Centers for Medicare & Medicaid Services
CMS is the U.S. federal agency that administers Medicare, Medicaid, and CHIP, serving over 65 million Medicare beneficiaries, tens of millions of Medicaid enrollees, and millions of CHIP participants through statutory coverage rules, reimbursement rates, and federal-state program partnerships.
- Company typePublic
- Founded1965
- HeadquartersBaltimore, United States
- Headcount5,001–10,000
- GTM typeB2B and B2C
- OfferingServices
What Centers for Medicare & Medicaid Services does
Centers for Medicare & Medicaid Services (CMS) is the sole federal agency responsible for administering Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) in the United States, serving more than 65 million Medicare beneficiaries, tens of millions of Medicaid enrollees, and millions of CHIP participants. The agency operates under the U.S. Department of Health and Human Services and is led by Administrator Dr. Mehmet Oz. CMS is funded through congressional appropriations and does not generate commercial revenue; instead, it administers federal healthcare spending in excess of $1 trillion annually and exercises monopsonistic purchasing leverage over the U.S. healthcare system.
CMS's core technology infrastructure includes the legacy Medicare claims-processing systems that handle 1.2 billion claims per year (approximately $460 billion), the in-development ClaimsCore modernization platform (initial $2.5 billion obligation to HealthEdge Software, up to $825 million to Peraton), and a portfolio of AI-enabled programs including the WISeR AI-assisted prior authorization model, the ACCESS reimbursement framework for AI clinical systems, and a C3 AI Agentic Platform supporting fraud detection across 4 to 5 million claims daily. Supporting platforms include the Medicare Coverage Database, the Data Element Library, the Care Compare consumer portal, and the Innovation Center (CMMI) for payment-model development.
The business model is regulatory rather than commercial: CMS sets coverage rules, reimbursement rates, coding standards, and quality measures; negotiates drug prices under the Inflation Reduction Act (38–79% list price reductions on 10 drugs effective January 2026); enforces anti-fraud actions ($6.5 billion in 2026 takedown charges, over 2,400 provider revocations); and disburses federal healthcare funding through state Medicaid agencies, contracted Medicare Advantage and Part D plans, the Healthcare.gov Marketplace, and the $50 billion Rural Health Transformation Program. Recent expansion has included the GLP-1 Bridge demonstration program (effective July 2026) and the new Office of Health Technology and Products (effective June 9, 2026) to consolidate digital modernization across all CMS-administered programs.
Centers for Medicare & Medicaid Services firmographics
Firmographics- Name
- Centers for Medicare & Medicaid Services
- Legal name
- Centers for Medicare & Medicaid Services
- Website
- https://cms.gov
- Company type
- Public
- Founded year
- 1965
- Operating status
- Operating
- Headcount range
- 5,001–10,000 employees
- Short description
- CMS is the U.S. federal agency that administers Medicare, Medicaid, and CHIP, serving over 65 million Medicare beneficiaries, tens of millions of Medicaid enrollees, and millions of CHIP participants through statutory coverage rules, reimbursement rates, and federal-state program partnerships.
- Ownership category
- akta.pro rank
Centers for Medicare & Medicaid Services industry classification
Industry- Product category
- Government Healthcare Administration
- NAICS
- Direct Health and Medical Insurance Carriers (524114), Health and Welfare Funds (525120), Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds (524292), Computing Infrastructure Providers, Data Processing, Web Hosting, and Related Services (518)
- SIC
- Hospital & Medical Service Plans (6324), Services-Computer Programming, Data Processing, Etc. (7370), Services-Health Services (8000)
- akta.pro primary industry
- Medicare Quality, Risk Adjustment & Stars Analytics/Services (FSAIAGAJ)
- akta.pro secondary industries
- Medicare Advantage (MA) Plans (FSAIAGAA), Medicare Part D Prescription Drug Plans (PDP) (FSAIAGAC), Medicare Provider Networks & Delegated Medical Groups (MA-focused) (FSAIAGAK), Medigap Fraud, Waste & Abuse (FWA) & Payment Integrity (HLAEADAI)
Keywords
Where Centers for Medicare & Medicaid Services is headquartered
LocationHeadquarters
- HQ city
- Baltimore
- HQ country
- United States
- HQ region
- North America
Offices1 record
Markets served
Centers for Medicare & Medicaid Services business model
Business model- GTM type
- B2B and B2C
- Offering type
- Services
- Cost components
- Personnel, Operations, Technology or R&D, Infrastructure, Others
Distribution channels4 records
Marketing channels4 records
Centers for Medicare & Medicaid Services product offering
Product offeringCore offering
CMS administers the nation's major federal healthcare programs, including Medicare (Parts A, B, and D), Medicaid, CHIP, and the Health Insurance Marketplace, providing healthcare coverage administration for over 65 million Medicare beneficiaries and tens of millions of Medicaid/CHIP enrollees. The agency operates comprehensive claims processing infrastructure handling 1.2 billion Medicare claims annually worth approximately $460 billion, conducts Medicare drug price negotiations, runs fraud detection and enforcement programs, and is modernizing its technology infrastructure through AI-enabled initiatives like the WISeR prior authorization pilot and the ACCESS payment model.
