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HHS Federal Program Inventory

Centers for Medicare & Medicaid Services (CMS)

Budget Authority (in millions of dollars)

 FY 2012FY 2013FY 2014
Discretionary4,1304,1555,528
Mandatory761,078794,656855,905

 

8.1    Children’s Health Insurance Program

The Children’s Health Insurance Program (CHIP) provides health coverage to nearly 8 million children in families with incomes too high to qualify for Medicaid, but can’t afford private coverage.

CHIP is a partnership between the federal government and States and territories to help provide low-income children with the health insurance coverage they need.  The program improves access to health care and the quality of life for millions of vulnerable children under 19 years of age.

CHIP is administered by the states, but is jointly funded by the federal government and states.  Every state administers its own CHIP program with broad guidance from CMS. States with an approved CHIP plan are eligible to receive an enhanced federal matching rate, which ranges from 65 to 85 percent of total costs for child health care services and program administration, drawn from a capped allotment. Since September 1999, every state, the District of Columbia, and all five territories have had approved CHIP plans.  States have a high degree of flexibility in designing their programs.  They can implement CHIP by expanding Medicaid, creating a separate program, or a combination of both approaches.

  • Supported Strategic Goal:  Strengthen health care
  • Supported Strategic Objective:  Ensure access to quality, culturally competent care for vulnerable populations

8.2    Medicaid

Authorized under title XIX of the Social Security Act, Medicaid is generally a means-tested health care entitlement program financed by states and the government that provides health care coverage to low-income families with dependent children, pregnant women, children, and aged, blind and disabled individuals.  The Affordable Care Act extends, at the state’s option, Medicaid eligibility to non-elderly individuals with family incomes up to 133 percent of the federal poverty level, with the federal government paying most of the costs of coverage starting in calendar year 2014.  In addition, Medicaid provides home and community-based services and supports to seniors and individuals with disabilities, as well as institutional long-term care services.

States have considerable flexibility in structuring their Medicaid programs within broad federal guidelines governing eligibility, provider payment levels, and benefits.  As a result, Medicaid programs vary widely from state to state.

  1. Supported Strategic Goal:  Strengthen health care
  2. Supported Strategic Objective:  Ensure access to quality, culturally competent care for vulnerable populations

8.3. Health Care Fraud and Abuse Control

Title II of the Health Insurance Portability and Accountability Act of 1996 established the Health Care Fraud and Abuse Control (HCFAC) program to detect, prevent, and combat health care fraud, waste, and abuse.

Since its inception, HCFAC has been financed from the Federal Hospital Insurance Trust Fund, which provides a stable stream of mandatory funds, and began receiving discretionary funds in FY 2009.

With the receipt of discretionary funds, HCFAC has been able to expand its activities to include strengthened program integrity activities in Medicare Advantage and Medicare Part D; program integrity staffing and support; funding for program integrity initiatives; preventing excessive payments; and program integrity oversight efforts.  In addition, HCFAC funds have allowed CMS to carryout traditional HCFAC actions such as medical review and provider audits.

Additionally, CMS is also committed to fighting fraud, waste and abuse in the Medicaid program, and since 2009 HCFAC funds provide support for Medicaid program integrity efforts in addition to the efforts of the Medicaid Integrity Program, which was funded separately from HCFAC in the Deficit Reduction Act of 2005.  For example, HCFAC funds support payment error rate measurement, fund critical updates to data and systems needed to monitor and detect fraud and improper payments, and support and enhance oversight and financial management if state Medicaid programs.

The HCFAC account has returned over $23.0 billion to the Medicare Trust Funds since the inception of the Program in 1997.  The return on investment from various HCFAC activities ranges from nearly $8 to $1 expended for audit, investigative, and prosecutorial work performed by the HHS Office of Inspector General and the Department of Justice to $14 to $1 for the Medicare Integrity Program’s activities.

  1. Supported Strategic Goal:  Increase efficiency, transparency and accountability of HHS programs
  2. Supported Strategic Objective:  Fight fraud and work to eliminate improper payments

8.4. Medicare

Established in 1965 as Title XVIII of the Social Security Act, Medicare was legislated as a complement to Social Security retirement, survivors, and disability benefits, and originally covered people age 65 and over. In 1972, the program was expanded to cover people with disabilities, people with end-stage renal disease requiring dialysis or kidney transplant, and people age 65 or older who elect Medicare coverage. Enacted in December 2003, the Medicare Prescription Drug, Improvement and Modernization Act of 2003, P.L. 108-173, was designed to improve and modernize the Medicare program, including the addition of a prescription drug benefit.

Medicare processes over one billion fee-for-service claims every year and is the nation’s largest purchaser of health care. Medicare is a combination of four programs: 

  • Part A, which pays for hospital care, as well as skilled nursing, home health, and hospice care; and is financed primarily through payroll taxes paid by workers and employers.
  • Part B, which is voluntary and pays for physician, outpatient hospital, home health, laboratory tests, durable medical equipment, designated therapy, outpatient prescription drugs, and other services.  Part B coverage is subject to monthly premium payments.
  • Part C, which is designed to provide more health care coverage choices for Medicare beneficiaries.  Those who are eligible because of age (65 or older) or disability may choose to join an MA plan, if they are entitled to Part A and enrolled in Part B, and if there is a plan available in their area.
  • Part D, which provides an optional prescription drug benefit (Medicare Part D) for individuals who are entitled to or enrolled in Medicare benefits under Part A or Part B.

