Utilization Management: Medicare Beneficiaries

Course overview

Medicare is the largest health insurance provider in the U.S. with more than 62 million people enrolled (Centers for Medicare and Medicaid Services [CMS], 2022b). Medicare offers four primary plans and multiple forms of supplemental or other insurance coverage for people who meet specific eligibility criteria. Some forms of Medicare must be paid, while some people are able to enroll in premium-free coverage plans. To ensure adequate coverage, anyone interested in Medicare services should discuss eligibility requirements, enrollment dates, and covered services with a knowledgeable professional. This course will describe the four parts of Medicare, including coverage, eligibility, and enrollment, and allows the learner to identify eligible Medicare participants. The goal of this course is to equip nurses and social workers with knowledge of utilization management as it applies to Medicare beneficiaries in the acute care setting.