NUR7570 Exam 1 Blueprint PDF

**NUR7570 Exam 1 Blueprint Due 9/27/24** 1. **Primary, secondary, and tertiary prevention. Be able to differentiate each and recognize examples**. Primary care: Prevention and management of chronic conditions. Secondary Care: Secondary care occurs when your primary care provider...

**NUR7570 Exam 1 Blueprint Due 9/27/24** 1. **Primary, secondary, and tertiary prevention. Be able to differentiate each and recognize examples**. Primary care: Prevention and management of chronic conditions. Secondary Care: Secondary care occurs when your primary care provider refers you to a specialist Tertiary Care: Hospital treatment 2. **Care of the Transgender Patient. Know definitions, cultural sensitivity**. Use Pt preferred gender identity, sex and pronoun. **Sexual orientation**: A person\'s sexual and emotional attraction to others Gender Identity: A person\'s internal sense of being a man/male, woman/female, both, neither, or another gender Queer: Which term describes a person who is attracted to people of their own gender and people of other genders but may use other terms to describe their sexual orientation. Transgender: What is the term used to describe a wide range of people, including those with a gender identity that falls outside the traditional gender binary. Heterosexual: Which term describes a female who is emotionally and sexually attracted to men. **gender identity**: A person\'s internal sense of being a man/male, woman/female, both, neither, or another gender **Genderqueer**: What is the term used to describe a wide range of people, including those with a gender identity that falls outside the traditional gender binary? LBGTQ care barriers: Limited Access, Negative Experiences, Lack of Knowledge 3. **NP Role**. History. 1960s. Henry Silver (Professor of Medicine) and Loretta Ford (Nurse and Educator) develop the Pediatric Nurse Practitioner program in the University of Colorado. Insurance ethical concepts and definitions, effective communication, patient rights. 4. **Power of Attorney. Definition and terms of Power of attorney**. POA: When some designates someone else to make decision on their behalf in case of lack of capacity to make decisions. Financial vs medical POA. **Living Will**: Which advance health directive document contains the patient\'s instructions and preferences regarding healthcare if they become seriously ill. 5. **Reimbursement. How are NPs reimbursed. What is considered third party reimbursement**. Omnibus Reconciliation Act (1989) created limited reimbursement for the NPs. Sine 1997, NPs gained direct reimbursement through the Balanced Budget Act. Currently Medicare pays 85% of reimbursement for visits covered by a NP NPI. - Reimbursement (third-party payers managed-care HMO/PPO, Medicaid, Medicare, concierge, COBRA) 6. **Medicare A, B, C, D, Affordable Care Act. Differentiate coverage**. **Medicare A**: Hospital Stay, Skilled Nursing. Free premium coverage. Must pay 20% co-pay and deductible. There is no annual limit on out-of-pocket costs for Medicare Part A, Part B or Part D coverage. A list of medical personnel Description automatically generated **Medicare B**: Not free coverage. Covers out-patient providers and services (PT/Wound care/Infusion clinics). Has a deductible separate from Medicare A and covers at 80%. In 2024 \$174.70/monthly premium.  A white background with black text Description automatically generated  A screenshot of a medical report Description automatically generated **Medicare C**: HMOs (Private administration of Medicare Funds). Co-payments vary. Some have as low as \$0 premium for coverage enrollment. In 2024 out-of-pocket limits for Medicare Advantage plans are as follows: **\$8,850** for in-network services. \$13,300 for out-of-network and in-network services combined. They offer additional coverage not included with Original Medicare such as prescription drug coverage, vision and hearing exams, preventive dental coverage. **Medicare D**: Think Drugs. Prescription. Enrollment premium in 2024 is \$36.78/monthly. \$2,000 cap on out-of-pocket drug spending The deductible amounts for Medicare in 2024 are: - **Medicare Part A deductible**: \$1,632 - **Medicare Part B deductible**: \$240 - **Medicare Part D deductible**: \$545 With Original Medicare, there are gaps in coverage. For example, Original Medicare has deductibles and does not have a limit on out-of-pocket spending. Original Medicare doesn't cover Part D prescription drugs, routine vision and hearing exams, and certain other services. In order to have enough coverage, many people choose to enroll in an HMO plan or a Medicare Supplement plan. In 2022, the average Medigap plan costs **around \$150 per month**, or about \$1,800 per year. 7. **Cultural and Spiritual Awareness, Health Beliefs, Cultural Sensitivity. Define and recognize examples**. **Awareness** and **appreciation** of the values, norms, and beliefs characteristic of a cultural, ethnic, racial, or other group that is not one's own. 8. **Ethics Principles** **Nonmaleficence**: Avoid Harm and