Product overview
The Centers for Medicare & Medicaid Services (CMS) is a federal agency that administers the nation's major healthcare programs rather than a commercial product company. CMS's offerings consist of government healthcare programs and digital platforms including Medicare (Parts A, B, and D), Medicaid/CHIP, the Health Insurance Marketplace, and various quality measurement and fraud prevention initiatives. Key platforms include the Medicare Coverage Database for coverage determinations, the Data Element Library for interoperability standards, Care Compare for consumer provider comparison, and the Innovation Center for payment model development. Recent AI-enabled initiatives include the WISeR prior authorization pilot, the ACCESS payment model for AI reimbursement, and the CRUSH fraud detection program. CMS also administers the Medicare Drug Price Negotiation Program, Rural Health Transformation Program ($50 billion), and the Medicare GLP-1 Bridge demonstration program.
Differentiator
Problem solved
Functional benefit
Brands
- Medicare.gov: Official Medicare website for beneficiaries
- Medicaid.gov
- Healthcare.gov
- InsureKidsNow.gov
Products and services
- Medicare Part D Voluntary Medicare prescription drug benefit program administered by CMS through private insurance plans, covering approximately 50 million beneficiaries and including the Drug Price Negotiation Program and Inflation Rebate Program.
- Medicaid/CHIP Federal-state health insurance programs providing coverage to eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities, including new community engagement requirements.
- Medicare Coverage Database CMS online searchable database containing national and local coverage determinations, approved facilities, trials, and registries for Medicare beneficiaries.
- Medicare GLP-1 Bridge Program Time-limited demonstration program allowing eligible Medicare Part D enrollees to access FDA-approved GLP-1 weight loss medications (Wegovy, Zepbound, Foundayo) for a $50 monthly copay through December 31, 2027.
- WISeR Model (Wasteful and Inappropriate Services Reduction) AI-enabled prior authorization pilot program for traditional Medicare that requires physicians to seek advance approval for targeted medical procedures across six states (Oklahoma, Arizona, New Jersey, Ohio, Texas, Washington) to reduce fraud and save costs, covering approximately 207,500 beneficiaries in its first year through 2031.
- Office of Health Technology and Products (OHTP) CMS office established to modernize CMS healthcare technology and digital products across Medicare, Medicaid, CHIP, and other CMS-administered programs, including divisions focused on open-source frameworks, data and interoperability platforms, policy development, and core products such as Medicare claims systems and the National Provider Directory.
- ACCESS Payment Model First federal reimbursement mechanism for AI systems that monitor patients between visits, coordinate care, and manage medications outside traditional clinical settings, within the $900 billion Medicare program.
- Medicare Drug Price Negotiation Program CMS initiative to negotiate prices directly with drug manufacturers for high-cost, single-source medications under Medicare Part D, implementing provisions from the Inflation Reduction Act and achieving 38% to 79% list price reductions for 10 common drugs effective January 1, 2026.
- Rural Health Transformation Program $50 billion federal initiative to states over five years to improve healthcare and strengthen rural communities through grants for infrastructure, workforce, and health IT, targeting rural hospitals, critical access hospitals, rural emergency hospitals, rural health clinics, and community health centers.
- Crushing Fraud, Waste & Abuse Initiative (CRUSH) CMS program to combat healthcare fraud, waste, and abuse and protect Americans in Medicare and Medicaid programs through enforcement actions, moratoria, and AI-driven data analytics, achieving $14 return for every dollar spent on fraud prevention in 2024.
