (BFCC)-QIOs and Quality Innovation Network (QIN)-QIOs (CMS.gov, 2023). BFCC-QIOs primarily concentrate on overseeing beneficiary grievances, guaranteeing the provision of high-quality healthcare, and addressing appeals about discharge determinations. QIN-QIOs lead data-driven programs to improve patient safety, community health, coordination of post-hospital care, and overall clinical quality.

Quality Improvement Organizations gather and assess healthcare data related to services, results, and patient contentment to pinpoint areas needing enhancement (Abu-Rumman et al., 2021). They offer educational and instructional initiatives for healthcare professionals covering subjects like evidence-based approaches, patient safety, and methods for improving quality. QIOs aid healthcare personnel in organizing care across various settings to guarantee smooth transitions while minimizing care fragmentation. These organizations also examine beneficiaries’ grievances and probe potential Medicare rule breaches (Marrelli, 2023). QIOs are crucial in shaping healthcare policy by gathering and assessing data on healthcare quality and patient outcomes. These insights are valuable for policymakers to evaluate the effectiveness of existing policies and consider necessary adjustments. QIOs also collaborate with policymakers to formulate new strategies focused on enhancing healthcare quality, such as creating pay-for-performance programs to incentivize high-quality care delivery by healthcare providers (CMS.gov, 2023). In addition to their policy work, QIOs directly interact with healthcare providers to enhance care quality for Medicare beneficiaries through various initiatives that help identify gaps in care, promote evidence-based practices, and improve patient safety measures.

Recognizing the ever-changing healthcare landscape, CMS has undergone a significant overhaul of the QIO program. This redesign entails separating case review from quality improvement, extending the contract period to five years, and expanding the range of entities eligible for this work. The BFCC-QIOs are now focused on addressing concerns about care quality and appeals (CMS.gov, 2023). At the same time, the QIN-QIOs work alongside providers, stakeholders, and beneficiaries to enhance healthcare quality for specific health conditions. Mandated under Sections 1152-1154 of the Social Security Act, the QIO program is essential to CMS’s ongoing efforts to enhance care quality and effectiveness (CMS.gov, 2023). By transparently reporting its administration, cost, and impact through annual Congress, CMS underscores its dedication to accountability and enhancement. As it evolves, the dynamic QIO program aligns with national quality strategies, embraces innovation, and ardently advocates for the well-being of Medicare beneficiaries. Exploring its diverse functions reveals that the QIO program regulates and drives transformative change in healthcare quality.

Qualifications for Medicare and Medicaid Benefits

The Quality Improvement Organization (QIO) is a cornerstone in the healthcare edifice, pivotal in advancing the quality of services and policies tailored for Medicare beneficiaries. Medicare is a federal health insurance program that serves individuals 65 or older and those with specific disabilities (LaPelusa & Bohlen, 2023). That person must be at least 65 years old to be permitted. People under 65 may also be eligible if they have worked at a Medicare-covered job for at least ten years or have a condition that meets the Social Security Administration’s criteria. Individuals with End-Stage Renal Disease or Amyotrophic Lateral Sclerosis also qualify for Medicare (LaPelusa & Bohlen, 2023). Medicaid is a federal-state program that provides low-income people and families with health insurance coverage. State-by-state variations exist in the qualifying requirements, but generally speaking, these consist of residency in the state of application, U.S. citizenship or qualified noncitizenship, and income below the threshold set by the individual state.

It is crucial to adjust the eligibility criteria to address the specific obstacles vulnerable groups encounter. When considering Medicare, evaluating alternative pathways for qualification may be necessary, especially for individuals with disabilities who find it challenging to meet the work history requirement (Thompson et al., 2021). Similarly, enhancing access for Medicaid beneficiaries can be achieved by raising income eligibility limits and eliminating mandatory work requirements. Expanding Medicaid coverage can benefit vulnerable populations as broader enrollment could occur by removing income eligibility limits and work requirements (Creedon et al., 2022). Additionally, extending coverage to immigrants—currently excluded from Medicaid—would align with principles of inclusivity. Ultimately, transitioning towards a universal healthcare approach would go beyond traditional boundaries and provide healthcare coverage to all Americans regardless of income or employment status while ensuring fair access to high-quality care.