protect the patient. Reimbursement Payment standards in the United States are driven by insurance companies, particularly those that administer Medicare and Medicaid. APRNs have made great strides in this area and now receive third-party reimbursement in most settings. In managed care contracts, sometimes called advantage plans, providers, whether APRNs or physicians, are paid a fixed, predetermined rate. Payment by private insurance companies is contract specific and varies with each state's insurance commission. **Reimbursement has long been a controversial issue. Medicare and some other insurance companies reimburse NPs at 85% of physician rates, even though they provide the same services as physicians. This is called "incident to" billing**, indicating that the care was provided incident to the supervising physician's care. Incident to billing allows for services to be paid to the supervising physician for 100% of the charged amount rather than 85%, which an independent NP would be paid. Although incident to billing is advantageous for practices, it isn't for NPs. This form of billing suggests that NP care is not the same quality as physician care, but many patients would disagree. Incident to billing also suggests a hierarchical approach to care rather than a team approach, suggesting that NPs need physician oversight, which is not the case. From a national standpoint, incident to billing makes NP care invisible because all services are billed under physicians' NPI numbers rather than the NPs' numbers who provide the services. Because NPI numbers are used to collect data regarding services provided, it is difficult for Medicare to identify and support all clinicians providing primary care services. In 2019, the Medicare Payment Advisory Commission (MedPAC) suggested doing away with incident to billing to create a more unified system (LaPointe, 2019). Other organizations, such as the AANP, support this recommendation and are working politically to remove this barrier to NP full practice authority and access to care for all persons. THIRD-PARTY PAYER RULES Whether NPs are employed by a hospital, a medical practice, a community health center (such as federally qualified health centers \[FQHCs\]), or are self-employed, a third-party payer most often determines reimbursement policies. Third-party payers fall into seven general categories: 1\. Medicare -- A, B, C (Medicare Advantage Plans), D 2\. Medicaid 3\. Indemnity insurance companies 4\. Managed care organizations (MCOs) 5\. Workers' compensation (WC) 6\. Veterans Administration 7\. Auto liability In addition to these third-party payers, there are patients without health insurance, some who have strong financial assets that allow them to pay out of pocket, but most (the uninsured) do not. These patients are considered private pay. Each payer source has its own policies and fee schedules. All, however, use the Centers for Medicare and Medicaid Services (CMS) guidelines as a foundation. CMS works to make sure that the beneficiaries in its government-funded programs can obtain high-quality health care. In response to rising health-care costs, CMS enacted the Balanced Budget Act of 1997 and gave billing approval for nonphysician practitioners, including NPs. MCOs were slow to add NPs as providers. Over time, these carriers have had a growing number of NPs credentialed as providers. Payments were based on the CMS billing rules (85% of the fee schedule rate) or providers who do not credential NPs may instruct NPs to bill under the physician's provider number. Medicare is a health insurance program for people 65 and older that has four parts: Part A, Part B, Part C, and Part D:  - - - - Medicare A---Hospital Inpatient Services Health-care providers wishing to bill Medicare can join the program by applying online at the Provider Enrollment Chain and Ownership System (PECOS) or by a using the traditional paper form (CMS-855I). Each Medicare provider is assigned a National Provider Identifier (NPI) for billing that must be used in Health Insurance Portability and Accountability Act (HIPAA) transactions. Medicare providers agree to take assignments (accept the CMS-approved amount for health services as full payment) when performing services according to current Medicare physician fee schedules and guidelines. Providers are required to submit a claim (bill) to CMS for all services (covered and uncovered) and will be paid, based on the claim for specified services. The NP's scope of practice, prescriptive authority, and requirement of physician collaboration are designated by state legislation. Each state gives authority to the nurse licensing board to regulate APRNs. In 2021, the Medicare Part A (hospital services) deductible was \$1,484, and premiums were based on the quarters of lifetime work in which Medicare taxes are paid. Medicare A out-of-pocket expense was determined by the deductible rate and limits on what is covered. In 2021, out-of-pocket hospital fees was charged as follows: Hospital stays of 1 to 60 days: no additional payment in each benefit