© 2010 principles of healthcare reimbursement third edition chapter 4 government-sponsored...
TRANSCRIPT
© 2010
Principles of Healthcare Reimbursement
Third Edition
Chapter 4
Government-Sponsored Healthcare Programs
© 2010
Objectives
• To differentiate among and to identify the various government-sponsored healthcare programs
• To understand the history of the Medicare and Medicaid programs in America
• To recognize the impact that government-sponsored healthcare programs have on the American healthcare system
© 2010
Medicare
• Medicare– Title XVIII of the Social Security Act – 1965 (implemented 1966)– Beneficiaries
• Age 65 or older– Eligible for Social Security or Railroad Retirement
Benefits
• Persons with permanent disability
• End-stage renal disease
© 2010
Medicare (cont’d)
• Medicare– Part A: Hospitalization insurance
• Inpatient hospital• Long-term care• Skilled nursing services• Home health services• Hospice care
– Beneficiary pays deductible and copayments after certain periods of time
– Part B: Voluntary supplemental medical insurance• Physician services• Medical services• Medical supplies
– Beneficiary pays monthly premium plus annual deductible and copayments
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Medicare (cont’d)
• Medicare– Part C: Medicare Advantage (MMA 2003)
• Was Medicare+Choice (1997) – HMO– PSO– PPO– Beneficiary pays monthly premiums $50–$350– Expanded scope of services (e.g., vision services)
– Part D: Medicare Drug Benefit• Implemented January 1, 2006
– Outpatient drug coverage provided by private prescription drug plans and Medicare Advantage
– Beneficiaries pay monthly premium, deductible, and copayments– Medigap: Supplementary insurance to cover items and services
not covered by Medicare– Must meet Federal guidelines
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Medicaid
• Medicaid– Title XIX of Social Security Act (1965)– Individuals and families with low incomes and
limited financial resources– Joint program between federal government and states– Administered by individual states
• Determine eligibility, type, amount, durations, scope of covered services
• Calculate the rate of payment• May offer a managed care option
– 60.68% in 2004; up from 32.1% in 1995
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Medicaid (cont’d)
• Required Medicaid coverage for– Low income families with children including
Temporary Assistance for Needy Families (TANF)– Supplemental Security Income recipients– Infants born to Medicaid-eligible pregnant women– Children under the age of six whose family income
is at or below 133 percent of the federal poverty level
– Recipients of adoption assistance and foster care– Certain Medicare beneficiaries– Special protected groups
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TANF
• Temporary Assistance for Needy Families– The Personal Responsibility and Work Opportunity
Reconciliation Act of 1996 (welfare reform)
– Provides states with grant money designated to provide low-income families with assistance
– Replaced Aid to Families with Dependent Children (AFDC)
• Many changes under welfare reform and the change from AFDC to TANF
• Many individuals are not aware that they are eligible for Medicaid under this program.
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PACE
• Programs of All-Inclusive Care for the Elderly– Balanced Budget Act 1997 (BBA)– Joint Medicare-Medicaid venture– Offers states the option of creating and administering
a managed care option for the frail elderly population– Enhance the quality of life for the frail elderly
population• Live in their own homes and communities• Have service facilities in various geographical service areas
– Increased accessibility to frail elderly population
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SCHIP
• State Children’s Health Insurance Program– Title XXI of Social Security Act
– BBA (Balanced Budget Act) 1997
– Covers children who are not eligible for Medicaid
– Services• Inpatient
• Outpatient
• Physician’s surgical and medical
• Lab and x-ray
• Well-baby/child care services and immunizations
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TRICARE
• TRICARE (formerly CHAMPUS: Civilian Health and Medical Program–Uniformed Services)– Active-duty members of the military and qualified
family members– Activated guard or reserve members– Three options
• TRICARE Prime and Prime Remote– ADSM or ADFM
• TRICARE Extra– ADFM
• TRICARE Standard– ADFM
• TRICARE for Life– Secondary coverage for those eligible for Medicare
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CHAMPVA
• Civilian Health and Medical Program Veterans Administration– Dependents and survivors of disabled
veterans– Survivors of veterans who died of service-
related conditions– Survivors of military personnel who died in
the line of duty– Treated for free at participating VA
healthcare facilities
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IHS
• Indian Health Service– American Indians
– Alaska Natives
– Covers:• Preventive health services
• Primary medical services (hospital and ambulatory care)
• Community health services
• Substance abuse treatment services
• Rehabilitative services
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Worker’s Compensation
• Worker’s Compensation– Work-related injuries– Covers:
• Healthcare costs
• Lost income
– Legislated by individual states• Set coverage
• Can exclude certain workers
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Worker’s Compensation
• Worker’s Compensation– Federal Employee’s Compensation Act
• Federal government employees
• Established in 1916 and administered by the Office of Workers’ Compensation Programs
• Provides for– Medical benefits
– Death benefits
– Income benefits