TY - CHAP M1 - Book, Section TI - Introduction to Medicare and Medicaid A1 - Navarro, Robert A2 - Whalen, Karen A2 - Hardin, Heather C. PY - 2018 T2 - Medication Therapy Management: A Comprehensive Approach, 2e AB - KEY POINTSMedicare and Medicaid are two of the three largest medical insurance programs in the United States, with each program comprising approximately 60 million enrollees. The largest health insurance programs are employer group insurance programs (commercial), with about 150 million members.Medicare and Medicaid have unique roles and influence in US healthcare financing and delivery. Both are government programs, and thus quite complex, with arcane, changing policies, regulations, and procedures.Medicare and Medicaid are heavily monitored for quality and cost outcomes, and both may impose significant financial penalties if providers or participating private insurers violate required compliance policies.The Centers for Medicare & Medicaid Services1 (CMS) Innovation Center is actively testing novel payment and delivery models and concepts, and other patient access and quality initiatives.The CMS establishes payment standards for medical benefit drugs, bundled-payment models, preventive care, and quality programs that, if successful, are often adopted, or influence, private health insurance programs. Thus, although Medicaid and Medicare programs are each one-half the size of the employer group private insurance market, the state and federal regulatory authority and compliance penalties influence commercial employer group insurance, hospital, and all other healthcare delivery program operations.Although Medicaid is a state-administered program, the CMS has both financial investment and regulatory oversight, and can monitor and promulgate recommendations and requirements on all 54 state and US territory Medicaid programs, thus ensuring standardized and consistent minimum benefit coverage, although states can apply for waivers and benefit coverage.Both Medicaid and Medicare have been significantly altered through the Patient Protection and Affordable Care Act (PPACA) provisions, including benefit changes and expansion, as discussed in the following text. Today, both Medicare and Medicaid include inpatient and outpatient prescription drug benefits, but they are quite different in terms of drugs covered, access rules, and financial structure. SN - PB - McGraw-Hill Education CY - New York, NY Y2 - 2024/03/29 UR - accesspharmacy.mhmedical.com/content.aspx?aid=1150195200 ER -