period Days 61 to 90: \$371 per day coinsurance Days 91 and beyond: \$742 coinsurance per "lifetime reserved day" used. After 90 days for each benefit period, the beneficiary can use up to 60 days over their lifetime. Beyond lifetime reserve days: All costs paid by the patient (CMS, 2020e; Medicareworld, 2021) Postacute care for beneficiaries who are responsible for a \$185.50 per day copayment---days 21 to 100 in a skilled nursing facility (SNF). Days 1 to 20 have no out-of-pocket post discharge for acute hospital care. Medicare B---Physician Services CMS payment policy for calendar year 2021 (CY 2021) was based on the annual physician and nonphysician provider fee schedule (Medicare Physician Fee Schedule \[PFS\]) (CMS, 2020e). Comments for the fee schedule were placed in the Federal Register on August 4, 2020, and took effect, as they do yearly, on or after January 1, 2021 (CMS, 2020e). The physician fee schedule reflected an administrative strategy aiming to result in "better accessibility, quality, affordability, empowerment, and innovation" (CMS, 2020e, p 1). For CMS-covered physicians, CMS identifies which services will be reimbursed (100% of the physician PFS) and then stipulates that 80% of the allowed rate will be paid by CMS and 20% is the responsibility of the patient. NPs are reimbursed by CMS at 85% of the physician's fee, with the patient still paying a 20% share; NP fees are typically 15% lower than that of physicians (Frakes, 2006). Most patients on the traditional Medicare plan acquire a secondary insurance plan (premium costs vary by patient health status from \$50 to \$300 per month) to cover the 20% patient out-of-pocket expense. In addition to the 20% patient responsibility, Medicare has a yearly deductible. In 2021, the Medicare B (physician/provider and outpatient services) deductible was \$203 per year. Once paid, the patient is charged 20% of the approved Medicare rate for physician office visits and some diagnostic tests. Information about Medicare beneficiary out-of-pocket expenses can be found at the official U.S. government site for Medicare (CMS, 2020e). For all CMS patients, the out-of-pocket patient responsibility payments (copays and deductibles) should be collected before rendering services. This is especially important at the beginning of the calendar year when most Medicare beneficiaries have not yet met their deductible. Patient out-of-pocket payment responsibility should be verified at each medical treatment episode. If these fees are not collected before the services are rendered, they remain the patient's payment responsibility and will require direct patient billing. Patient billing increases the expense to the practice because of the cost and time involved in collecting funds. CMS providers are required to attempt to collect the copayments and deductible patient payments, and best practice recommends providers do so before rendering services. Medicare D---Pharmaceutical Coverage In 2003, Medicare D was added as part of the Medicare Modernization Act, and the donut hole was initially included to encourage patients to be participative consumers aware of drug costs and choices. This program offers prescription drug coverage for drugs not covered under Medicare A or B. The donut hole is a gap in coverage that begins after the person exceeds the initial coverage limit in their plan. In 2021, the initial coverage limit was \$4,120, up from \$4,020 in 2020. ACA legislation planned to eliminate the hole in coverage. When the out-of-pocket expenses reached \$6,350 in 2021, catastrophic coverage was available. After this, the beneficiary paid only 5% of the copay for drugs for the remainder of the year (Healthline, 2019). CMS across the year pays 75% of medication costs; however, the patient must pay premiums, copayments, and deductibles. Beneficiaries can choose a plan that fits their needs and affects their premium rates. Beneficiaries must be enrolled in the Medicare A or Medicare B program, and this is an optional addition to their coverage. Plan selection affects covered medications, and there are many plan options offered to citizens across the United States. Key categories of drugs must be covered by all plan options, such as cancer treatment medications and antidepressant medication (total of six required drug categories). Pharmaceutical costs are substantial for most CMS beneficiaries, and costs have increased yearly. Premium costs per month range from approximately \$12 to \$195 per month. Plan coverage is seen as four parts: (1) deductible phase (pay 100% of drug discount until meet rate; range from \$0 to \$435/year), (2) initial coverage phase (pay copay, with plan paying \$1 for generics on some plans or up to 25%), (3) coverage gap or donut hole (25% of discounted rate of brand drugs), (4) catastrophic phase (5% copay discount rate) (Eligibility Medicare, 2020). ACA plan policy included fully closing the donut hole in 2020; however, the Bipartisan Budget Act of 2018 affected this closure and delayed implementation. Medicare Advantage Plans Medicare