Part B of Title XI of the Social Security Act, as amended by the Peer Review Improvement Act of 1982, provides the statutory authority for the Medicare Quality Improvement Organization Program. The mission of this program is to promote the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries and to ensure that those services are reasonable and necessary. The program is funded through transfers from the Medicare Hospital Insurance Trust Fund and the Medicare Supplementary Medical Insurance Trust Fund.

  • Supported Strategic Goal:  Strengthen health care
  • Supported Strategic Objective:  Make coverage more secure for those who have insurance and extend affordable coverage to the uninsured and Improve health care quality and patient safety

8.5. Clinical Laboratory Improvement Amendments

The Clinical Laboratory Improvement Amendments of 1988 (CLIA) establish quality standards for laboratory testing to ensure the accuracy, reliability, and timeliness of patient test results regardless of where the test is performed.  CLIA strengthens quality performance requirements under the Public Health Service Act and extends these requirements to all laboratories that test human specimens to diagnose, prevent, or treat illness or impairment.  CLIA applies to all sites which perform laboratory testing either on a permanent or temporary basis, such as physician office laboratories (POLs); hospitals;

nursing facilities; independent laboratories; end-stage renal disease facilities; ambulatory surgical centers; rural health clinics; insurance laboratories; federal, state, city and county laboratories; and community health screenings.  CLIA provisions are based on the complexity of performed tests, not the type of laboratory where the testing occurs.  Thus, laboratories performing similar tests must meet similar standards, whether located in a hospital, doctor’s office, or other site.

  • Supported Strategic Goal:  Strengthen health care
  • Supported Strategic Objective:  Improve health care quality and patient safety

8.6. Research, Demonstrations and Innovations

Research, Demonstrations, and Innovations includes the development and testing of innovative health care payment and service delivery models.  This funding is currently focused on the following priorities:  (1) testing new payment and service delivery models, (2) spreading results and advancing best practices, and (3) engaging a broad range of stakeholders to develop additional models for testing.

This funding also provides federal funding for a diverse group of grant programs and other activities established under several legislative authorities.  The grants assist in providing state-infrastructure support, program integrity initiatives and services to targeted populations.  Targeted populations include working individuals with disabilities and other eligible Medicaid beneficiaries.

  • Supported Strategic Goal:  Strengthen health care
  • Supported Strategic Objective:   Reduce growth of healthcare costs while promoting high-value, effective care

8.7.   Private Market Insurance

The Private Market Insurance programs provide national leadership in setting and enforcing standards for health insurance that promote fair and reasonable practices to ensure that affordable, quality health coverage is available to all Americans.  These programs also provide consumers with comprehensive information on coverage options currently available so they may make informed choices on the best health insurance for their family.

  • Supported Strategic Goal:  Strengthen health care
  • Supported Strategic Objective:  Make coverage more secure for those who have insurance and extend affordable coverage to the uninsured

8.8.   Health Insurance Marketplaces

Health Insurance Marketplaces facilitate the purchase of qualified health plans by individuals, provide for the establishment of a Small Business Health Options Program designed to assist qualified employers in facilitating the enrollment of their employees in QHPs offered through the SHOP, and to meet other requirements specified in 1311(d) of the Affordable Care Act and federal regulations.  A Federally-facilitated Marketplace or State-Partnership Marketplace will operate in those states that elect not to pursue a State-based Marketplace.  Marketplaces will provide millions of Americans and small businesses access to affordable health insurance coverage.  By January 1, 2014, Marketplaces will help individuals and small employers better understand their insurance options, and assist them to shop for, select, and enroll in high-quality, competitively-priced private health insurance plans.  The Marketplaces will also facilitate receipt of advance payments of the premium tax credits to offset premium costs and cost-sharing assistance, as well as help eligible individuals enroll in other federal or state insurance affordability programs.  By providing one-stop shopping, Marketplaces will make purchasing health insurance easy and understandable, giving individuals and small businesses access to increased options and greater control over their health insurance purchases.

  • Supported Strategic Goal:  Strengthen health care
  • Supported Strategic Objective:  Make coverage more secure for those who have insurance and extend affordable coverage to the uninsured

8.9.   Consumer Operated and Oriented Plan Program

The Affordable Care Act required HHS to establish the Consumer-Operated and Oriented Plan (CO-OP) Program to foster the creation of CO-OPs that will offer non-profit qualified health plans in the individual and small group health insurance markets.  The program provided Start-up Loans (repayable in 5 years) for start-up costs and Solvency Loans (repayable in 15 years) to meet state reserve and solvency requirements to support the development of CO-OPs.  Priority for the award of loans was given to applicants that will offer Qualified Health Plans on a state-wide basis, use an integrated care model, and have significant private support. 

  • Supported Strategic Goal:  Strengthen health care
  • Supported Strategic Objective:  Make coverage more secure for those who have insurance and extend affordable coverage to the uninsured

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