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Public Insurance.

Public Insurance- Professional Practice

What are categorical programs? Benefits are designed for defined categories of people
Three main public health insurance programs Medicare Medicaid Children's Health Insurance Program (CHIP)
What is the most influential insurance program affecting the US HC system? Medicare It is the largest payer, but this does not mean it pays the most Organized & managed by the federal gov't
When did Medicare begin? 1950-60's as a mvmt to provide universal national HC to all Americans Most insurance companies follow what Medicare does (to an extent)
In 2010, what act expanded gov't HC even more? ACA of 2010
Title 18 of SS Act Entitlement program- people contribute thru taxes, are entitled regardless of income/assets (must meet qualifications) Federal program- CMS, an agency under US Dept of Health/Human Services
Medicare Administration CMS designates MACs (Medicare Admin Contractor) WPS (WI Physician Service Health Insurance) is Medicare Part A & B MAC that covers JF which including KS, IA, MO, NE Different states are under different agencies & contractors
WPS Coverage- LCD's Local Coverage Determination Coverage policies pertaining to services/items not addressed in NCDs Coding & utilization guidelines
Why were LCD's developed? To define appropriate use of new technologies To address services with an abuse history or potential High volume, high dollar services LCD = WPS for KS
What are NCDs? National Coverage Determination Originate from CMS & apply to all Medicare jurisdictions NCD = CMS
Are LCD & NCD restrictions the same? LCD must have the same restrictions as NCD,c an't take away any, but can add additional restrictions as they see fit
Medicare Cost Trends First year- <$2 billion & funded by .35% payroll taxes of 1st $6,600 in earnings Now Medicare pays $406 bill & collects 2.9% payroll taxes on all earnings
Medicare Eligibility Requirements 65+ Disabled who are entitled to & have been receiving SS benefits x24 mod End-stage renal disease Payroll contributions for at least 10 yrs: vested Spouses age 65 of vested beneficiaries
Services not covered by Medicare Vision Eyeglasses Dental care Hearing aids Many long-term care services
Public Financing- What is Medigap? Private insurance used to cover gaps in Medicare
Medicare Part A- Hospital Insurance Financed by payroll taxes Medicare tax: paid by all working individuals, on all income earned, equally by the employer/employee
Medicare Part A covers: IP services Short-term convalescence & rehab in SNF Home Health Hospice
Part A timing of benefits is determined by a benefit period Begins on day beneficiary is hospitalized Ends when beneficiary hasn't been in hospital/SNF for 60 consecutive days Then a new benefit period begins Beneficiary has unlimited benefit periods >60 days, Part B kicks in for coverage
Hospital Benefits of Part A Deductible paid for first 60 days Co-payment req'd from 61-90 days Higher copayment req'd after 90 days
SNF Benefits of Part A Eligibility beings after 3 consecutive days of hospital stay 100 days max in SNF First 20 days at no charge to beneficiary; co-pay applies from day 21
Part A benefits Benefit period is 60 days in hospital, then 100 day period for SNF starts after release from hospital. 100 days starts over if they go back to hospital for a different dx
Home Health Benefits of Part A Patient must be homebound AND require intermittent or part-time skilled nursing care or rehab care
Hospice Benefit of Part A Pt must be temrinally ill (not anticipated to live >6 months) Only a token co-pay is req'd
Supplementary Medical Insurance (SMI) Part B- Coverage Therapy services Physician services Hospital OP services (surgery) Dx tests Radiology DME Screening/preventive services (well-women, physical) Annual Wellness exam provided no charge
Part B- what does pt have to pay for services? An annual deductible must be paid 80:20 co-insurance
Medicare Advantage Part C Not government financed Doesn't specifically include add'l medical benefits Add'l benefits may be offered by private managed care plans Beneficiary receives all Pt A, B, D services through MCO
What exactly is Part C? Option for supplement to part A Covers what part A doesn't Lots of private insurances also offer Medicare part C as a supplement (must follow MC rules, but administer them differently)
Part D (Prescription Drug Coverage) Available to those with Part A or B Monthly premium must be paid Annual deductible applies 3 layers based on spending
Donut Hole MC doens't pay until person has paid 100% to $4,700, then MC starts paying 95%
Deductible- Part D Drug costs- $320 MC Pays- None Beneficiary Pays- $320
Initial Coverage- Part D Drug Costs- $321-2,930 MC Pays- 75% up to $1,957.50 Beneficiary Pays- 25% up to $652.50
Gap/Doughnut Hole- Part D Drug Costs- $2,931-6,657.50 MC Pays- None Beneficiary Pays- 100% up to $3,727.50 (up to 50% discount on drugs)
Catastrophic Damage- Part D Drug Costs- >$6,657.50 MC Pays- ~95% Beneficiary Pays- ~5% Beneficiary must pay total $4,700 (320+652.50+3727.50) before catastrophic coverage begins
4 Primary Processes of MC Quality Control Report cards Provider certification Utilization review (looking at medical records) Oversight by PROs (peer review orgs)
Fraud & Abuse False Claims Act of 1986 & HIPAA of 1996 both helped to deal with fraud & abuse FIs (fiscal intermediaries [now MACs]) perform routine & non-routine audits
Medicaid HC for indigent, but not all poor. Financed by state & federal gov'ts Each state establishes own eligibility by: income/assets, medicaid is a means-tested program Each state administers own Medicaid program
Children's Health Insurance Program (CHIP) Title 21 of SS Act Available to families with incomes up to 200% of federal poverty level States can use existing Medicaid, create separate CHIP program, or use combined approach Financed by federal & state funds
Created by: 1190550002