Advantage plans offer another way for eligible citizens to obtain Medicare A (hospital) and B (physician) coverage, and these may be called Medicare C or Medicare MA plans. These plans must be approved by CMS and are offered by private insurance companies. Each Medicare MA must offer all required services. They offer all required benefits of Medicare and usually offer additional benefits, such as drug coverage, uncovered eye care, dental care, and lower copayments. Ease of using one plan for covered benefits is attractive to users. Medicare Advantage carriers are paid subsidies per member by CMS for services rendered by their plan. Beneficiaries, however, must use the health providers that participate in these plans. A limit of out-of-pocket yearly expenses for covered services is identified to beneficiaries to avoid concerns of unexpected costs. Medicare Advantage plans were designed on the premise of offering lower costs based on economic efficiencies realized by volume discounts from commercial business relationships. However, problems have been noted with these plans. Because of the high medical utilization of and greater health-care costs incurred by their beneficiaries, many Medicare MA plans have found this market to be less financially viable. In addition, beneficiaries can use noncovered services or out-of-pocket services but at a higher cost. If a plan's payout exceeds the fixed CMS payment they receive annually, the plan incurs a loss, causing many of these carriers to leave this market. Common types of Medicare MA include the following (CMS, 2020b): Health maintenance organization (HMO) plans Preferred provider organization (PPO) plans Private fee-for-service (PFFS) plans Special needs plans (SNPs) Medicaid Medicaid offers medical assistance to individuals and families with low incomes and limited resources, as well as for those with chronic disabilities. Unlike Medicare, it was designed to be jointly funded by both federal and state governments. The federal government assists states in providing medical care to people who meet the program's financial eligibility criteria, including children, pregnant women, parents, seniors (those with dual eligibility on Medicare with Medicaid paying copay and deductibles), and individuals with disabilities. The ACA established the income eligibility method used today, replacing the previous allocation method overseen by Aid to Families with Dependent Children. The ACA determines income eligibility for Medicaid based on the Modified Adjusted Gross Income (MAGI). Citizens who are blind, disabled, or older than 65 years are exempt from meeting the MAGI requirements. Medicaid, together with the Children's Health Insurance Program (CHIP), provided coverage in 2020 to over 72.5 million Americans (Medicaid.gov, 2019; https://Medicaid.gov/Medicaid/eligibility/index.html). Medicaid payments are made directly to the participating providers, who in turn must accept the Medicaid (lower) payment as payment in full. Two exceptions are (1) disproportionate-share hospital payments (hospitals that care for a disproportionate share of Medicaid-eligible patients) and (2) hospice care. Although lawmakers have discussed changing the Medicaid system, with an overarching focus of putting more control in the hands of each state, currently no changes have been made. The federal government matches dollar spending for qualifying mandatory services offered by the individual state. Reimbursement rates must remain sufficient to enlist enough providers willing to perform services and ensure that medical care is available to the general population in the region. In recent years, since the MAGI, citizens have benefited from a reduced delay experienced when seeking enrollment and entering or renewing Medicaid and CHIP (Medicaid.gov, 2020). Guidelines for the Medicaid plan are available at the Medicaid Web site by state and on the Benefits for Medicaid Web site (Medicaid.gov, 2019). There are limitations and criteria for APRN reimbursable services outlined in each state's guidelines that can be located by selecting each state on the ANA Web site (ANA, 2020). There has been an expansion of coverage services for the four APRN roles, as there is a need for practitioner services in the growing physician shortage areas. APRNs are also a cost savings as they are paid at a fraction of the Medicaid PFS. Political opposition to ACA legislation for Medicaid recipients is linked to states' participation in the Medicaid expansion (National Academy for State Health Policy, 2020). On June 28, 2012, the U.S. Supreme Court found that the ACA Medicaid expansion was coercive to the states, ruling that the Department of Health and Human Services (HHS) had no enforcement authority over Medicaid expansion. States could opt not to accept Medicaid expansion funds, which reduced health-care services for Medicaid patient populations in those states. However, this ruling left the health-care coverage and other provisions of the ACA intact. States that did not accept the Medicaid expansion proved to have lower