Impact of the Affordable Care Act (ACA) on Medicare and Medicaid

            Undoubtedly, Obamacare, also known as the Affordable Care Act (ACA), has had a profound and long-lasting impact on the benefits offered by Medicare and Medicaid. The Affordable Care Act (ACA) has increased the number of low-income Americans covered by Medicaid, including people whose incomes are up to 138% of the federal poverty threshold (KFF, 2022). In keeping with the goal of the Affordable Care Act, which is to increase access to healthcare, this endeavor resulted in notable increases in the number of people with health insurance, especially among low-income adults and children (Buck, 2019). Medicare recipients have additional advantages due to the ACA, particularly preventative healthcare. The legislation introduced provisions for essential services such as cancer screenings and immunizations.

The elimination of the coverage gap in Medicare Part D prescription medication benefits relieved financial hardships for beneficiaries, promoting a healthcare system that is more complete and accessible. The ACA effectively tackled the urgent need to manage Medicare expenses by curbing the expenditure growth rate. Judicious reductions in payments to hospitals and other providers accomplished this (Buck, 2019). Although there were concerns about the potential effects on healthcare access, the deliberate approach focused on tackling the primary cause of the government budget deficit.

Despite the encouraging progress, the ACA increased premiums for certain Medicare enrollees. This change occurred partially due to the law’s need for Medicare Advantage plans to include a broader range of benefits. The balance between improved coverage and heightened financial responsibilities raised concerns among specific categories of beneficiaries. The payment modifications implemented by the ACA decreased the selection of healthcare providers available to particular Medicare beneficiaries (Buck, 2019). The modified payment frameworks posed difficulties for certain providers to engage in Medicare Advantage plans, thereby affecting the range of healthcare choices accessible to enrollees.

The ACA’s influence on Medicare and Medicaid benefits creates a complex balance between expansion and challenges, contributing to a complicated equilibrium. Although coverage extensions and novel benefits give beneficiaries more options and advantages, they often bring challenges, such as higher premiums and limitations on provider choice (Buck, 2019). Therefore, it is essential to assess and improve these aspects continuously. The ACA, a revolutionary influence in healthcare policy, has had a lasting impact on the benefits provided by Medicare and Medicaid. The ACA has significantly influenced healthcare access by increasing coverage, adding benefits, and adjusting spending trends. However, like any comprehensive policy, the complex interaction of positive and negative factors highlights the continuous discussion and adaptation needed to ensure that these crucial programs align with the constantly changing requirements of varied groups of beneficiaries.

Leadership in Advocating for Cost-Effective Care

            Healthcare leaders are crucial in supporting affordable and quality care for disadvantaged groups. My duty as a healthcare leader is to lead efforts that enhance access to cost-effective healthcare for those who require it the most. This requires a comprehensive strategy involving advocacy, community involvement, and forming strategic alliances (Sacks et al., 2019). I actively work with policymakers to push for measures prioritizing economic healthcare for vulnerable populations by examining healthcare data to pinpoint inequalities and opportunities for efficient interventions. Providing evidence-based information on the impact of healthcare expenses on vulnerable communities is vital in educating policymakers. Furthermore, I contribute to shaping policies that promote cost-effective care by advocating for payment models based on value and endorsing initiatives focused on coordinating care.

Interacting with susceptible groups is essential for comprehending their distinct healthcare requirements. As part of my role, I work with community organizations to tackle inequalities and proactively engage with the community to understand their healthcare obstacles and preferences. Through providing information and tools, we strive to enable community members to make well-informed healthcare decisions that align with their specific requirements.