- Innovation Center (CMMI) CMS center supporting the development and testing of innovative healthcare payment and service delivery models, including accountable care organizations, bundled payments, and new quality-based payment models.
- Data Element Library (DEL) Centralized CMS resource for assessment instrument data elements (questions and responses) and associated health IT standards, promoting interoperability and standardization across care settings including IRFs, HHAs, LTCHs, SNFs, and hospice.
- Care Compare Website CMS consumer-facing website enabling comparison of healthcare providers based on quality and other information across dialysis facilities, home health services, hospice, hospitals, nursing homes, physicians, and medical equipment suppliers.
- Health Technology Ecosystem CMS initiative to modernize the nation's digital health ecosystem, empowering patients and delivering better outcomes through interoperability, open-source frameworks, and data platforms.
- Qualified Health Plan Certification CMS process for certifying health insurance plans sold on the Health Insurance Marketplace, including standardized plan options, essential health benefits, and premium adjustments.
Quantifiable outcome
- Medicare drug price negotiations resulted in 38% to 79% list price reductions for 10 common drugs effective January 1, 2026
- +2 more outcomes
Companies that use Centers for Medicare & Medicaid Services
Customer profileSegments3 records
Ideal customer profiles4 records
Centers for Medicare & Medicaid Services technology and API
TechnologyTechnology focussed Yes
API detail
- Has API
- No
- API docs
- API detail
Core technology
AI maturity
App detail
AI capability5 records
Feature4 records
Centers for Medicare & Medicaid Services partnerships and signals
Strategic signalPartnerships
Six partnerships are on record, tiered major and strategic.
- Goldman Edwards Tantus (GET) Joint VenturemajorGoldman Edwards won a $101 million prime contract through its GET Joint Venture to support CMS Center for Clinical Standards and Quality Security Innovation and Operations and Modernization Support program. The joint venture outperformed seven competing bidders in a highly competitive procurement process to secure the five-year contract supporting CMS in advancing secure, resilient, and modern digital operations.
- ID.me and Verisys PartnershipstrategicID.me and Verisys launched a strategic partnership to help state Medicaid agencies verify provider identities, validate credentials, and manage CMS provider revalidation requirements through an integrated system. The partnership combines ID.me's identity verification infrastructure with Verisys' healthcare credentialing capabilities to address growing pressure to strengthen Medicaid enrollment integrity and reduce fraud.
- C3 AIstrategicC3 AI was selected to deploy its Agentic AI Platform at CMS and NIH, creating a unified data layer across fragmented legacy systems. The implementation integrates data from eligibility systems, claims databases, IRS, SSA, and policy documents to enable fraud detection, predictive risk scoring, and natural language policy research capabilities.
- Ohio and Indiana State GovernmentsstrategicOhio and Indiana entered into new data-sharing agreements with the U.S. Department of Justice and CMS to combat Medicaid fraud. The agreements were announced by acting U.S. Attorney General Todd Blanche and CMS Administrator Dr. Mehmet Oz.
- HealthEdge SoftwaremajorCMS selected HealthEdge Software as a finalist for a potential seven-year contract to develop ClaimsCore, a new software system for processing Medicare claims. HealthEdge received an initial $2.5 billion obligation with a $1.1 billion ceiling for the ClaimsCore development.
- PeratonmajorCMS selected Peraton as a finalist for the ClaimsCore contract competition. Peraton received an initial $9.1 million obligation with a potential value of $825 million for the Medicare claims processing modernization project.
Scale indicators13 records
Recent moves6 records
Expansion highlights7 records
Centers for Medicare & Medicaid Services competitors and assessment
Company assessmentBroad incumbents
- U.S. Department of Health and Human Services: Parent department of CMS and the broader federal health policy apparatus. HHS sets the strategic and regulatory direction that CMS implements, and is directly comparable as the umbrella organization for U.S. federal health program administration.
- NHS England: Operates the National Health Service in England, providing universal healthcare coverage to 55 million residents. Comparable to CMS as a single-payer administrator setting coverage policy, negotiating drug prices, processing claims, and operating quality measurement frameworks at national scale.