quality of care and reduced access for Medicaid services. Medicaid expansion had a positive financial budget and economic impact in states accepting expansion due to higher federal investment related to this program offering (RWJF, 2019) THIRD-PARTY PAYER RULES Whether NPs are employed by a hospital, a medical practice, a community health center (such as federally qualified health centers \[FQHCs\]), or are self-employed, a third-party payer most often determines reimbursement policies. Third-party payers fall into seven general categories: 1\. Medicare -- A, B, C (Medicare Advantage Plans), D 2\. Medicaid 3\. Indemnity insurance companies 4\. Managed care organizations (MCOs) 5\. Workers' compensation (WC) 6\. Veterans Administration 7\. Auto liability In addition to these third-party payers, there are patients without health insurance, some who have strong financial assets that allow them to pay out of pocket, but most (the uninsured) do not. These patients are considered private pay. Each payer source has its own policies and fee schedules. All, however, use the Centers for Medicare and Medicaid Services (CMS) guidelines as a foundation. CMS works to make sure that the beneficiaries in its government-funded programs can obtain high-quality health care. In response to rising health-care costs, CMS enacted the Balanced Budget Act of 1997 and gave billing approval for nonphysician practitioners, including NPs. MCOs were slow to add NPs as providers. Over time, these carriers have had a growing number of NPs credentialed as providers. Payments were based on the CMS billing rules (85% of the fee schedule rate) or providers who do not credential NPs may instruct NPs to bill under the physician's provider number. Medicare A---Hospital Inpatient Services Health-care providers wishing to bill Medicare can join the program by applying online at the Provider Enrollment Chain and Ownership System (PECOS) or by a using the traditional paper form (CMS-855I). Each Medicare provider is assigned a National Provider Identifier (NPI) for billing that must be used in Health Insurance Portability and Accountability Act (HIPAA) transactions. Medicare providers agree to take assignments (accept the CMS-approved amount for health services as full payment) when performing services according to current Medicare physician fee schedules and guidelines. Providers are required to submit a claim (bill) to CMS for all services (covered and uncovered) and will be paid, based on the claim for specified services. The NP's scope of practice, prescriptive authority, and requirement of physician collaboration are designated by state legislation. Each state gives authority to the nurse licensing board to regulate APRNs. In 2021, the Medicare Part A (hospital services) deductible was \$1,484, and premiums were based on the quarters of lifetime work in which Medicare taxes are paid. Medicare A out-of-pocket expense was determined by the deductible rate and limits on what is covered. In 2021, out-of-pocket hospital fees was charged as follows: Hospital stays of 1 to 60 days: no additional payment in each benefit period Days 61 to 90: \$371 per day coinsurance Days 91 and beyond: \$742 coinsurance per "lifetime reserved day" used. After 90 days for each benefit period, the beneficiary can use up to 60 days over their lifetime. Beyond lifetime reserve days: All costs paid by the patient (CMS, 2020e; Medicareworld, 2021) Postacute care for beneficiaries who are responsible for a \$185.50 per day copayment---days 21 to 100 in a skilled nursing facility (SNF). Days 1 to 20 have no out-of-pocket post discharge for acute hospital care. Medicare B---Physician Services CMS payment policy for calendar year 2021 (CY 2021) was based on the annual physician and nonphysician provider fee schedule (Medicare Physician Fee Schedule \[PFS\]) (CMS, 2020e). Comments for the fee schedule were placed in the Federal Register on August 4, 2020, and took effect, as they do yearly, on or after January 1, 2021 (CMS, 2020e). The physician fee schedule reflected an administrative strategy aiming to result in "better accessibility, quality, affordability, empowerment, and innovation" (CMS, 2020e, p 1). For CMS-covered physicians, CMS identifies which services will be reimbursed (100% of the physician PFS) and then stipulates that 80% of the allowed rate will be paid by CMS and 20% is the responsibility of the patient. NPs are reimbursed by CMS at 85% of the physician's fee, with the patient still paying a 20% share; NP fees are typically 15% lower than that of physicians (Frakes, 2006). Most patients on the traditional Medicare plan acquire a secondary insurance plan (premium costs vary by patient health status from \$50 to \$300 per month) to cover the 20% patient out-of-pocket expense. In addition to the 20% patient responsibility, Medicare has a yearly deductible. In 2021, the Medicare B (physician/provider and outpatient services) deductible was \$203 per year. Once paid, the patient is charged 20% of the approved Medicare rate for physician office visits and