Establishing strategic alliances is essential for attaining cost-efficient healthcare. I facilitate cooperation among healthcare providers to exchange optimal methodologies and minimize redundant services (Noel et al., 2022). Negotiating with payers to obtain equitable payment rates for services rendered to vulnerable groups is crucial. In addition, I utilize and exploit community resources to offer supplementary support services for marginalized people, establishing a more all-encompassing and enduring healthcare system. Healthcare executives have a crucial role in promoting cost-effective care for disadvantaged populations. Through integrating policy advocacy, community participation, and strategic collaborations, we may establish a healthcare system that is universally accessible, financially feasible, and impartially distributed to all individuals.

Conclusion

In the U.S., Medicare and Medicaid offer a vital safety net for healthcare by covering a variety of needs. Medicare is broken down into four parts for those 65 years of age or older who meet specific requirements. In addition to Medicare, Medicaid is a federal-state program that offers vital assistance. “Dual eligibles” receive substantial benefits. Enhancement of Quality Policies are shaped dynamically by organizations. Comprehending benefit eligibility emphasizes flexibility for marginalized populations. Raising income thresholds and doing away with employment requirements are examples of modifying the criteria. The Affordable Care Act has benefits as well as drawbacks. As a leader in the field, I advocate for affordable care through legislation, community involvement, and strategic collaborations to clear the path for a future in healthcare that is just, long-lasting, and open to all.

References

Abu-Rumman, A., Al Shraah, A., Al-Madi, F., & Alfalah, T. (2021). The impact of quality framework application on patients’ satisfaction. International Journal of Human Rights in Healthcare, ahead-of-print(ahead-of-print). https://doi.org/10.1108/ijhrh-01-2021-0006

Aggarwal, R., Gondi, S., & Wadhera, R. K. (2022). Comparison of medicare advantage vs traditional Medicare for health care access, affordability, and use of preventive services among adults with low income. JAMA Network Open, 5(6), e2215227. https://doi.org/10.1001/jamanetworkopen.2022.15227

Buck, I. D. (2019). Affording Obamacare. Hastings Law Journal, 71, 261. https://heinonline.org/HOL/LandingPage?handle=hein.journals/hastlj71&div=9&id=&page=

CMS.gov. (2023). Quality improvement organizations | CMS. Www.cms.gov. https://www.cms.gov/medicare/quality/quality-improvement-organizations#:~:text=The%20QIO%20Program%2C%20one%20of

Creedon, T. B., Zuvekas, S. H., Hill, S. C., Ali, M. M., McClellan, C., & Dey, J. G. (2022). Effects of medicaid expansion on insurance coverage and health services use among adults with disabilities newly eligible for medicaid. Health Services Research. https://doi.org/10.1111/1475-6773.14034

KFF. (2022, February 24). Status of state medicaid expansion decisions: Interactive map. KFF. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/#:~:text=The%20Affordable%20Care%20Act

LaPelusa, A., & Bohlen, J. (2023). Medicare, medicaid, and military and VA healthcare programs. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK594241/

Marrelli, T. (2023). Hospice & palliative care handbook, fourth edition.

Noel, L., Chen, Q., Petruzzi, L. J., Phillips, F., Garay, R., Valdez, C., Aranda, M. P., & Jones, B. (2022). Interprofessional collaboration between social workers and community health workers to address health and mental health in the United States: A systematised review. Health & Social Care in the Community, 30(6). https://doi.org/10.1111/hsc.14061

Sacks, E., Morrow, M., Story, W. T., Shelley, K. D., Shanklin, D., Rahimtoola, M., Rosales, A., Ibe, O., & Sarriot, E. (2019). Beyond the building blocks: Integrating community roles into health systems frameworks to achieve health for all. BMJ Global Health, 3(Suppl 3), e001384. https://doi.org/10.1136/bmjgh-2018-001384

Thompson, F. J., Farnham, J., Tiderington, E., Gusmano, M. K., & Cantor, J. C. (2021). Medicaid waivers and tenancy supports for individuals experiencing homelessness: Implementation challenges in four states. The Milbank Quarterly, 99(3), 648–692. https://doi.org/10.1111/1468-0009.12514