APPENDIX
3.2
SOME MISSION-CRITICAL CENTERS OF THE CENTERS FOR MEDICARE & MEDICAID SERVICES
The descriptions provided for the CMS centers included here are adapted and abstracted from CMS’s website (CMS 2020).
The Center for Medicare serves the following functions:
- Acts as CMS’s focal point for the formulation, coordination, integration, implementation, and evaluation of national Medicare program policies and operations.
- Identifies and proposes modifications to Medicare programs and policies to reflect changes or trends in the healthcare industry, program objectives, and the needs of Medicare beneficiaries.
- Coordinates with the Office of Legislation on the development and advancement of new legislative initiatives and improvements.
- Acts as CMS’s lead for management, oversight, budget, and performance issues relating to Medicare Advantage, Medicare’s prescription drug plans, and Medicare fee-for-service providers and contractors.
- Oversees all CMS collaboration with key stakeholders and other interactions relating to Medicare (i.e., plans, providers, other government entities, advocacy groups, consortia); oversees all communication and dissemination of policies, guidance, and materials to these same stakeholders to understand their perspectives and to drive best practices in the healthcare industry.
- Develops and implements a comprehensive strategic plan, objectives, and measures to carry out CMS’s Medicare program mission and goals and to position the organization to meet future challenges with the Medicare program and its beneficiaries.
- Coordinates with the Center for Program Integrity to identify program vulnerabilities and to implement strategies to eliminate fraud, waste, and abuse.
Center for Medicaid and CHIP Services
The Center for Medicaid and CHIP Services serves the following functions:
- Acts as CMS’s focal point for the formulation, coordination, integration, implementation, and evaluation of all national program policies and operations relating to Medicaid, the Children’s Health Insurance Program (CHIP), and the Basic Health Program (BHP).
- In partnership with states, assists state agencies in successfully carrying out their responsibilities for effective program administration and beneficiary protection and, as necessary, supports states in correcting problems and improving the quality of their operations.
- Identifies and proposes modifications to Medicaid and CHIP program measures, regulations, laws, and policies to reflect changes or trends in the healthcare industry, program objectives, and the needs of Medicaid, CHIP, and BHP beneficiaries.
- Collaborates with the Office of Legislation on the development and advancement of new legislative initiatives and improvements.
- Acts as CMS’s lead for management, oversight, budget, and performance issues relating to Medicaid, CHIP, BHP, and the related interactions with the states and stakeholder community.
- Coordinates with the Center for Program Integrity on the identification of program vulnerabilities and implementation of strategies to eliminate fraud, waste, and abuse. Leads and supports all CMS interactions and collaborations relating to Medicaid, CHIP, and BHP with states and local governments, territories, Indian tribes, and tribal healthcare providers, key stakeholders (e.g., consumer and policy organizations and the healthcare provider community) and other federal government entities. Facilitates communication and disseminates policy and operational guidance and materials to all stakeholders. Works to understand stakeholders and consider their perspectives, support their efforts, and develop best practices for beneficiaries across the country and throughout the healthcare system.
- Develops and implements a comprehensive strategic plan, objectives, and measures to carry out CMS’s Medicaid, CHIP, and BHP mission and goals and to position the organization to meet future challenges with Medicaid, CHIP, and BHP.
Center for Consumer Information and Insurance Oversight
The Center for Consumer Information and Insurance Oversight serves the following functions:
- Provides national leadership in setting and enforcing health-insurance standards that promote fair and reasonable practices to ensure that affordable, quality healthcare coverage is available to all Americans.
- Provides consumers with comprehensive information on insurance coverage options currently available so they may make informed choices on the best health insurance for themselves and their families; issues consumer assistance grants to states.
- Implements, monitors compliance with, and enforces the new rules governing the insurance market such as the prohibition on rescissions and on preexisting condition exclusions for children. Conducts external appeals for states that do not have that authority.
- Implements, monitors compliance with, and enforces the new rules on medical loss ratio standards and insurance premium rate reviews, and issues premium rate review grants to states.
- Administers the Pre-Existing Condition Insurance Plan and associated grant funding to states, the Early Retiree Reinsurance Program, and the Consumer Operated and Oriented Plan Program.
- Collects, compiles, and maintains comparative pricing data for an internet portal providing information on insurance options, and provides assistance to enable consumers to obtain maximum benefit from the new health insurance system.
- Collects, compiles, and maintains comparative pricing data for the department’s website, provides assistance to enable consumers to understand the new health insurance laws and regulations, and establishes and issues consumer assistance grants to states.
- Develops and implements policies and rules governing state-based exchanges, establishes and issues exchange planning and establishment to states, oversees the operations of state-based exchanges, and administers exchanges in states that elect not to establish their own.
- Oversees and directs the development and operations of the back-end and systems functions for healthcare.gov in support of the federally facilitated marketplace, distributed hub services, and multidimensional insurance data analytics systems.