some diagnostic tests. Information about Medicare beneficiary out-of-pocket expenses can be found at the official U.S. government site for Medicare (CMS, 2020e). For all CMS patients, the out-of-pocket patient responsibility payments (copays and deductibles) should be collected before rendering services. This is especially important at the beginning of the calendar year when most Medicare beneficiaries have not yet met their deductible. Patient out-of-pocket payment responsibility should be verified at each medical treatment episode. If these fees are not collected before the services are rendered, they remain the patient's payment responsibility and will require direct patient billing. Patient billing increases the expense to the practice because of the cost and time involved in collecting funds. CMS providers are required to attempt to collect the copayments and deductible patient payments, and best practice recommends providers do so before rendering services. Medicare D---Pharmaceutical Coverage In 2003, Medicare D was added as part of the Medicare Modernization Act, and the donut hole was initially included to encourage patients to be participative consumers aware of drug costs and choices. This program offers prescription drug coverage for drugs not covered under Medicare A or B. The donut hole is a gap in coverage that begins after the person exceeds the initial coverage limit in their plan. In 2021, the initial coverage limit was \$4,120, up from \$4,020 in 2020. ACA legislation planned to eliminate the hole in coverage. When the out-of-pocket expenses reached \$6,350 in 2021, catastrophic coverage was available. After this, the beneficiary paid only 5% of the copay for drugs for the remainder of the year (Healthline, 2019). CMS across the year pays 75% of medication costs; however, the patient must pay premiums, copayments, and deductibles. Beneficiaries can choose a plan that fits their needs and affects their premium rates. Beneficiaries must be enrolled in the Medicare A or Medicare B program, and this is an optional addition to their coverage. Plan selection affects covered medications, and there are many plan options offered to citizens across the United States. Key categories of drugs must be covered by all plan options, such as cancer treatment medications and antidepressant medication (total of six required drug categories). Pharmaceutical costs are substantial for most CMS beneficiaries, and costs have increased yearly. Premium costs per month range from approximately \$12 to \$195 per month. Plan coverage is seen as four parts: (1) deductible phase (pay 100% of drug discount until meet rate; range from \$0 to \$435/year), (2) initial coverage phase (pay copay, with plan paying \$1 for generics on some plans or up to 25%), (3) coverage gap or donut hole (25% of discounted rate of brand drugs), (4) catastrophic phase (5% copay discount rate) (Eligibility Medicare, 2020). ACA plan policy included fully closing the donut hole in 2020; however, the Bipartisan Budget Act of 2018 affected this closure and delayed implementation. Medicare Advantage Plans Medicare Advantage plans offer another way for eligible citizens to obtain Medicare A (hospital) and B (physician) coverage, and these may be called Medicare C or Medicare MA plans. These plans must be approved by CMS and are offered by private insurance companies. Each Medicare MA must offer all required services. They offer all required benefits of Medicare and usually offer additional benefits, such as drug coverage, uncovered eye care, dental care, and lower copayments. Ease of using one plan for covered benefits is attractive to users. Medicare Advantage carriers are paid subsidies per member by CMS for services rendered by their plan. Beneficiaries, however, must use the health providers that participate in these plans. A limit of out-of-pocket yearly expenses for covered services is identified to beneficiaries to avoid concerns of unexpected costs. Medicare Advantage plans were designed on the premise of offering lower costs based on economic efficiencies realized by volume discounts from commercial business relationships. However, problems have been noted with these plans. Because of the high medical utilization of and greater health-care costs incurred by their beneficiaries, many Medicare MA plans have found this market to be less financially viable. In addition, beneficiaries can use noncovered services or out-of-pocket services but at a higher cost. If a plan's payout exceeds the fixed CMS payment they receive annually, the plan incurs a loss, causing many of these carriers to leave this market. Common types of Medicare MA include the following (CMS, 2020b): Health maintenance organization (HMO) plans Preferred provider organization (PPO) plans Private fee-for-service (PFFS) plans Special needs plans (SNPs) Medicaid Medicaid offers medical assistance to individuals and families with low incomes and limited resources, as well as for those with chronic disabilities. Unlike Medicare, it was designed to be jointly funded by