Health Care Policy and Insurance: Medicare, Medicaid, and Private Coverage

The Joint Commission

Accredits health care facilities that meet established standards for safety, quality, and performance excellence.

TJC Accreditation

Demonstrates strong safety processes, quality improvement, and risk management, and may reduce liability and streamline Medicare and Medicaid certification.

National Performance Goals (NPGs)

Replace the previous National Patient Safety Goals for facilities and critical care facilities, including updated safety expectations.

Magnet Recognition Program

Recognizes health care organizations that provide excellence in nursing care throughout the facility.

Magnet Status

Based on an evidence-based study that identifies elements of nursing practice that attract nurses to facilities.

Pathway to Excellence Program

A Nursing Excellence Program awarded to organizations demonstrating a commitment to providing a healthy workplace for their staff.

Health Policy Acts

Play a critical role in shaping population health, requiring nurse awareness and involvement.

Federal Laws

Form national health policy and influence health outcomes across populations.

Patient Protection and Affordable Care Act

Approach to provide affordable health coverage to each person in the United States.

Health Insurance Portability and Accountability Act

Protects individuals' health insurance coverage portability and establishes national standards for health care transactions.

Emergency Medical Treatment and Active Labor Act

Intended to prevent client dumping by requiring emergency departments to provide medical screening and stabilizing treatment regardless of a client's ability to pay.

Patient Self-Determination Act

Requires health care organizations to inform clients of their rights to make health care decisions, including refusing treatment.

Controlled Substances Act

Regulates drugs with abuse potential by classifying them into five schedules based on medical use and risk of dependence.

Mental Health Parity and Addiction Equity Act

Ensures individuals with mental illness receive coverage equal to those with medical illness or need for surgical intervention.

Americans with Disabilities Act

Prohibits discrimination against individuals with physical or mental disabilities and ensures equal access to employment and health care services.

Uniform Anatomical Gift Act

Ensures that an individual's decision to donate organs cannot be overturned by someone else after their death.

Omnibus Budget Reconciliation Act

Created national standards that protect individuals living in nursing facilities.

Health Disparities

Preventable differences in health outcomes caused by unequal access to care.

Quality Health Care

Depends heavily on creating a safe environment that minimizes medical errors.

Patient's Bill of Rights

Helps ensure that people receiving health care are protected through clearly defined consumer rights and responsibilities.

Employer-Sponsored Health Insurance

The most common and often most affordable form of coverage.

Medicaid

Covers individuals younger than age 65 with a disability or those with socioeconomic hardship and no other insurance.

Children's Health Insurance Program (CHIP)

Provides coverage for comprehensive preventive and medical services for children from families who do not qualify for Medicaid.

Accountable Care Organizations (ACOs)

Networks of providers that share responsibility for the cost and coordination of care for a defined population.

Medicare

Insurance for individuals older than 65 years or with certain disabilities.

Part A (Hospital Insurance)

Insurance for hospital stays, skilled nursing facilities, home health, hospice.

Part B (Medical Insurance)

Insurance for outpatient and provider services, requiring a monthly premium.

Part C (Advantage Plan)

A Medicare advantage plan or supplement plan covering parts A and B, and sometimes D.

Part D (Medication Coverage)

Medication coverage for those eligible, requiring a monthly premium.

Private Insurance

Insurance coverage not provided by a government agency, such as employer-sponsored insurance.