The CMS Innovation Center serves the following functions:
- Identifies, validates, and disseminates information about new care models and payment approaches to serve Medicare and Medicaid beneficiaries seeking to enhance the quality of health and healthcare and reducing cost through improvements.
- Consults with representatives of relevant federal agencies and clinical and analytical professionals with expertise in medicine and healthcare management (e.g., management of providers, payers, states, businesses, and community agencies) to develop new and effective models of care.
- Creates and tests new models in clinical care, integrated care, and community health, and disseminates information on these models through CMS, Health and Human Services (HHS), states, local organizations, and industry channels.
- Performs rapid cycle evaluation of innovation and demonstration activities to determine effectiveness and feasibility for broader dissemination, scale, and sustainability.
- Works closely with other CMS components and regional offices to study healthcare industry trends and data to design, implement, and evaluate innovative payment and service delivery models and to disseminate information about effective models.
- Builds collaborative learning networks to facilitate collection and analysis of relevant data. Develops the necessary technology to support this activity.
- Develops professionals with expertise in innovation, demonstration, and diffusion to help introduce effective practices across the nation.
- Carries out core business functions (e.g., budget, facilities, HR, communications).
Center for Clinical Standards and Quality
The Center for Clinical Standards and Quality serves the following functions:
- Acts as the focal point for all quality, clinical, and medical science issues; the survey and certification of health facilities; and policies for CMS’s programs.
- Provides leadership and coordination for the development and implementation of a cohesive, CMS-wide approach to measuring and promoting quality, and leads CMS’s priority-setting process for clinical quality improvement.
- Coordinates quality-related activities with outside organizations; monitors quality of Medicare, Medicaid, and the Clinical Laboratory Improvement Amendments (CLIA).
- Identifies and develops best practices and techniques in quality improvement. The implementation of these techniques will be overseen by appropriate components of CMS.
- Develops and collaborates on demonstration projects to test and promote quality measurement and improvement.
- Develops, tests, evaluates, adopts, and supports performance measurement systems (i.e., quality measures) to evaluate care provided to CMS beneficiaries except for demonstration projects in other components.
- Ensures that CMS’s quality-related activities (the survey and certification of facilities), technical assistance, beneficiary information, payment policies, and provider/plan incentives) are fully integrated.
- Carries out the Health Care Quality Improvement Program for the Medicare, Medicaid, and CLIA programs.
- Oversees the planning, policy, coordination, and implementation of the survey, certification, and enforcement programs for all Medicare and Medicaid providers and suppliers and for laboratories under the auspices of CLIA.
- Acts as CMS’s lead for management, oversight, budget, and performance issues relating to the survey and certification program and the related interactions with the states.
- Leads in the specification and operational refinement of an integrated CMS quality information system, which includes tools for measuring the coordination of care between healthcare settings. Analyzes data supplied by that system to identify ways to improve care and assess the success of improvement interventions.
- Develops the requirements of participation for providers and plans in the Medicare, Medicaid, and CLIA programs; bases these requirements on statutory change and input from other components.
- Operates the Quality Improvement Organization Program and the End-Stage Renal Disease Network Program in conjunction with regional offices, providing policies and procedures, contract design, program coordination, and leadership in selected projects.
- Identifies, prioritizes, and develops content for clinical and health-related aspects of CMS’s consumer information strategy; collaborates with other components to develop comparative provider and plan performance information for consumer choices.
- Prepares the scientific, clinical, and procedural basis for coverage of new and established technologies and services, and provides coverage recommendations to the CMS administrator. Coordinates activities of CMS’s Technology Advisory Committee, and maintains liaison with other departmental components regarding the safety and effectiveness of technologies and services. Prepares the scientific and clinical basis for, and recommends approaches to, quality-related medical review activities of carriers and payment policies.
- Identifies new and innovative approaches, and tests for improving quality programs and lowering costs.
Center for Program Integrity
The Center for Program Integrity serves the following functions:
- Acts as CMS’s focal point for all national and statewide Medicare and Medicaid programs and CHIP integrity fraud and abuse issues.
- Promotes the integrity of the Medicare and Medicaid programs and CHIP through provider/contractor audits and policy reviews, the identification and monitoring of program vulnerabilities, and the provision of support to states.
- Recommends modifications to programs and operations as necessary, and works with CMS centers, offices, and the chief operating officer (COO) to effect changes as appropriate.
- Collaborates with the Office of Legislation on the development and advancement of new legislative initiatives and improvements to deter, reduce, and eliminate fraud, waste, and abuse.
- Oversees all CMS collaborations and other interactions with key stakeholders relating to program integrity (e.g., the Department of Justice, the HHS Office of Inspector General, state law enforcement agencies, other federal entities, CMS components) to detect, deter, monitor, and combat fraud and abuse and to take action against those who commit or participate in fraudulent or other unlawful activities.
- In collaboration with other CMS centers, offices, and the COO, develops and implements a comprehensive strategic plan, objectives, and measures to carry out CMS’s Medicare, Medicaid, and CHIP program integrity mission and goals and to ensure that program vulnerabilities are identified and resolved.