Direct peers
- Veterans Health Administration: Operates the largest integrated healthcare system in the U.S., providing direct healthcare to over 9 million veterans annually. Comparable to CMS as a federal entity that administers health coverage, operates provider networks, processes claims, and negotiates drug prices at scale.
- Defense Health Agency (TRICARE): Administers TRICARE, the U.S. military health program covering 9.6 million active-duty service members, retirees, and families. Directly comparable to CMS as a federal health benefit administrator that contracts with private plans, processes claims, and enforces fraud and quality standards.
- Indian Health Service: Federal agency within HHS that provides healthcare to 2.6 million American Indians and Alaska Natives. Comparable to CMS as a federal health program administrator delivering direct care, operating provider networks, and administering benefits for a defined population.
Regional players
- California Department of Health Care Services (Medi-Cal): Administers California's Medicaid program (Medi-Cal), the largest state Medicaid program in the U.S. covering approximately 15 million beneficiaries. Comparable to CMS as a federal-state Medicaid administrator that operates within CMS guidelines while managing state-level payment, eligibility, and fraud programs.
- New York State Department of Health: Administers New York State's Medicaid program (covering 7+ million enrollees), Essential Plan, and public health functions. Comparable to CMS as a large state-level health insurance administrator operating within federal CMS guidelines while managing state-specific payment, eligibility, and quality programs.
Others
- Centers for Disease Control and Prevention (CDC): Sister HHS agency that operates public health surveillance, data systems, and population health programs. Comparable to CMS as a federal data-intensive healthcare entity with large-scale operational infrastructure, though focused on public health rather than insurance administration.
Market position
Strengths4 records
Weaknesses5 records
Competitive moat5 records
Key risks6 records
Key highlights7 records
Customer concentration
Centers for Medicare & Medicaid Services social profiles
Digital presenceCenters for Medicare & Medicaid Services financial estimates
Financial estimateRevenue estimate
Valuation estimate
Centers for Medicare & Medicaid Services leadership team
Management profileNumber of profiles
Profiles5 records
Centers for Medicare & Medicaid Services funding detail
Funding detailFunding overview
Funding rounds
Investors
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Centers for Medicare & Medicaid Services M&A and investment
M&A and investmentM&A
Investments7 records
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Frequently asked questions about Centers for Medicare & Medicaid Services
What does Centers for Medicare & Medicaid Services do?
CMS administers the nation's major federal healthcare programs, including Medicare (Parts A, B, and D), Medicaid, CHIP, and the Health Insurance Marketplace, providing healthcare coverage administration for over 65 million Medicare beneficiaries and tens of millions of Medicaid/CHIP enrollees. The agency operates comprehensive claims processing infrastructure handling 1.2 billion Medicare claims annually worth approximately $460 billion, conducts Medicare drug price negotiations, runs fraud detection and enforcement programs, and is modernizing its technology infrastructure through AI-enabled initiatives like the WISeR prior authorization pilot and the ACCESS payment model.
Is Centers for Medicare & Medicaid Services a public or private company?
Centers for Medicare & Medicaid Services is a public company. It is classified as state government owned and is currently operating.
When was Centers for Medicare & Medicaid Services founded?
Centers for Medicare & Medicaid Services was founded in 1965. It employs 5,001 to 10,000 people.
Where is Centers for Medicare & Medicaid Services based?
Centers for Medicare & Medicaid Services is headquartered in Baltimore, United States, in the North America region.
Who are Centers for Medicare & Medicaid Services's main competitors?
Broad incumbents on record are U.S. Department of Health and Human Services and NHS England. Direct peers are Veterans Health Administration, Defense Health Agency (TRICARE) and Indian Health Service. Regional players are California Department of Health Care Services (Medi-Cal) and New York State Department of Health. Centers for Disease Control and Prevention (CDC) is listed as an others.
Does Centers for Medicare & Medicaid Services have an API?
No public API is recorded for Centers for Medicare & Medicaid Services.
What industry is Centers for Medicare & Medicaid Services in?
Centers for Medicare & Medicaid Services's product category is Government Healthcare Administration. Its primary akta.pro industry code is FSAIAGAJ, Medicare Quality, Risk Adjustment & Stars Analytics/Services, with a secondary code of FSAIAGAA, Medicare Advantage (MA) Plans. Its NAICS code is 524114 and its SIC code is 6324.