both federal and state governments. The federal government assists states in providing medical care to people who meet the program's financial eligibility criteria, including children, pregnant women, parents, seniors (those with dual eligibility on Medicare with Medicaid paying copay and deductibles), and individuals with disabilities. The ACA established the income eligibility method used today, replacing the previous allocation method overseen by Aid to Families with Dependent Children. The ACA determines income eligibility for Medicaid based on the Modified Adjusted Gross Income (MAGI). Citizens who are blind, disabled, or older than 65 years are exempt from meeting the MAGI requirements. Medicaid, together with the Children's Health Insurance Program (CHIP), provided coverage in 2020 to over 72.5 million Americans (Medicaid.gov, 2019; https://Medicaid.gov/Medicaid/eligibility/index.html). Medicaid payments are made directly to the participating providers, who in turn must accept the Medicaid (lower) payment as payment in full. Two exceptions are (1) disproportionate-share hospital payments (hospitals that care for a disproportionate share of Medicaid-eligible patients) and (2) hospice care. Although lawmakers have discussed changing the Medicaid system, with an overarching focus of putting more control in the hands of each state, currently no changes have been made. The federal government matches dollar spending for qualifying mandatory services offered by the individual state. Reimbursement rates must remain sufficient to enlist enough providers willing to perform services and ensure that medical care is available to the general population in the region. In recent years, since the MAGI, citizens have benefited from a reduced delay experienced when seeking enrollment and entering or renewing Medicaid and CHIP (Medicaid.gov, 2020). Guidelines for the Medicaid plan are available at the Medicaid Web site by state and on the Benefits for Medicaid Web site (Medicaid.gov, 2019). There are limitations and criteria for APRN reimbursable services outlined in each state's guidelines that can be located by selecting each state on the ANA Web site (ANA, 2020). There has been an expansion of coverage services for the four APRN roles, as there is a need for practitioner services in the growing physician shortage areas. APRNs are also a cost savings as they are paid at a fraction of the Medicaid PFS. Political opposition to ACA legislation for Medicaid recipients is linked to states' participation in the Medicaid expansion (National Academy for State Health Policy, 2020). On June 28, 2012, the U.S. Supreme Court found that the ACA Medicaid expansion was coercive to the states, ruling that the Department of Health and Human Services (HHS) had no enforcement authority over Medicaid expansion. States could opt not to accept Medicaid expansion funds, which reduced health-care services for Medicaid patient populations in those states. However, this ruling left the health-care coverage and other provisions of the ACA intact. States that did not accept the Medicaid expansion proved to have lower quality of care and reduced access for Medicaid services. Medicaid expansion had a positive financial budget and economic impact in states accepting expansion due to higher federal investment related to this program offering (RWJF, 2019) **Health Insurance Portability and Accountability Act (HIPAA)** HIPAA can mean different policy concerns to different people. The act is separated into two parts, Title I and Title II: Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II addresses administrative simplification and requires the U.S. Department of Health and Human Services to establish national standards for electronic health-care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data. These standards were implemented to improve the efficiency and effectiveness of the nation's health-care system by encouraging the widespread use of electronic data interchange in health care (CMS, 2005). HIPAA legislation is important to the daily management of the practitioner practice setting. This legislation focuses on password management, workstation security, e-mail and Internet use, and facility/physical security. Password protection ensures the privacy of patients' health-care information. With increased mandatory submission of electronic billing files and EMRs, a provider must take added precautions to protect the patient's electronic personal information **PRIMARY PREVENTION**: Immunizations, health education, skin cancer prevention methods, weight control, seat belt use, education on: smoking, alcohol, drugs, protective hearing, nutrition, exercise, stress reduction **SECONDARY PREVENTION:** Screenings -- cancers, diabetes, hypertension, stds, anemia, height, weight, BMI screenings **TERIARY PREVENTION:** Treatment to prevent further sequelae of cardiovascular disease, respiratory disease, etc **Primary, secondary, and tertiary prevention are three levels of health promotion and disease prevention**:  - - - - - - - - - - - - - -